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Jing S, Chen H, Bao L, Lyu R, Boqi X, Pu L, Bian X, Tao L, Wang M. ω-3 Fish Oil Fat Emulsion can reduce the incidence of Delayed Gastric Emptying after Roux-en-Y Reconstruction for Gastric Cancer. J Gastrointest Surg 2025:102066. [PMID: 40268084 DOI: 10.1016/j.gassur.2025.102066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2025] [Revised: 04/12/2025] [Accepted: 04/14/2025] [Indexed: 04/25/2025]
Abstract
PURPOSE Despite standardized surgical techniques, delayed gastric emptying (DGE) remains a major complication after Roux-en-Y reconstruction in gastric cancer patients. This study aimed to evaluate the efficacy of ω-3 fish oil fat emulsion in reducing DGE incidence and improving postoperative outcomes. METHODS In this retrospective cohort study, 210 patients undergoing radical gastrectomy with Roux-en-Y reconstruction (Nanjing Drum Tower Hospital, 2018-2020) were stratified into two groups: the intervention group (n=139) received parenteral nutrition (PN) with ω-3 fish oil emulsion (0.2g/kg/day), while controls (n=71) received standard PN. DGE diagnosis required persistent symptoms (>72h postoperatively) and objective evidence of impaired motility (CT contrast retention ≥50% at 4h or scintigraphic T½ >90min), excluding mechanical obstructions (luminal stenosis <8mm). RESULTS The ω-3 group exhibited significantly lower DGE incidence (4.3% vs. 15.5%, P=0.005) and shorter median postoperative hospital stay (10 vs. 13 days, P<0.001). Multivariate analysis identified ω-3 supplementation as an independent protective factor against DGE (OR=0.32, 95% CI:0.11-0.96, P=0.042). Symptom severity (Gastroparesis Cardinal Symptom Index) showed progressive improvement in the ω-3 cohort, with significant reductions in nausea and vomiting scores by week 4 (P<0.05). CONCLUSION Perioperative ω-3 fish oil fat emulsion supplementation reduces DGE risk by 71%, accelerates recovery, and improves surgical outcomes in gastric cancer patients undergoing Roux-en-Y reconstruction. These findings support its integration into enhanced recovery protocols, particularly in high-risk populations.
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Affiliation(s)
- Siqing Jing
- Division of Gastric Surgery, Department of General Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Hao Chen
- Division of Gastric Surgery, Department of General Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Linsen Bao
- Department of Pediatric and hernia abdominal wall surgery，The Bozhou Hospital Affiliated to Anhui Medical University, Bozhou, Anhui Province, China
| | - Ruohan Lyu
- Department of statistics, Beijing Forestry University, Beijing, China
| | - Xu Boqi
- Department of General Surgery, Suzhou Municipal Hospital, Suzhou, China
| | - Lingxiao Pu
- Department of General SurgeryⅠ, Jiangyin People's Hospital, Affiliated Jiangyin Hospital of Nantong University, Jiangyin, Jiangsu, China
| | - Xiaojie Bian
- Department of Pharmacy, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China.
| | - Liang Tao
- Division of Gastric Surgery, Department of General Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China.
| | - Meng Wang
- Division of Gastric Surgery, Department of General Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China.
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Kusaka Y, Ueno T, Minami T. Effect of restrictive versus liberal fluid therapy for laparoscopic gastric surgery on postoperative complications: a randomized controlled trial. J Anesth 2025; 39:101-110. [PMID: 39680086 PMCID: PMC11782308 DOI: 10.1007/s00540-024-03439-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2024] [Accepted: 11/24/2024] [Indexed: 12/17/2024]
Abstract
PURPOSE Currently, laparoscopic surgery is a standard technique in the field of abdominal surgery. However, the most adequate fluid regimen during laparoscopic surgery remains unclear. The aim of this trial is to compare a restricted fluid therapy with a liberal fluid therapy for laparoscopic abdominal surgery. Our hypothesis was that restrictive fluid therapy would reduce postoperative complications better than liberal fluid therapy. METHOD In this randomized controlled trial, patients scheduled for laparoscopic gastric surgery were randomized to either the liberal group (receiving 7-10 ml/kg/h of crystalloid) or the restrictive group (receiving 1-2 ml/kg/h of crystalloid) for each stratum of surgical procedure from April 2017 to March 2019. For both groups, blood loss was replaced by an equal volume of hydroxyethyl starch. The primary endpoint was postoperative complications up to 30 days after surgery, according to the Clavien-Dindo classification. RESULTS We enrolled 148 patients, and 140 of these were randomized to either the liberal or the restrictive group after exclusion. As a result, 69 cases were included in the liberal group for analysis, and 67 patients composed the restrictive group. Median fluid administration for the liberal and restrictive groups was 2950 ml and 800 ml, respectively. As well, overall complications in the liberal and restrictive groups were 27.5% and 19.4%, respectively (risk ratio 0.71, 95% confidence interval 0.38-1.31, p value = 0.264). CONCLUSION Restricted fluid therapy and liberal fluid therapy did not show any statistical differences in postoperative complications after laparoscopic gastric surgery.
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Affiliation(s)
- Yusuke Kusaka
- Department of Anesthesiology, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan.
| | - Takeshi Ueno
- Department of Anesthesiology, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
| | - Toshiaki Minami
- Department of Anesthesiology, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
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Obana A, Iwasaki K, Suwa T. Impact of postoperative complications on gastric cancer survival. Surgery 2025; 178:108873. [PMID: 39433448 DOI: 10.1016/j.surg.2024.09.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 09/16/2024] [Accepted: 09/22/2024] [Indexed: 10/23/2024]
Abstract
BACKGROUND Long-term implications of postoperative complications, particularly non-cancer-related mortality in patients with gastric cancer following gastrectomy, remain unclear. We aimed to evaluate the impact of these complications on non-cancer-related deaths. METHODS A cohort of 236 patients who underwent curative gastrectomy for gastric cancer in a Japanese hospital was divided based on complications classified as Clavien-Dindo grade II or higher. The Kaplan-Meier method, log-rank tests, and Cox hazard ratio analysis were used to evaluate recurrence-free survival and overall survival and to identify complications and survival predictors. RESULTS Delirium was the most common complication (21 of 52 patients). A significant difference was observed in the overall survival (with complications, 3-year: 58.1% and 5-year: 51.6%; without complications, 3-year: 82.3% and 5-year: 73.6%; P < .001) but not in recurrence-free survival (with complications, 3-year: 77.8% and 5-year: 77.8%; without complications, 3-year: 87.5% and 5-year: 85.2%). Non-cancer-related deaths, predominantly resulting from pneumonia, were more prevalent in the complications group than in the noncomplications group. Factors, including high American Society of Anesthesiologists Physical Status scores, blood transfusion, open surgery, male sex, total gastrectomy, and a history of neurologic/psychiatric disease, were independently associated with decreased overall survival. CONCLUSION Postoperative complications affect long-term prognosis, resulting in decreased overall survival and increased noncancer mortality. Proactive strategies, including optimizing preoperative management, preventing complications, and postdischarge interventions, are essential, with a focus on pulmonary disease prevention to improve prognosis after gastrectomy.
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Affiliation(s)
- Ayato Obana
- Department of Surgery, Kashiwa Kousei General Hospital, Chiba, Japan.
| | - Kenichi Iwasaki
- Department of Surgery, Kashiwa Kousei General Hospital, Chiba, Japan
| | - Tatsushi Suwa
- Department of Surgery, Kashiwa Kousei General Hospital, Chiba, Japan
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Parakonthun T, Gonggetyai G, Nampoolsuksan C, Suwatthanarak T, Tawantanakorn T, Swangsri J, Methasate A. Higher compliance with the enhanced recovery after surgery protocol improves postoperative recovery and 6-month mortality in upper gastrointestinal surgery. SURGERY IN PRACTICE AND SCIENCE 2024; 19:100265. [PMID: 39844954 PMCID: PMC11749180 DOI: 10.1016/j.sipas.2024.100265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2024] [Revised: 11/19/2024] [Accepted: 11/19/2024] [Indexed: 01/24/2025] Open
Abstract
Introduction The enhanced recovery after surgery (ERAS) protocol has been proven to accelerate recovery without increasing morbidity, but few data are available from developing countries. We aimed to demonstrate the correlation between compliance with the ERAS protocol and short-term outcomes in upper gastrointestinal (UGI) surgery. Materials and Methods Patients that underwent esophageal and gastric surgeries during March 2019 to June 2021 were prospectively enrolled in this nonrandomized cohort study. The ERAS protocol was applied based on patient-doctor agreement. Patients were categorized into conventional care (CC), moderate-compliance (MC), and high-compliance (HC) groups. Short-term outcomes including gastrointestinal (GI) function recovery, length of hospital stay (LOS), postoperative complications and mortality rate were compared. Results 158 patients were enrolled: 58 in the CC, 33 in the MC, and 67 in the HC group. The HC group demonstrated reduced time to tolerate oral diet (8 vs 7 vs 3 days; p = 0.034), recovery of GI function (72 vs 96 vs 61 h; p = 0.001) and median LOS (12.5 vs 10 vs 6 days; p < 0.001). Postoperative overall (p = 0.08) and major complications (p = 0.09) were not significantly different. Non-surgical complications were lower in the HC group (31.0 % vs 54.5 % vs 25.4 %; p = 0.013). The 28-day readmission rate was not different (8.6 % vs 3.0 % vs 1.5 %; p = 0.14). The 30-day postoperative mortality was not different (0 % vs 3.1 % vs 0 %; p = 0.15), but the 6-month mortality rate was significantly lower in the HC group (13.8 % vs 15.2 % vs 0 %; p < 0.001). Conclusion The level of compliance with the ERAS protocol is associated with improved short-term postoperative outcome in UGI surgery. High compliance patients recovered faster, were discharged sooner, and had better 6-month survival.
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Affiliation(s)
- Thammawat Parakonthun
- Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
- Siriraj Upper GI Cancer Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Gritin Gonggetyai
- Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
- Division of Surgery, Nakhonpathom Hospital, Nakhon Pathom 73000, Thailand
| | - Chawisa Nampoolsuksan
- Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
- Siriraj Upper GI Cancer Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Tharathorn Suwatthanarak
- Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Thikhamporn Tawantanakorn
- Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Jirawat Swangsri
- Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
- Siriraj Upper GI Cancer Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Asada Methasate
- Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
- Siriraj Upper GI Cancer Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
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Wu Z, Ge X, Shi D. ERAS and Gastrointestinal Site Infections: Insights from a Comprehensive Systematic Review and Meta-Analysis. Surg Infect (Larchmt) 2024; 25:699-709. [PMID: 39172651 DOI: 10.1089/sur.2024.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2024] Open
Abstract
Background: Enhanced recovery after surgery (ERAS) protocols are proposed to enhance perioperative care, but their impact on various surgical outcomes requires further insight. Objective: This extensive meta-analysis aimed to systematically estimate the effectiveness of ERAS in reducing postoperative complications and improving recovery metrics. Materials and Methods: We meticulously searched multiple databases and rigorously screened studies, ultimately including 16 high-quality research articles in our meta-analysis. We carefully assessed heterogeneity using the Cochran Q test and I2 index. Results were visualized using forest plots, displaying effect sizes and 95% confidence intervals (CIs). Results: The current meta-analysis reveals compelling evidence of ERAS protocols' impact on postoperative effects. Lung infection rates were significantly reduced, with an odds ratio (OR) of 0.4393 (95% CI: 0.2674; 0.7216, p = 0.0012), highlighting the protocols' effectiveness. Although the reduction in surgical site infections (SSIs) was not significant, with an OR of 0.8003 (95% CI: 0.3908; 1.6389, p = 0.5425), the data suggests a trend toward benefit. Urinary tract infections (UTI) also showed a promising decrease, with an OR of 0.4754 (95% CI: 0.2028; 1.1143, p = 0.0871), revealing ERAS protocols may mitigate UTI risks. No significant effects were observed on postoperative anastomotic leakage or ileus, with ORs indicating neutrality. The incidence of readmission was similarly unaffected, with an OR of 1.4018 (95% CI: 0.6860; 2.8647, p = 0.3543). These outcomes underscore the selective efficacy of ERAS protocols, advocating for their strategic implementation to optimize surgical recovery. Conclusions: This meta-analysis offers compelling evidence supporting the implementation of ERAS in mitigating specific post-surgical conditions. It underscores the potential of ERAS to enhance recovery experiences and improve healthcare efficiency. Further targeted research is warranted to fully understand the impact of ERAS on SSI, anastomotic leakage, ileus, and readmissions and to optimize its benefits across diverse surgical populations.
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Affiliation(s)
- Zhiwei Wu
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang, China
| | - Xiaofang Ge
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang, China
| | - Dike Shi
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang, China
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Ueno K, Nishigori T, Tokoro Y, Nakakura A, Tsunoda S, Hisamori S, Hashimoto K, Kanaya S, Hirai K, Tanaka E, Hata H, Manaka D, Sakaguchi M, Kondo M, Kan T, Itami A, Miki A, Kawamura Y, Toda K, Okabe H, Yamamoto M, Yamashita Y, Kinjo Y, Kawada H, Obama K. The efficacy of simple oral nutritional supplements versus usual care in postoperative patients with gastric cancer: study protocol for a multicenter, open-label, parallel, randomized controlled trial. Trials 2024; 25:445. [PMID: 38961505 PMCID: PMC11223300 DOI: 10.1186/s13063-024-08169-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 05/09/2024] [Indexed: 07/05/2024] Open
Abstract
BACKGROUND Body weight loss (BWL) after gastrectomy impact on the short- and long-term outcomes. Oral nutritional supplement (ONS) has potential to prevent BWL in patients after gastrectomy. However, there is no consistent evidence supporting the beneficial effects of ONS on BWL, muscle strength and health-related quality of life (HRQoL). This study aimed to evaluate the effects of ONS formulated primarily with carbohydrate and protein on BWL, muscle strength, and HRQoL. METHODS This will be a multicenter, open-label, parallel, randomized controlled trial in patients with gastric cancer who will undergo gastrectomy. A total of 120 patients who will undergo gastrectomy will be randomly assigned to the ONS group or usual care (control) group in a 1:1 ratio. The stratification factors will be the clinical stage (I or ≥ II) and surgical procedures (total gastrectomy or other procedure). In the ONS group, the patients will receive 400 kcal (400 ml)/day of ONS from postoperative day 5 to 7, and the intervention will continue postoperatively for 8 weeks. The control group patients will be given a regular diet. The primary outcome will be the percentage of BWL (%BWL) from baseline to 8 weeks postoperatively. The secondary outcomes will be muscle strength (handgrip strength), HRQoL (EORTC QLQ-C30, QLQ-OG25, EQ-5D-5L), nutritional status (hemoglobin, lymphocyte count, albumin), and dietary intake. All analyses will be performed on an intention-to-treat basis. DISCUSSION This study will provide evidence showing whether or not ONS with simple nutritional ingredients can improve patient adherence and HRQoL by reducing BWL after gastrectomy. If supported by the study results, nutritional support with simple nutrients will be recommended to patients after gastrectomy for gastric cancer. TRIAL REGISTRATION jRCTs051230012; Japan Registry of Clinical Trails. Registered on Apr. 13, 2023.
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Affiliation(s)
- Kohei Ueno
- Department of Surgery, Kyoto University Hospital, 54 Shogoinkawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Tatsuto Nishigori
- Department of Surgery, Kyoto University Hospital, 54 Shogoinkawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan.
| | - Yukinari Tokoro
- Department of Surgery, Kyoto University Hospital, 54 Shogoinkawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Akiyoshi Nakakura
- Department of Biomedical Statistics and Bioinformatics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shigeru Tsunoda
- Department of Surgery, Kyoto University Hospital, 54 Shogoinkawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Shigeo Hisamori
- Department of Surgery, Kyoto University Hospital, 54 Shogoinkawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | | | | | - Kenjiro Hirai
- Department of Surgery, Japanese Red Cross Otsu Hospital, Shiga, Japan
| | - Eiji Tanaka
- Department of Surgery, The Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Hiroaki Hata
- Department of Surgery, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Dai Manaka
- Department of Surgery, Kyoto Katsura Hospital, Kyoto, Japan
| | | | - Masato Kondo
- Department of Surgery, Kobe City Medical Center, General Hospital, Hyogo, Japan
| | - Takatsugu Kan
- Department of Surgery, Kobe City Medical Center, West Hospital, Hyogo, Japan
| | - Atsushi Itami
- Department of Surgery, Kobe City Nishi-Kobe Medical Center, Hyogo, Japan
| | - Akira Miki
- Department of Surgery, Toyooka Hospital, Hyogo, Japan
| | | | - Kosuke Toda
- Department of Surgery, Shiga General Hospital, Shiga, Japan
| | - Hiroshi Okabe
- Department of Surgery, New Tokyo Hospital, Chiba, Japan
| | | | - Yoshito Yamashita
- Department of Surgery, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Yosuke Kinjo
- Department of Surgery, National Hospital Organization Himeji Medical Center, Hyogo, Japan
| | - Hironori Kawada
- Department of Surgery, Hyogo Prefectural Amagasaki General Medical Center, Hyogo, Japan
| | - Kazutaka Obama
- Department of Surgery, Kyoto University Hospital, 54 Shogoinkawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
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Sauro KM, Smith C, Ibadin S, Thomas A, Ganshorn H, Bakunda L, Bajgain B, Bisch SP, Nelson G. Enhanced Recovery After Surgery Guidelines and Hospital Length of Stay, Readmission, Complications, and Mortality: A Meta-Analysis of Randomized Clinical Trials. JAMA Netw Open 2024; 7:e2417310. [PMID: 38888922 PMCID: PMC11195621 DOI: 10.1001/jamanetworkopen.2024.17310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 04/17/2024] [Indexed: 06/20/2024] Open
Abstract
Importance A comprehensive review of the evidence exploring the outcomes of enhanced recovery after surgery (ERAS) guidelines has not been completed. Objective To evaluate if ERAS guidelines are associated with improved hospital length of stay, hospital readmission, complications, and mortality compared with usual surgical care, and to understand differences in estimates based on study and patient factors. Data Sources MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central were searched from inception until June 2021. Study Selection Titles, abstracts, and full-text articles were screened by 2 independent reviewers. Eligible studies were randomized clinical trials that examined ERAS-guided surgery compared with a control group and reported on at least 1 of the outcomes. Data Extraction and Synthesis Data were abstracted in duplicate using a standardized data abstraction form. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Risk of bias was assessed in duplicate using the Cochrane Risk of Bias tool. Random-effects meta-analysis was used to pool estimates for each outcome, and meta-regression identified sources of heterogeneity within each outcome. Main Outcome and Measures The primary outcomes were hospital length of stay, hospital readmission within 30 days of index discharge, 30-day postoperative complications, and 30-day postoperative mortality. Results Of the 12 047 references identified, 1493 full texts were screened for eligibility, 495 were included in the systematic review, and 74 RCTs with 9076 participants were included in the meta-analysis. Included studies presented data from 21 countries and 9 ERAS-guided surgical procedures with 15 (20.3%) having a low risk of bias. The mean (SD) Reporting on ERAS Compliance, Outcomes, and Elements Research checklist score was 13.5 (2.3). Hospital length of stay decreased by 1.88 days (95% CI, 0.95-2.81 days; I2 = 86.5%; P < .001) and the risk of complications decreased (risk ratio, 0.71; 95% CI, 0.59-0.87; I2 = 78.6%; P < .001) in the ERAS group. Risk of readmission and mortality were not significant. Conclusions and Relevance In this meta-analysis, ERAS guidelines were associated with decreased hospital length of stay and complications. Future studies should aim to improve implementation of ERAS and increase the reach of the guidelines.
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Affiliation(s)
- Khara M. Sauro
- Department of Community Health Sciences and O’Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Oncology and Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christine Smith
- Department of Community Health Sciences and O’Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Seremi Ibadin
- Department of Community Health Sciences and O’Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Abigail Thomas
- Department of Community Health Sciences and O’Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Heather Ganshorn
- Libraries and Cultural Resources, University of Calgary, Calgary, Alberta, Canada
| | - Linda Bakunda
- Department of Community Health Sciences and O’Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Bishnu Bajgain
- Department of Community Health Sciences and O’Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Steven P. Bisch
- Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Gregg Nelson
- Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Ariadne Labs, Brigham and Women’s Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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You K, Han H. Application of ERAS in older patients with gastric cancer. Medicine (Baltimore) 2024; 103:e38409. [PMID: 39259095 PMCID: PMC11142792 DOI: 10.1097/md.0000000000038409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 04/12/2024] [Accepted: 05/09/2024] [Indexed: 09/12/2024] Open
Abstract
BACKGROUND The purpose of this study was to investigate the effectiveness and feasibility of enhanced recovery after surgery (ERAS) in older gastric cancer (GC) patients by observing the changes in postoperative intestinal function recovery, nutritional indicators, and inflammatory markers following the surgery. METHODS A total of 61 older GC patients who underwent laparoscopic radical gastrectomy were selected as the subjects of this study. They were divided into an ERAS group (n = 28) and a conventional control group (n = 33) based on the different management modes during the perioperative period. General data, inflammatory response indicators, nutritional indicators, and perioperative indicators of the 2 groups were collected and compared. The changes in relevant indicators were analyzed, and the underlying reasons for these changes were explored. RESULTS There were no significant differences in general data and preoperative indicators between the 2 groups (P > .05). In the ERAS group, the inflammatory markers decreased more rapidly, and the nutritional indicators recovered more quickly after surgery. The differences between the 2 groups were statistically significant on the 5th and 7th postoperative days (P < .05). The ERAS group had significantly shorter postoperative hospital stay (10.07 ± 1.41 vs 13.04 ± 3.81), shorter time to first flatus (3.70 ± 0.72 vs 4.18 ± 1.17), shorter drainage tube retention time (8.96 ± 1.53 vs 10.93 ± 3.36), and shorter nasogastric tube retention time (3.36 ± 1.72 vs 6.14 ± 3.99) compared to the control group (P < .05). CONCLUSION The application of the ERAS program in older GC patients is effective and feasible, and significantly contributes to faster postoperative recovery in older patients.
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Affiliation(s)
- Kuanxuan You
- Department of Gastrointestinal Surgery, Affiliated Hospital of Jiangsu University, Zhenjiang, Jiangsu Province, China
| | - He Han
- Department of Gastrointestinal Surgery, Affiliated Hospital of Jiangsu University, Zhenjiang, Jiangsu Province, China
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Li ZW, Luo XJ, Liu F, Liu XR, Shu XP, Tong Y, Lv Q, Liu XY, Zhang W, Peng D. Is recovery enhancement after gastric cancer surgery really a safe approach for elderly patients? World J Gastrointest Oncol 2024; 16:1334-1343. [PMID: 38660659 PMCID: PMC11037074 DOI: 10.4251/wjgo.v16.i4.1334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/15/2024] [Accepted: 02/20/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND This study aimed to evaluate the safety of enhanced recovery after surgery (ERAS) in elderly patients with gastric cancer (GC). AIM To evaluate the safety of ERAS in elderly patients with GC. METHODS The PubMed, EMBASE, and Cochrane Library databases were used to search for eligible studies from inception to April 1, 2023. The mean difference (MD), odds ratio (OR) and 95% confidence interval (95%CI) were pooled for analysis. The quality of the included studies was evaluated using the Newcastle-Ottawa Scale scores. We used Stata (V.16.0) software for data analysis. RESULTS This study consists of six studies involving 878 elderly patients. By analyzing the clinical outcomes, we found that the ERAS group had shorter postoperative hospital stays (MD = -0.51, I2 = 0.00%, 95%CI = -0.72 to -0.30, P = 0.00); earlier times to first flatus (defecation; MD = -0.30, I² = 0.00%, 95%CI = -0.55 to -0.06, P = 0.02); less intestinal obstruction (OR = 3.24, I2 = 0.00%, 95%CI = 1.07 to 9.78, P = 0.04); less nausea and vomiting (OR = 4.07, I2 = 0.00%, 95%CI = 1.29 to 12.84, P = 0.02); and less gastric retention (OR = 5.69, I2 = 2.46%, 95%CI = 2.00 to 16.20, P = 0.00). Our results showed that the conventional group had a greater mortality rate than the ERAS group (OR = 0.24, I2 = 0.00%, 95%CI = 0.07 to 0.84, P = 0.03). However, there was no statistically significant difference in major complications between the ERAS group and the conventional group (OR = 0.67, I2 = 0.00%, 95%CI = 0.38 to 1.18, P = 0.16). CONCLUSION Compared to those with conventional recovery, elderly GC patients who received the ERAS protocol after surgery had a lower risk of mortality.
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Affiliation(s)
- Zi-Wei Li
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Xiao-Juan Luo
- Department of Endoscopy Center, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400012, China
| | - Fei Liu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Xu-Rui Liu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Xin-Peng Shu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Yue Tong
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Quan Lv
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Xiao-Yu Liu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Wei Zhang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Dong Peng
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
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Hao Y, Zhao Q, Jiang K, Feng X, Ma Y, Zhang J, Han X, Ji G, Dong H, Nie H. Association of adherence to the enhanced recovery after surgery pathway and outcomes after laparoscopic total gastrectomy. BMC Anesthesiol 2024; 24:110. [PMID: 38519945 PMCID: PMC10958831 DOI: 10.1186/s12871-024-02433-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 01/26/2024] [Indexed: 03/25/2024] Open
Abstract
OBJECTIVE The current study used a composite outcome to investigate whether applying the ERAS protocol would enhance the recovery of patients undergoing laparoscopic total gastrectomy (LTG). EXPOSURES Laparoscopic total gastrectomy and perioperative interventions were the exposure. An ERAS clinical pathway consisting of 14 items was implemented and assessed. Patients were divided into either ERAS-compliant or non-ERAS-compliant group according the adherence above 9/14 or not. MAIN OUTCOMES AND MEASURES The primary study outcome was a composite outcome called 'optimal postoperative recovery' with the definition as below: discharge within 6 days with no sever complications and no unplanned re-operation or readmission within 30 days postoperatively. Univariate logistic regression analysis and multivariate logistic regression analysis were used to model optimal postoperative recovery and compliance, adjusting for patient-related and disease-related characteristics. RESULTS A total of 252 patients were included in this retrospective study, 129 in the ERAS compliant group and 123 in the non-ERAS-compliant group. Of these, 79.07% of the patients in ERAS compliant group achieved optimal postoperative recovery, whereas 61.79% of patients in non-ERAS-compliant group did (P = 0.0026). The incidence of sever complications was lower in the ERAS-compliant group (1.55% vs. 6.5%, P = 0.0441). No patients in ERAS compliant group had unplanned re-operation, whereas 5.69% (7/123) of patients in non-ERAS-compliant group had (p = 0.006). The median length of the postoperative hospital stay was shorter in the in the ERAS compliant group (5.51 vs. 5.68 days, P = 0.01). Both logistic (OR 2.01, 95% CI 1.21-3.34) and stepwise regression (OR 2.07, 95% CI 1.25-3.41) analysis showed that high overall compliance with the ERAS protocol facilitated optimal recovery in such patients. In bivariate analysis of compliance for patients who had an optimal postoperative recovery, carbohydrate drinks (p = 0.0196), early oral feeding (P = 0.0043), early mobilization (P = 0.0340), and restrictive intravenous fluid administration (P < 0.0001) were significantly associated with optimal postoperative recovery. CONCLUSIONS AND RELEVANCE Patients with higher ERAS compliance (almost 70% of the accomplishment) suffered less severe postoperative complications and were more likely to achieve optimal postoperative recovery.
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Affiliation(s)
- Yiming Hao
- Department of Gastrointestinal Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Qingchuan Zhao
- Department of Gastrointestinal Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Kun Jiang
- Department of Digital Center, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Xiangying Feng
- Department of Gastrointestinal Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Yumei Ma
- Department of Anesthesiology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | | | - Xi'an Han
- The Unimed Scientific Inc, Wu Xi, China
| | - Gang Ji
- Department of Gastrointestinal Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Hailong Dong
- Department of Anesthesiology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Huang Nie
- Department of Anesthesiology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
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11
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Fan X, Xu Y, Wan R, Zhang L, Han H, Chen J. A clinical study on gastric cancer patients administered EN and PN versus PN alone in enhanced recovery after surgery. Ann Med Surg (Lond) 2024; 86:1433-1440. [PMID: 38463057 PMCID: PMC10923272 DOI: 10.1097/ms9.0000000000001753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 12/28/2023] [Indexed: 03/12/2024] Open
Abstract
Background and objectives Enhanced recovery after surgery (ERAS) recommends avoiding enteral nutrition (EN) due to undesirable sequelae such as pulmonary aspiration and infections. Not using of EN in nongastric resections under ERAS pathways is often successful. However, parenteral nutrition (PN) alone followed by early postoperative oral feeding in gastric cancer patients, recommended by the ERAS guidelines, has unclear benefit and is only adopted after gastric resection. This study aimed to compute the postoperative outcomes of EN and PN compared to those of the ERAS-recommended nutritional pathway. Our secondary objective was to compare postoperative complications between the two groups. Materials and methods Of 173 gastrectomy patients, 116 patients were in the combined group (EN and PN), whereas 57 patients were in the PN alone group. Statistical analysis was performed with the Statistical Package for the Social Sciences (SPSS) version 26.0.0 software. The data were analyzed by one-way ANOVA, the independent sample t-test, or, in the case of several independent samples, by the Kruskal-Wallis test. Categorical data were analyzed by Pearson's χ2 test or Fisher's exact test. Results The observed indices included C-reactive protein (CRP), platelet (PLT), white blood cells (WBC), hemoglobin (Hb), albumin, and PRE-albumin. The secondary outcomes included length of hospital stay (LOS), cost, incidence of pulmonary infection, and total incidence of infection. Conclusion The combined mode of nutrition is feasible and is not associated with postoperative complications in gastric cancer patients under ERAS.
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Affiliation(s)
| | | | | | | | | | - Jixiang Chen
- Department of Gastrointestinal Surgery, Affiliated Hospital of Jiangsu University, Zhenjiang, People’s Republic of China
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12
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Yoshikawa K, Shimada M, Tokunaga T, Nakao T, Nishi M, Takasu C, Kashihara H, Wada Y, Yoshimoto T. The application of enhanced recovery after surgery in total gastrectomy: a propensity score-matched analysis. World J Surg Oncol 2023; 21:148. [PMID: 37194033 DOI: 10.1186/s12957-023-03034-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/11/2023] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND This study aimed to investigate the feasibility and safety of our enhanced recovery after surgery protocol including early oral intake and omitting nasogastric tube (NGT) placement after total gastrectomy. METHODS We analyzed 182 consecutive patients who underwent total gastrectomy. The clinical pathway was changed in 2015, and patients were divided into 2 groups (conventional group and modified group). Postoperative complications, bowel movement, and postoperative hospital stays were compared in the two groups in all cases and propensity score matching (PSM). RESULTS Flatus and defecation were significantly earlier in the modified group compared with those in the conventional group (flatus: 2 (1-5) days vs 3 (2-12) days, p = 0.03; defecation: 4 (1-14) days vs 6 (2-12) days p = 0.04). The postoperative hospital stay was 18 (6-90) days in the conventional group and 14 (7-74) days in the modified group (p = 0.009). Days until discharge criteria were met were earlier in the modified group compared with that in the conventional group (10 (7-69) days vs 14 (6-84) days p = 0.01). Overall and severe complications occurred in nine patients (12.6%) and three patients (4.2%) in the conventional group and twelve patients (10.8%) and four patients (3.6%) in the modified group, respectively (p = 0.70 and p = 0.83) in all cases. In PSM, there is no significant difference between the two groups concerning the postoperative complications (overall complication 6 (12.5%) vs 8 (16.7%) p = 0.56, severe complications 1 (2%) vs 2 (4.2%) p = 0.83). CONCLUSIONS Modified ERAS for total gastrectomy may be feasible and safe.
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Affiliation(s)
- Kozo Yoshikawa
- The Department of Surgery, The University of Tokushima, 3-18-15, Kuramoto-Cho, Tokushima, 770-8503, Japan.
| | - Mitsuo Shimada
- The Department of Surgery, The University of Tokushima, 3-18-15, Kuramoto-Cho, Tokushima, 770-8503, Japan
| | - Takuya Tokunaga
- The Department of Surgery, The University of Tokushima, 3-18-15, Kuramoto-Cho, Tokushima, 770-8503, Japan
| | - Toshihiro Nakao
- The Department of Surgery, The University of Tokushima, 3-18-15, Kuramoto-Cho, Tokushima, 770-8503, Japan
| | - Masaaki Nishi
- The Department of Surgery, The University of Tokushima, 3-18-15, Kuramoto-Cho, Tokushima, 770-8503, Japan
| | - Chie Takasu
- The Department of Surgery, The University of Tokushima, 3-18-15, Kuramoto-Cho, Tokushima, 770-8503, Japan
| | - Hideya Kashihara
- The Department of Surgery, The University of Tokushima, 3-18-15, Kuramoto-Cho, Tokushima, 770-8503, Japan
| | - Yuma Wada
- The Department of Surgery, The University of Tokushima, 3-18-15, Kuramoto-Cho, Tokushima, 770-8503, Japan
| | - Toshiaki Yoshimoto
- The Department of Surgery, The University of Tokushima, 3-18-15, Kuramoto-Cho, Tokushima, 770-8503, Japan
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Feng JY, Wang SF, Yan J. The Application of Enhanced Recovery After Surgery for Gastrectomy and Colorectal Resection: A Systematic Review and Meta-Analysis. J Laparoendosc Adv Surg Tech A 2023. [PMID: 37130316 DOI: 10.1089/lap.2023.0036] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023] Open
Abstract
Purpose: Enhanced recovery after surgery (ERAS) protocols not only positively affect gastrointestinal surgery outcomes but may also increase the risk of some complications. This meta-analysis was conducted to assess the impact of ERAS on the recovery and complications following gastrointestinal surgery. Materials and Methods: Studies published before December 2022 were retrieved from the following databases, EMBASE, PubMed, Cochrane Library, and Web of Science, without limitations of language or race. The endpoints included lung infection, surgical site infection, postoperative ileus, length of hospitalization, urinary tract infection, readmission, anastomotic leakage, and C-reactive protein serum levels. Results: A total of 23 studies were included. The results of the meta-analysis revealed that there was a decrease in incidence of the lung infection (risk ratio = 0.46, 95% confidence interval 0.27-0.74, P = .002) and postoperative length of hospitalization (P < .00001). However, ERAS protocol groups had higher readmission rates, nausea, and vomiting. There was no significant difference in the incidence of anastomotic leakage, ileus, surgical site infection, and urinary tract infection between the experimental and control groups. Conclusions: ERAS protocols can reduce the risk of postoperative lung infections, shorten hospital stays, and expedite patient recovery. Furthermore, ERAS protocols are not associated with serious complications following gastrointestinal surgeries.
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Affiliation(s)
- Jia-Ying Feng
- Department of Medicine, Yangtze University, Jingzhou, China
| | - Su-Fei Wang
- Gynaecology and Obstetrics, Jingzhou No. 1 People's Hospital and First Affiliated Hospital of Yangtze University, Jingzhou, China
| | - Jing Yan
- Department of Medicine, Yangtze University, Jingzhou, China
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Abstract
The sixth edition of the Japanese Gastric Cancer Treatment Guidelines was completed in July 2021, incorporating new evidence that emerged after publication of the previous edition. It consists of a text-based "Treatments" part and a "Clinical Questions" part including recommendations and explanations for clinical questions. The treatments parts include a comprehensive description regarding surgery, endoscopic resection and chemotherapy for gastric cancer. The clinical question part is based on the literature search and evaluation by an independent systematic review team. Consequently, not only evidence for each therapeutic recommendation was clearly shown, but it also identified the research fields that require further evaluation to provide appropriate recommendations.
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15
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Romario UF, Ascari F, De Pascale S. Implementation of the ERAS program in gastric surgery: a nationwide survey in Italy. Updates Surg 2023; 75:141-148. [PMID: 36307670 PMCID: PMC9616397 DOI: 10.1007/s13304-022-01400-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 10/04/2022] [Indexed: 01/14/2023]
Abstract
Enhanced recovery after surgery (ERAS) programs have been developed by combining several evidence-based techniques for perioperative care, with the intention of reducing the stress response and organ dysfunction, thus allowing improved clinical results. ERAS programs have been widely adopted for colorectal surgery; however, their adoption for upper gastrointestinal surgery has been challenging even though good results have been reported in the literature. Our intent was to investigate the adoption of ERAS programs for resective gastric surgery in Italy. A survey was conducted among 20 departments of surgery belonging to the Italian Group for Research on Gastric Cancer (GC). Analysis of our survey showed that several evidence-based practices and many items of the ERAS guidelines for gastric surgery are not implemented in real practice in Italian centers dedicated to GC. This situation may be related to the hesitation of surgeons to introduce radical changes to the traditional postoperative management after gastrectomy. A multidisciplinary approach to the perioperative care of these patients is not routinely applied in many Italian centers. A strict collaboration of all clinicians involved in the perioperative care of patients undergoing gastrectomy for GC is key for the future implementation of ERAS in gastric surgery in our departments.
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Affiliation(s)
| | - Filippo Ascari
- Digestive Surgery, European Institute of Oncology, IRCCS, Via Ripamonti 435, Milan, Italy
| | - Stefano De Pascale
- Digestive Surgery, European Institute of Oncology, IRCCS, Via Ripamonti 435, Milan, Italy.
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Enhanced Recovery Protocols Reduce Mortality Across Eight Surgical Specialties at Academic and University-affiliated Community Hospitals. Ann Surg 2023; 277:101-108. [PMID: 33214486 DOI: 10.1097/sla.0000000000004642] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine if implementation of a simplified ERP across multiple surgical specialties in different hospitals is associated with improved short and long-term mortality. Secondary aims were to examine ERP effect on length of stay, 30-day readmission, discharge disposition, and complications. SUMMARY BACKGROUND DATA Enhanced recovery after surgery and various derivative ERPs have been successfully implemented. These protocols typically include elaborate sets of multimodal and multidisciplinary approaches, which can make implementation challenging or are variable across different specialties. Few studies have shown if a simplified version of ERP implemented across multiple surgical specialties can improve clinical outcomes. METHODS A simplified ERP with 7 key domains (minimally invasive surgical approach when feasible, pre-/intra-operative multimodal analgesia, postoperative multimodal analgesia, postoperative nausea and vomiting prophylaxis, early diet advancement, early ambulation, and early removal of urinary catheter) was implemented in 5 academic and community hospitals within a single health system. Patients who underwent nonemergent, major orthopedic or abdominal surgery including hip/knee replacement, hepatobiliary, colorectal, gynecology oncology, bariatric, general, and urological surgery were included. Propensity-matched, retrospective case-control analysis was performed on all eligible surgical patients between 2014 and 2017 after ERP implementation or in the 12 months preceding ERP implementation (control population). RESULTS A total of 9492 patients (5185 ERP and 4307 controls) underwent ERP eligible surgery during the study period. Three thousand three hundred sixty-seven ERP patients were matched by surgical specialty and hospital site to control non-ERP patients. Short and long-term mortality was improved in ERP patients: 30 day: ERP 0.2% versus control 0.6% ( P = 0.002); 1-year: ERP 3.9% versus control 5.1% ( P < 0.0001); 2-year: ERP 6.2% versus control 9.0% ( P < 0.0001). Length of stay was significantly lower in ERP patients (ERP: 3.9 ± 3.8 days; control: 4.8 ± 5.0 days, P < 0.0001). ERP patients were also less likely to be discharged to a facility (ERP: 11.3%; control: 14.8%, P < 0.0001). There was no significant difference for 30-day readmission. All complications except venous thromboembolism were significantly reduced in the ERP population (P < 0.02). CONCLUSIONS A simplified ERP can uniformly be implemented across multiple surgical specialties and hospital types. ERPs improve short and long-term mortality, clinical outcomes, length of stay, and discharge disposition to home.
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17
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Imai Y, Tanaka R, Honda K, Matsuo K, Taniguchi K, Asakuma M, Lee SW. The usefulness of presepsin in the diagnosis of postoperative infectious complications after gastrectomy for gastric cancer: a prospective cohort study. Sci Rep 2022; 12:21289. [PMID: 36494434 PMCID: PMC9734175 DOI: 10.1038/s41598-022-24780-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 11/21/2022] [Indexed: 12/13/2022] Open
Abstract
This prospective study aimed to evaluate presepsin use as a biomarker of on postoperative infectious complications after gastrectomy, compared to C-reactive protein (CRP), white blood cells (WBCs), and neutrophils (Neuts). Overall, 108 patients were enrolled between October 2019 and December 2020. Presepsin, CRP, WBC, and Neut levels were measured preoperatively and on postoperative days (PODs) 1, 3, 5, and 7, using a postoperative morbidity survey. Grade II or higher infectious complications occurred in 18 patients (16.6%). Presepsin levels on all evaluated PODs were significantly higher in the infectious complication group than in the non-complication group (p = 0.002, p < 0.0001, p < 0.0001, and p = 0.025, respectively). The area under the curve (AUC) values were the highest for presepsin on PODs 3 and 7 (0.89 and 0.77, respectively) and similar to that of CRP, with a high value > 0.8 (0.86) on POD 5. For presepsin, the optimal cut-off values were 298 pg/mL (sensitivity, 83.3%; specificity, 83.3%), 278 pg/mL (sensitivity, 83.3%; specificity, 82.2%), and 300 pg/mL (sensitivity, 83.3%; specificity, 82%) on PODs 3, 5, and 7, respectively. Presepsin levels on PODs 3, 5, and 7 after gastrectomy is a more useful biomarker of postoperative infectious complications compared to CRP, WBCs, and Neuts, with a high sensitivity and specificity.
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Affiliation(s)
- Yoshiro Imai
- Departments of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-Machi, Takatsuki, Osaka, 569-8686, Japan.
| | - Ryo Tanaka
- Departments of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-Machi, Takatsuki, Osaka, 569-8686, Japan
| | - Kotaro Honda
- Departments of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-Machi, Takatsuki, Osaka, 569-8686, Japan
| | - Kentaro Matsuo
- Departments of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-Machi, Takatsuki, Osaka, 569-8686, Japan
| | - Kohei Taniguchi
- Department of Translational Research Program, Faculty of Medicine, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-Machi, Takatsuki, Osaka, 569-8686, Japan
| | - Mitsuhiro Asakuma
- Departments of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-Machi, Takatsuki, Osaka, 569-8686, Japan
| | - Sang-Woong Lee
- Departments of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-Machi, Takatsuki, Osaka, 569-8686, Japan
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Düzgün Ö, Özcan P, Özçelik MF. Did the ERAS Protocol Improve Our Results in Locally Advanced Gastric Cancer Surgery? J Pers Med 2022; 12:1549. [PMID: 36294688 PMCID: PMC9605348 DOI: 10.3390/jpm12101549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 09/14/2022] [Accepted: 09/16/2022] [Indexed: 08/10/2023] Open
Abstract
ERAS is a protocol consisting of multidisciplinary approaches, including patient education, fluid resuscitation, keeping patients' innormothermic state, early feeding, and mobilization. We aimed to present and compare the postoperative results of patients operated on due to locally advanced gastric cancer who received neoadjuvant therapy in two high-volume tertiary centers, and aimed to present that ERAS protocols can be applied with success without increasing the complication rate. This retrospective study consisted of two groups: a non-ERAS group and an ERAS group. The ERAS group consisted of 106 patients and the non-ERAS group consisted of 104 patients. The time to first flatus was shorter in the ERAS group compared with the non-ERAS group: 2.8 (1-5) and 3.5 (1-5, p = 0.008), respectively. The average stay at the hospital was 9 (7-22) days in thenon-ERAS group and 6.5 (5-14) days in the ERAS group. Readmission to the hospital within first 15 days after discharge was observed in one (%0.9) patient in the non-ERAS group and in four (%3.8) patients in the ERAS group. ERAS protocols contribute positively to the nutritional status of patients by reducing surgical stress and the rate of hospitalization, and reducing health costs. However, it appears to be associated with increased readmission rates.
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Affiliation(s)
- Özgül Düzgün
- Department of Surgical Oncology, İstanbul Umraniye Training and Research Hospital, University of Health Sciences, Istanbul 34766, Turkey
| | - Pırıltı Özcan
- Department of General Surgery, Cerrahpaşa Faculty of Medicine, İstanbul University, Istanbul 34098, Turkey
| | - Mehmet Faik Özçelik
- Department of General Surgery, Cerrahpaşa Faculty of Medicine, İstanbul University, Istanbul 34098, Turkey
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Lee B, Han HS. Tackling Surgical Morbidity and Mortality through Modifiable Risk Factors in Cancer Patients. Nutrients 2022; 14:3107. [PMID: 35956284 PMCID: PMC9370480 DOI: 10.3390/nu14153107] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 07/25/2022] [Accepted: 07/27/2022] [Indexed: 11/16/2022] Open
Abstract
Despite advances in surgical techniques, surgical morbidity and mortality remain important public health problems. Postoperative complications often lead to greater morbidity and mortality, as well as increased length of hospital stay and medical costs. Therefore, a reduction in postoperative complications is particularly important with regard to positive long-term outcomes in patients with cancer. To improve patients' postoperative prognosis, it is necessary to screen for and focus on modifiable risk factors and their subsequent resolution. Recently, it was reported that nutritional status, inflammation and surgical approaches are related to postoperative morbidity and mortality. Therefore, in this review article, we describe the current evidence regarding modifiable risk factors influencing surgical morbidity and mortality as well as future directions for improved postoperative management in cancer patients.
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Affiliation(s)
| | - Ho-Seong Han
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul 13620, Korea;
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20
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Sang G, Zhang X, Fan H, Ao X, Chen Y, Shi Q. Implementation of an enhanced recovery after surgery program in the treatment of uterine fibroids with focused ultrasound ablation surgery. Int J Hyperthermia 2022; 39:414-420. [PMID: 35236194 DOI: 10.1080/02656736.2022.2037740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) can reduce the length of hospital stay, incidence of surgery-related complications, and postoperative pain. We aimed to demonstrate the implementation of an ERAS pathway in the treatment of uterine fibroids with focused ultrasound ablation surgery (FUAS). MATERIALS AND METHODS A retrospective data analysis was performed on clinical outcomes encompassing the following three phases: before ERAS (pre-ERAS), during adjustment of ERAS (interim-ERAS), and after the introduction of an ERAS program (post-ERAS). The purpose of describing the interim-ERAS was to provide references for the formulation of the program during the course of FUAS by describing the adjustment processes. Data from patients admitted to the hospital from September 2019 to December 2019 and April 2020 to November 2020 and who met the criteria for FUAS in the treatment of their uterine fibroids were examined. Length of stay, cost of surgery, postoperative pain score, utilization of postoperative analgesics, and incidence of postoperative adverse events were compared across the abovementioned three phases. RESULTS Compared with the pre-phase, the cost of treatment and length of stay were reduced after the implementation of ERAS. The use of analgesics before leaving the operating room, as well as the incidence of postoperative nausea and vomiting, were also reduced. CONCLUSION The implementation of an ERAS protocol might benefit patients with uterine fibroids treated with FUAS in terms of requiring a shorter hospitalization period, lower costs, and reduced opioid use.
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Affiliation(s)
- Guowei Sang
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China
| | - Xin Zhang
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China
| | | | - Xing Ao
- HAIFU Hospital, Chongqing, China
| | | | - Qiuling Shi
- State Key Laboratory of Ultrasound in Medicine and Engineering, School of Public Health and Management, Chongqing Medical University, Chongqing, China
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Rosa F, Longo F, Pozzo C, Strippoli A, Quero G, Fiorillo C, Mele MC, Alfieri S. Enhanced recovery after surgery (ERAS) versus standard recovery for gastric cancer patients: The evidences and the issues. Surg Oncol 2022; 41:101727. [PMID: 35189515 DOI: 10.1016/j.suronc.2022.101727] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 01/25/2022] [Accepted: 02/13/2022] [Indexed: 12/24/2022]
Abstract
The significant advances that have been reached, in the last decades, in the treatment of gastric cancer, contributed to the concept of enhanced recovery after surgery (ERAS) with the aim to reduce the surgical stress, accelerate postoperative recovery, and reduce the length of hospital stay. The most important items included in the ERAS protocols are the pre-operative patient education, early mobilization and immediate oral intake from the first postoperative day. The aim of this narrative review is to focus the attention on the possible advantages of ERAS program on perioperative functional recovery outcomes after gastrectomy for gastric cancer.
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Affiliation(s)
- Fausto Rosa
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Fabio Longo
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Carmelo Pozzo
- Oncology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Antonia Strippoli
- Oncology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giuseppe Quero
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Claudio Fiorillo
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Maria Cristina Mele
- Nutrition in Oncology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Sergio Alfieri
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
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22
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Li CQ, Zhang C, Yu F, Li XY, Wang DX. The composite risk index based on frailty predicts postoperative complications in older patients recovering from elective digestive tract surgery: a retrospective cohort study. BMC Anesthesiol 2022; 22:7. [PMID: 34979937 PMCID: PMC8722296 DOI: 10.1186/s12871-021-01549-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 12/17/2021] [Indexed: 12/21/2022] Open
Abstract
Background Limitations exist in available studies investigating effect of preoperative frailty on postoperative outcomes. This study was designed to analyze the association between composite risk index, an accumulation of preoperative frailty deficits, and the risk of postoperative complications in older patients recovering from elective digestive tract surgery. Methods This was a retrospective cohort study. Baseline and perioperative data of older patients (age ≥ 65 years) who underwent elective digestive tract surgery from January 1, 2017 to December 31, 2018 were collected. The severity of frailty was assessed with the composite risk index, a composite of frailty deficits including modified frailty index. The primary endpoint was the occurrence of postoperative complications during hospital stay. The association between the composite risk index and the risk of postoperative complications was assessed with a multivariable logistic regression model. Results A total of 923 patients were included. Of these, 27.8% (257) developed postoperative complications. Four frailty deficits, i.e., modified frailty index ≥0.27, malnutrition, hemoglobin < 90 g/L, and albumin ≤30 g/L, were combined to generate a composite risk index. Multivariable analysis showed that, when compared with patients with composite risk index of 0, the odds ratios (95% confidence intervals) were 2.408 (1.714–3.383, P < 0.001) for those with a composite risk index of 1, 3.235 (1.985–5.272, P < 0.001) for those with a composite risk index of 2, and 9.227 (3.568–23.86, P < 0.001) for those with composite risk index of 3 or above. The area under receiver-operator characteristic curve to predict postoperative complications was 0.653 (95% confidence interval 0.613–0.694, P < 0.001) for composite risk index compared with 0.622 (0.581–0.663, P < 0.001) for modified frailty index. Conclusion For older patients following elective digestive tract surgery, high preoperative composite risk index, a combination of frailty deficits, was independently associated with an increased risk of postoperative complications. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-021-01549-6.
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Affiliation(s)
- Chun-Qing Li
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, No. 8, Xishiku Street, Beijing, 100034, China
| | - Chen Zhang
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, No. 8, Xishiku Street, Beijing, 100034, China
| | - Fan Yu
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, No. 8, Xishiku Street, Beijing, 100034, China
| | - Xue-Ying Li
- Department of Biostatistics, Peking University First Hospital, Beijing, China
| | - Dong-Xin Wang
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, No. 8, Xishiku Street, Beijing, 100034, China. .,Outcomes Research Consortium, Cleveland, OH, USA.
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23
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Baxter MA, Marinho J, Soto-Perez-de-Celis E, Rodriquenz MG, Arora SP, Lok WCW, Shih YY, Liposits G, O'Hanlon S, Petty RD. Gastroesophageal adenocarcinoma in older adults: A comprehensive narrative review of management by the Young International Society of Geriatric Oncology. J Geriatr Oncol 2022; 13:7-19. [PMID: 34548259 DOI: 10.1016/j.jgo.2021.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 08/26/2021] [Accepted: 09/07/2021] [Indexed: 12/24/2022]
Abstract
Gastroesophageal adenocarcinoma is a disease of older adults with very poor survival rates. Its incidence has risen dramatically across the world in recent decades. Current treatment approaches for older adults are based largely on extrapolated evidence from clinical trials conducted in younger and fitter participants than those more commonly encountered in clinical practice. Understanding how to apply available evidence to our patients in the clinic setting is essential given the high morbidity of both curative and palliative treatment. This review aims to use available data to inform the management of an older adult with gastroesophageal adenocarcinoma.
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Affiliation(s)
- Mark A Baxter
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK; Tayside Cancer Centre, Ninewells Hospital, Dundee, UK.
| | - Joana Marinho
- Department of Medical Oncology, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal; Associação de Investigação de Cuidados de Suporte em Oncologia (AICSO), Espinho, Portugal
| | - Enrique Soto-Perez-de-Celis
- Department of Geriatrics, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
| | - Maria Grazia Rodriquenz
- Oncology Unit, Foundation IRCCS, Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Sukeshi Patel Arora
- Mays Cancer Center, University of Texas Health San Antonio, Leader in Gastrointestinal Malignancies, 7979 Wurzbach Rd, 78229 San Antonio, TX, USA
| | - Wendy Chan Wing Lok
- Department of Clinical Oncology, LKS Faculty of Medicine, University of Hong Kong, China
| | - Yung-Yu Shih
- Department of Hematology and Oncology, Kaiser Franz Josef Hospital-Clinic Favoriten, Vienna, Austria
| | - Gabor Liposits
- Department of Oncology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark; Academy of Geriatric Cancer Research (AgeCare), Odense, Denmark
| | - Shane O'Hanlon
- Department of Geriatric Medicine, St Vincent's University Hospital, Dublin, Ireland; University College, Dublin, Ireland
| | - Russell D Petty
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK; Tayside Cancer Centre, Ninewells Hospital, Dundee, UK
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24
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Tian Y, Cao S, Liu X, Li L, He Q, Jiang L, Wang X, Chu X, Wang H, Xia L, Ding Y, Mao W, Hui X, Shi Y, Zhang H, Niu Z, Li Z, Jiang H, Kehlet H, Zhou Y. Randomized Controlled Trial Comparing the Short-term Outcomes of Enhanced Recovery After Surgery and Conventional Care in Laparoscopic Distal Gastrectomy (GISSG1901). Ann Surg 2022; 275:e15-e21. [PMID: 33856385 PMCID: PMC8683257 DOI: 10.1097/sla.0000000000004908] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE This study aimed to compare the effects of ERAS and conventional programs on short-term outcomes after LDG. SUMMARY OF BACKGROUND DATA Currently, the ERAS program is broadly applied in surgical areas. Although several benefits of LDG with the ERAS program have been covered, high-level evidence is still limited, specifically in advanced gastric cancer. METHODS The present study was designed as a randomized, multicenter, unblinded trial. The enrollment criteria included histologically confirmed cT2-4aN0-3M0 gastric adenocarcinoma. Postoperative complications, mortality, readmission, medical costs, recovery, and laboratory outcomes were compared between the ERAS and conventional groups. RESULTS Between April 2019 and May 2020, 400 consecutive patients who met the enrollment criteria were enrolled. They were randomly allocated to either the ERAS group (n = 200) or the conventional group (n = 200). After excluding patients who did not undergo surgery or gastrectomy, 370 patients were analyzed. The patient demographic characteristics were not different between the 2 groups. The conventional group had a significantly longer allowed day of discharge and postoperative hospital stay (6.96 vs 5.83 days, P < 0.001; 8.85 vs 7.27 days, P < 0.001); a longer time to first flatus, liquid intake and ambulation (3.37 vs 2.52 days, P < 0.001; 3.09 vs 1.13 days, P < 0.001; 2.85 vs 1.38 days, P < 0.001, respectively); and higher medical costs (6826 vs 6328 $, P = 0.027) than the ERAS group. Additionally, patients in the ERAS group were more likely to initiate adjuvant chemotherapy earlier (29 vs 32 days, P = 0.035). There was no significant difference in postoperative complications or in the mortality or readmission rates. Regarding laboratory outcomes, the procalcitonin and C-reactive protein levels on postoperative day 3 were significantly lower and the hemoglobin levels on postoperative day 5 were significantly higher in the ERAS group than in the conventional group. CONCLUSION The ERAS program provides a faster recovery, a shorter postoperative hospitalization length, and lower medical costs after LDG without increasing complication and readmission rates. Moreover, enhanced recovery in the ERAS group enables early initiation of adjuvant chemotherapy.
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Affiliation(s)
- Yulong Tian
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Shougen Cao
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xiaodong Liu
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Leping Li
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital, Jinan, China
| | - Qingsi He
- Department of Gastrointestinal Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Lixin Jiang
- Department of Gastrointestinal Surgery, Yantai Yuhuangding Hospital, Yantai, China
| | - Xinjian Wang
- Department of Gastrointestinal Surgery, Weihai Central Hospital, Weihai, China
| | - Xianqun Chu
- Department of Gastrointestinal Surgery, Jining People's Hospital, Jining, China
| | - Hao Wang
- Department of Gastrointestinal Surgery, Dongying People's Hospital, Dongying, China
| | - Lijian Xia
- Department of Gastrointestinal Surgery, Qianfoshan Hospital of Shandong Province, Jinan, China
| | - Yinlu Ding
- Department of Gastrointestinal Surgery, Second Hospital of Shandong University, Jinan, China
| | - Weizheng Mao
- Department of Gastrointestinal Surgery, Qingdao Municipal Hospital, Qingdao, China
| | - Xizeng Hui
- Department of Gastrointestinal Surgery, Rizhao People's Hospital, Rizhao, China
| | - Yiran Shi
- Department of Oncological Surgery, Weifang People's Hospital, Weifang, China
| | - Huanhu Zhang
- Department of Gastrointestinal Surgery, Weihai Municipal Hospital, Weihai, China
| | - Zhaojian Niu
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Zequn Li
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Haitao Jiang
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Henrik Kehlet
- Section of Surgical Pathophysiology 7621, Rigshospitalet Copenhagen University, Copenhagen, Denmark
| | - Yanbing Zhou
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
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25
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Imai Y, Lee SW, Kawai M, Tashiro K, Kawashima S, Tanaka R, Honda K, Matsuo K, Uchiyama K. Visceral fat area is a better indicator of surgical outcomes after laparoscopic gastrectomy for cancer than the body mass index: a propensity score-matched analysis. Surg Endosc 2021; 36:3285-3297. [PMID: 34382123 DOI: 10.1007/s00464-021-08642-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 07/16/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND The number of overweight gastric cancer patients who are undergoing laparoscopic gastrectomy (LG) has increased in Japan. However, the relationship between obesity and surgical outcomes of LG remains unclear. Therefore, this study aimed to evaluate the effect of visceral fat area (VFA) on surgical outcomes of LG for gastric cancer compared to the body mass index (BMI). METHODS This study was a retrospective, cohort study that included 587 patients who underwent LG in our institution between January 2015 and December 2019. The patients were divided into two groups according to VFA (< 100 cm2 and ≥ 100 cm2) and BMI (< 25 kg/m2 and ≥ 25 kg/m2) values, respectively. Surgical outcomes and postoperative complications were compared between the low and high groups for each VFA and BMI value. Propensity score matching was used to minimize potential selection bias. RESULTS After propensity score matching, 144 pairs of patients in the VFA group and 82 pairs of patients in the BMI group were extracted. Operative time (p = 0.003), intraoperative blood loss (p = 0.0006), and CRP levels on postoperative day 1 (p = 0.002) and on postoperative day 3 (p = 0.004) were significantly higher in the high-VFA group than in the low-VFA group. However, these surgical outcomes were not significantly different between the high-BMI and low-BMI groups. There was no strong correlation between VFA and BMI (R2 = 0.64). There were no significant differences in postoperative complications between the high and low groups for both VFA and BMI values. On multivariate analysis, high VFA was an independent predictor of operative time, but it was not significantly associated with the incidence of postoperative complications. CONCLUSION VFA is a better indicator of longer operative time than BMI. However, increased VFA did not affect postoperative complications.
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Affiliation(s)
- Yoshiro Imai
- Department of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, 569-8686, Japan
| | - Sang-Woong Lee
- Department of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, 569-8686, Japan.
| | - Masaru Kawai
- Department of Gastroenterological Surgery, Hirakata City Hospital, Hirakata, Japan
| | - Keitaro Tashiro
- Department of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, 569-8686, Japan
| | - Satoshi Kawashima
- Department of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, 569-8686, Japan
| | - Ryo Tanaka
- Department of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, 569-8686, Japan
| | - Kotaro Honda
- Department of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, 569-8686, Japan
| | - Kentaro Matsuo
- Department of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, 569-8686, Japan
| | - Kazuhisa Uchiyama
- Department of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, 569-8686, Japan
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26
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Blumenthaler AN, Robinson KA, Kruse BC, Munder K, Ikoma N, Mansfield PF, Gottumukkala V, Kapoor R, Badgwell BD. Implementation of a perioperative-enhanced recovery protocol in patients undergoing open gastrectomy for gastric cancer. J Surg Oncol 2021; 124:780-790. [PMID: 34227691 DOI: 10.1002/jso.26591] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/03/2021] [Accepted: 06/23/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND OBJECTIVES The purpose of this study was to compare surgical outcomes before and after implementation of an enhanced recovery protocol (ERP) in gastrectomy for gastric cancer. METHODS We included patients who underwent open gastrectomy for gastric cancer before (January 2016 to September 2018) or after (October 2018 to September 2020) ERP implementation. The primary outcome was the postoperative length of stay (LOS). Secondary outcomes included 90-day readmission rates and Clavien-Dindo grade ≥ 3 complications. RESULTS One hundred patients underwent gastrectomy before (pre-ERP group) and 52 underwent gastrectomy after (ERP group) protocol implementation. Demographic and clinicopathologic characteristics were similar. The median (interquartile range) postoperative LOS was shorter in the ERP group (7.0 days [6.0-8.0] vs. 8.0 days [7.0-11.0]; p < 0.001). The ERP group had similar rates of readmission (33% vs. 24%; p = 0.34) and grade ≥ 3 complications (19% vs. 19%; p = 1.0) compared to the pre-ERP group, but experienced lower rates of surgical wound complications (0% vs. 19%; p < 0.001). Rates of other complications were similar. CONCLUSIONS Implementation of an ERP in patients undergoing open gastrectomy for gastric cancer is feasible and safe and has the potential to decrease postoperative LOS without increasing complication rates.
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Affiliation(s)
- Alisa N Blumenthaler
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kristen A Robinson
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Brittany C Kruse
- The Institute for Cancer Care Innovation, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kathryn Munder
- Department of Clinical Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Paul F Mansfield
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Vijaya Gottumukkala
- The Institute for Cancer Care Innovation, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ravish Kapoor
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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27
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Geng Z, Bi H, Zhang D, Xiao C, Song H, Feng Y, Cao X, Li X. The impact of multimodal analgesia based enhanced recovery protocol on quality of recovery after laparoscopic gynecological surgery: a randomized controlled trial. BMC Anesthesiol 2021; 21:179. [PMID: 34182929 PMCID: PMC8237447 DOI: 10.1186/s12871-021-01399-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 06/15/2021] [Indexed: 02/08/2023] Open
Abstract
Background Our objective was to evaluate the impact of multimodal analgesia based enhanced recovery protocol on quality of recovery after laparoscopic gynecological surgery. Methods One hundred forty female patients scheduled for laparoscopic gynecological surgery were enrolled in this prospective, randomized controlled trial. Participants were randomized to receive either multimodal analgesia (Study group) or conventional opioid-based analgesia (Control group). The multimodal analgesic protocol consists of pre-operative acetaminophen and gabapentin, intra-operative flurbiprofen and ropivacaine, and post-operative acetaminophen and celecoxib. Both groups received an on-demand mode patient-controlled analgesia pump containing morphine for rescue analgesia. The primary outcome was Quality of Recovery-40 score at postoperative day (POD) 2. Secondary outcomes included numeric pain scores (NRS), opioid consumption, clinical recovery, C-reactive protein, and adverse events. Results One hundred thirty-eight patients completed the study. The global QoR-40 scores at POD 2 were not significantly different between groups, although scores in the pain dimension were higher in Study group (32.1 ± 3.0 vs. 31.0 ± 3.2, P = 0.033). In the Study group, NRS pain scores, morphine consumption, and rescue analgesics in PACU (5.8% vs. 27.5%; P = 0.0006) were lower, time to ambulation [5.0 (3.3–7.0) h vs. 6.5 (5.0–14.8) h; P = 0.003] and time to bowel function recovery [14.5 (9.5–19.5) h vs.17 (13–23.5) h; P = 0.008] were shorter, C-reactive protein values at POD 2 was lower [4(3–6) ng/ml vs. 5 (3–10.5) ng/ml; P = 0.022] and patient satisfaction was higher (9.8 ± 0.5 vs. 8.8 ± 1.2, P = 0.000). Conclusion For minimally invasive laparoscopic gynecological surgery, multimodal analgesia based enhanced recovery protocol offered better pain relief, lower opioid use, earlier ambulation, faster bowel function recovery and higher patient satisfaction, while no improvement in QoR-40 score was found. Trial registration ChiCTR1900026194; Date registered: Sep 26,2019.
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Affiliation(s)
- Zhiyu Geng
- Department of Anesthesiology, Peking University First Hospital, Beijing, China.
| | - Hui Bi
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Dai Zhang
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Changji Xiao
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Han Song
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Ye Feng
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Xinni Cao
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Xueying Li
- Department of Biostatics, Peking University First Hospital, Beijing, China
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28
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Advantages of Laparoscopic Surgery for Gastric Cancer in Elderly Patients Aged Over 80 Years: A Propensity Score Matching Analysis. World J Surg 2021; 45:2830-2839. [PMID: 34019135 DOI: 10.1007/s00268-021-06157-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND The short- and long-term efficacy of laparoscopic surgery for elderly patients with gastric cancer has not been evaluated. We aimed to use propensity score matching to clarify the efficacy of laparoscopic gastrectomy (LG) for elderly patients with gastric cancer aged ≥80 years. METHODS We retrospectively collected data from 159 consecutive patients with gastric cancer aged ≥80 years who underwent gastrectomy with curative intent at our institution between 2004 and 2015. Propensity score matching was applied to compare the open gastrectomy (OG) and LG. Short- and long-term outcomes were evaluated between the propensity-matched groups. RESULTS Patients' backgrounds and surgical factors were similar in both groups except for blood loss. The median time to first flatus was significantly shorter in the LG group than in the OG group (P = 0.002). The postoperative hospital stay was significantly shorter in the LG group (P = 0.014). The complication rate of Clavien-Dindo grade III or higher was significantly lower in the LG group (3% vs. 23%, P = 0.023). The 5-year overall survival and 5-year disease-specific survival rates were better in the LG group than in the OG group, but the differences were not significant (45% vs. 42% and 67% vs 57%, respectively). CONCLUSION LG was associated with good short-term outcomes and acceptable oncologic outcomes compared with OG in these propensity-matched patients aged ≥80 years.
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29
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Lombardi PM, Mazzola M, Giani A, Baleri S, Maspero M, De Martini P, Gualtierotti M, Ferrari G. ERAS pathway for gastric cancer surgery: adherence, outcomes and prognostic factors for compliance in a Western centre. Updates Surg 2021; 73:1857-1865. [PMID: 34018142 DOI: 10.1007/s13304-021-01093-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 05/13/2021] [Indexed: 12/13/2022]
Abstract
Adherence to an ERAS program guarantees an evidence-based approach for patient care, but the compliance to ERAS in patients undergoing surgery for gastric cancer in Western countries has not been clearly investigated. Our Institution has implemented an ERAS pathway (EP) for gastric surgery, composed of 24 items, since December 2016. We retrospectively analyzed the data of all consecutive patients undergoing surgery with curative intent for gastric cancer between January 2017 and December 2019 at our Institution, and were eligible for our EP. The primary endpoint was patients' compliance to the EP. Secondary endpoints were patients' adherence to each ERAS item and detection of variables associated with compliance failure. Seventy-three patients were included. Among these, 75.3% completed the EP, with a median number of items accomplished per patient of 21. Items with critical adherence were restrictive intraoperative fluid infusion (37%), avoidance of abdominal drain (14%), first clear liquid intake (67%), first solid food intake (48%). At univariate analysis age > 75 years, ASA > 2 and total gastrectomy were associated with failure to complete the EP. At multivariate analysis, ASA Score > 2 was the only preoperative factor associated with EP failure. Application of an ERAS program for malignant gastric surgery seems to be feasible with an acceptable completion rate in a tertiary referral Western centre. Preoperative factors, such as old age, advanced stage at diagnosis and neoadjuvant chemotherapy should not be considered as exclusion criteria for ERAS.
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Affiliation(s)
- Pietro Maria Lombardi
- Division of Oncologic and Mini-Invasive General Surgery, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Michele Mazzola
- Division of Oncologic and Mini-Invasive General Surgery, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy.
| | - Alessandro Giani
- Division of Oncologic and Mini-Invasive General Surgery, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Sara Baleri
- Division of Oncologic and Mini-Invasive General Surgery, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Marianna Maspero
- Division of Oncologic and Mini-Invasive General Surgery, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Paolo De Martini
- Division of Oncologic and Mini-Invasive General Surgery, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Monica Gualtierotti
- Division of Oncologic and Mini-Invasive General Surgery, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Giovanni Ferrari
- Division of Oncologic and Mini-Invasive General Surgery, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
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30
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Hu Y, Hsu AW, Strong VE. Enhanced Recovery After Major Gastrectomy for Cancer. Ann Surg Oncol 2021; 28:6947-6954. [PMID: 33826004 DOI: 10.1245/s10434-021-09906-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 03/11/2021] [Indexed: 12/13/2022]
Abstract
Enhanced recovery after surgery (ERAS) protocols have gained increasing popularity over the past 10 years, and its overarching objectives are to improve perioperative morbidity and reduce postoperative length of stay. Consensus guidelines from the ERAS Society specific to major gastrectomy were published in 2014, however since that time, prospective and retrospective studies have expanded the collective evidence for both the content and efficacy of ERAS pathways for gastrectomy. This objective of this review was to summarize recent data pertinent to the preoperative, perioperative, and postoperative management of gastrectomy patients along an ERAS pathway.
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Affiliation(s)
- Yinin Hu
- Division of General and Oncologic Surgery, Department of Surgery, University of Maryland Baltimore, Baltimore, MD, USA
| | - Annie W Hsu
- Division of Pain Medicine and Pain Research, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Vivian E Strong
- Division of Gastric and Mixed Tumors, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
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Jeong O, Jang A, Jung MR, Kang JH, Ryu SY. The benefits of enhanced recovery after surgery for gastric cancer: A large before-and-after propensity score matching study. Clin Nutr 2021; 40:2162-2168. [DOI: 10.1016/j.clnu.2020.09.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 09/24/2020] [Accepted: 09/26/2020] [Indexed: 02/07/2023]
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Impact of drinking Chinese green tea on postoperative short outcomes for gastric cancer: a randomized controlled trial. Eur J Clin Nutr 2021; 75:1568-1577. [PMID: 33742159 PMCID: PMC8563416 DOI: 10.1038/s41430-021-00868-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 10/22/2020] [Accepted: 01/14/2021] [Indexed: 11/23/2022]
Abstract
Background Early intake after surgery can decrease postoperative ileus. Several studies show coffee can stimulate bowel activity and be safe in patients after elective colectomy, mainly due to caffeine. It was postulated that drinking Chinese green tea as rich caffeine beverage after subtotal distal gastrectomy accelerates postoperative recovery in patients. Method This was a single-centre parallel open-label randomized trial. Patients with gastric cancer undergoing robotic or laparoscopic subtotal gastrectomy were randomly allocated to receive drinking Chinese green tea (GT group) or potable water (PW group) after surgery. The primary endpoint was the time to gastrointestinal function recovery and tolerance of solid food, and the secondary endpoints included the incidence of postoperative complications, symptoms of postoperative adverse reaction, length of stay, pain as assessed by analgesic consumption and a visual analogue scale, and fatigue as assessed by a fatigue score model. Results A total of 80 patients were recruited, 40 to each group. Patient characteristics were similar in both groups. The GT group showed significantly shorter time to gastrointestinal function recovery compared with PW group to first flatus (47.23 ± 13.46 vs. 76.96 ± 20.35, P < 0.001), first bowel motion (78.70 ± 25.77 vs. 125.76 ± 36.25, P < 0.001) and tolerance of solid food (62.20 ± 16.15 vs. 98.66 ± 20.15, P < 0.001). Conclusion Drinking Chinese green tea after robotic or laparoscopic subtotal gastrectomy is safe and promotes postoperative recovery of gastrointestinal function, also was an add method with strengthening analgesia and anti-inflammatory effect in the presence of the Enhance Recovery After Surgery (ERAS) program. Registration number: ChiCTR1800018294 (http://www.chictr.org.cn).
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Nomura E, Kayano H, Seki T, Abe R, Yoshii H, Uda S, Kazuno A, Izumi H, Yamamoto S, Mukai M, Makuuchi H. Preventive procedure for stenosis after esophagojejunostomy using a circular stapler and transorally inserted anvil (OrVil™) following laparoscopic proximal gastrectomy and total gastrectomy involving reduction of anastomotic tension. BMC Surg 2021; 21:47. [PMID: 33478457 PMCID: PMC7818772 DOI: 10.1186/s12893-021-01054-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 01/06/2021] [Indexed: 01/08/2023] Open
Abstract
Background Recently, due to increasing reports of stenosis after esophagojejunostomy created using circular staplers and a transorally inserted anvil (OrVil™) following laparoscopic proximal gastrectomy (LPG) and total gastrectomy (LTG), linear staplers are being used instead. We investigated our preventive procedure for esophagojejunostomy stenosis following use of circular staplers. Methods Since the anastomotic stenosis is considered to be mainly caused by tension in the esophageal and jejunal stumps at the anastomotic site, we have been performing procedures to relieve this tension, by cutting off the rubber band and pushing the shaft of the circular stapler toward the esophageal side, since July 2015. We retrospectively compared the incidence of anastomotic stenosis in cases of LPG and LTG performed before July 2015 (early phase, 30 cases) versus those performed after this period (later phase, 22 cases). Results Comparison of the incidence of anastomotic stenosis according to the type of surgery, LPG or LTG, and between the two time periods versus all cases, indicated a significantly lower incidence in the later phase than in the early phase (4.5 vs. 26.7%, p < 0.05), especially for LPG (0 vs. 38.5%, p < 0.05). Conclusions It is possible to use a circular stapler during laparoscopic esophagojejunostomy, as with open surgery, if steps to reduce tension on the anastomotic site are undertaken. These procedures will contribute to the spread of safe and simple laparoscopic anastomotic techniques.
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Affiliation(s)
- Eiji Nomura
- Department of Gastroenterological and General Surgery, Tokai University Hachioji Hospital, 1838 Ishikawa-machi, Hachioji, Tokyo, 192-0032, Japan.
| | - Hajime Kayano
- Department of Gastroenterological and General Surgery, Tokai University Hachioji Hospital, 1838 Ishikawa-machi, Hachioji, Tokyo, 192-0032, Japan
| | - Takatoshi Seki
- Department of Gastroenterological and General Surgery, Tokai University Hachioji Hospital, 1838 Ishikawa-machi, Hachioji, Tokyo, 192-0032, Japan
| | - Rin Abe
- Department of Gastroenterological and General Surgery, Tokai University Hachioji Hospital, 1838 Ishikawa-machi, Hachioji, Tokyo, 192-0032, Japan
| | - Hisamichi Yoshii
- Department of Gastroenterological and General Surgery, Tokai University Hachioji Hospital, 1838 Ishikawa-machi, Hachioji, Tokyo, 192-0032, Japan
| | - Shuji Uda
- Department of Gastroenterological and General Surgery, Tokai University Hachioji Hospital, 1838 Ishikawa-machi, Hachioji, Tokyo, 192-0032, Japan
| | - Akihito Kazuno
- Department of Gastroenterological and General Surgery, Tokai University Hachioji Hospital, 1838 Ishikawa-machi, Hachioji, Tokyo, 192-0032, Japan
| | - Hideki Izumi
- Department of Gastroenterological and General Surgery, Tokai University Hachioji Hospital, 1838 Ishikawa-machi, Hachioji, Tokyo, 192-0032, Japan
| | - Soichiro Yamamoto
- Department of Gastroenterological and General Surgery, Tokai University Hachioji Hospital, 1838 Ishikawa-machi, Hachioji, Tokyo, 192-0032, Japan
| | - Masaya Mukai
- Department of Gastroenterological and General Surgery, Tokai University Hachioji Hospital, 1838 Ishikawa-machi, Hachioji, Tokyo, 192-0032, Japan
| | - Hiroyasu Makuuchi
- Department of Gastroenterological and General Surgery, Tokai University Hachioji Hospital, 1838 Ishikawa-machi, Hachioji, Tokyo, 192-0032, Japan
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Preoperative Intake of Carbohydrate-Rich Drinks Is Associated With Postoperative Pulmonary Complications in Patients After Gastric Cancer Surgery. Int Surg 2020. [DOI: 10.9738/intsurg-d-20-00007.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background
The aims of this study were to investigate the correlation between carbohydrate-rich drinks (CRDs) before gastric cancer surgery and postoperative nutrition laboratory findings and to determine whether CRDs affect the incidence of postoperative complications.
Materials and Methods
A retrospective study was conducted on 142 patients who underwent radical stomach cancer surgery. The patients were divided into 2 groups (nothing per oral group versus CRD group) according to the intake of CRDs before surgery. We performed statistical analysis using Student t test, the χ2 test, and a binary logistic regression model (SPSS Statistics software, version 24).
Results
Laboratory analysis of the nutrition status showed a significant increase in serum protein and albumin levels in the CRD group after postoperative day 1 (POD1; P < 0.05). The overall morbidity rate showed no difference between the 2 groups, but pulmonary complications showed significant differences of 1/72 and 9/70 (P = 0.008). In the univariate analysis, there were significantly increased pulmonary complications in patients with higher Eastern Cooperative Oncology Group (ECOG) scores (P = 0.001), existing pulmonary disease (P = 0.003), anastomotic leakage (P = 0.03), and CRD intake (P = 0.008). In the multivariate analysis, CRD intake was the only independent factor.
Conclusion
We found that administering a CRD is effective in improving albumin and protein levels in the short-term period after surgery but is an independent factor for pulmonary complications after gastrectomy. We recommend that patients with no medications for pulmonary disease and with low ECOG scores can safely ingest CRDs and expect short-term nutritional effects.
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Sun Y, Li Z, Liu X, Cao S, Liu X, Hu C, Tian Y, Xu J, Wang D, Zhou X, Zhou Y. A Nomogram for Prediction of Survival in Patients After Gastrectomy Within Enhanced Recovery After Surgery (ERAS): A Single-Center Retrospective Study. Med Sci Monit 2020; 26:e926347. [PMID: 33038207 PMCID: PMC7556291 DOI: 10.12659/msm.926347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) programs can optimize clinical outcomes and have been widely used across multiple specialties, but a personalized prediction model involving ERAS for the prognosis of gastric cancer is lacking. MATERIAL AND METHODS We retrospectively collected clinical data on 725 gastric cancer patients within ERAS who underwent curative gastric resection in the Affiliated Hospital of Qingdao University from 2007 to 2014. Kaplan-Meier method, log-rank test, and Cox proportional risk model were used to determine the independent prognostic factors of patients. The accuracy of model was evaluated by C-index, calibration curve, and Decision Curve Analysis (DCA), and the receiver operator characteristic (ROC) curve was used to compare the nomogram model with the predictive value of TNM staging system. RESULTS The 5-year overall survival (OS) of 725 patients within ERAS was 72.5%. Age at diagnosis, T stage, N stage, and postoperative complications were determined to be independent factors affecting the prognosis of patients within ERAS, and nomogram model was constructed. The C-index of the training group was 0.809 and that of the verification group was 0.804; the calibration curves and DCA of the 2 groups showed good accuracy. Through verification, we found that, compared with the TNM staging assessment method, the nomogram model was more accurate in predicting the prognosis of gastric cancer. CONCLUSIONS This study identified factors affecting the prognosis of patients with gastric cancer, and we constructed the first prognostic nomogram model in ERAS mode to facilitate postoperative personalized prognostic evaluation.
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Affiliation(s)
- Yuqi Sun
- Department of General Surgery, Affiliated Hospital of Qingdao University, Qingdao, Shandong, China (mainland)
| | - Zequn Li
- Department of General Surgery, Affiliated Hospital of Qingdao University, Qingdao, Shandong, China (mainland)
| | - Xiaodong Liu
- Department of General Surgery, Affiliated Hospital of Qingdao University, Qingdao, Shandong, China (mainland)
| | - Shougen Cao
- Department of General Surgery, Affiliated Hospital of Qingdao University, Qingdao, Shandong, China (mainland)
| | - Xuechao Liu
- Department of General Surgery, Affiliated Hospital of Qingdao University, Qingdao, Shandong, China (mainland)
| | - Chuan Hu
- Qingdao University Medical College, Qingdao, Shandong, China (mainland)
| | - Yulong Tian
- Department of General Surgery, Affiliated Hospital of Qingdao University, Qingdao, Shandong, China (mainland)
| | - Jianfei Xu
- Department of General Surgery, Affiliated Hospital of Qingdao University, Qingdao, Shandong, China (mainland)
| | - Daoshen Wang
- Department of General Surgery, Affiliated Hospital of Qingdao University, Qingdao, Shandong, China (mainland)
| | - Xin Zhou
- Department of General Surgery, Affiliated Hospital of Qingdao University, Qingdao, Shandong, China (mainland)
| | - Yanbing Zhou
- Department of General Surgery, Affiliated Hospital of Qingdao University, Qingdao, Shandong, China (mainland)
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Tian YL, Cao SG, Liu XD, Li ZQ, Liu G, Zhang XQ, Sun YQ, Zhou X, Wang DS, Zhou YB. Short- and long-term outcomes associated with enhanced recovery after surgery protocol vs conventional management in patients undergoing laparoscopic gastrectomy. World J Gastroenterol 2020; 26:5646-5660. [PMID: 33088158 PMCID: PMC7545391 DOI: 10.3748/wjg.v26.i37.5646] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 08/02/2020] [Accepted: 09/03/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND At present, the enhanced recovery after surgery (ERAS) protocol is widely implemented in the field of gastric surgery. However, the effect of the ERAS protocol on the long-term prognosis of gastric cancer has not been reported.
AIM To compare the effects of ERAS and conventional protocols on short-term outcomes and long-term prognosis after laparoscopic gastrectomy.
METHODS We retrospectively analyzed the data of 1026 consecutive patients who underwent laparoscopic gastrectomy between 2012 and 2015. The patients were divided into either an ERAS group or a conventional group. The groups were matched in a 1:1 ratio using propensity scores based on covariates that affect cancer survival. The primary outcomes were the 5-year overall and cancer-specific survival rates. The secondary outcomes were the postoperative short-term outcomes and inflammatory indexes.
RESULTS The patient demographics and baseline characteristics were similar between the two groups after matching. Compared to the conventional group, the ERAS group had a significantly shorter postoperative hospital day (7.09 d vs 8.67 d, P < 0.001), shorter time to first flatus, liquid intake, and ambulation (2.50 d vs 3.40 d, P < 0.001; 1.02 d vs 3.64 d, P < 0.001; 1.47 d vs 2.99 d, P < 0.001, respectively), and lower medical costs ($7621.75 vs $7814.16, P = 0.009). There was a significantly higher rate of postoperative complications among patients in the conventional group than among those in the ERAS group (18.1 vs 12.3, P = 0.030). Regarding inflammatory indexes, the C-reactive protein and procalcitonin levels on postoperative day 3/4 were significantly different between the two groups (P < 0.001 and P = 0.025, respectively). The ERAS protocol was associated with significantly improved 5-year overall survival and cancer-specific survival rates compared with conventional protocol (P = 0.013 and 0.032, respectively). When stratified by tumour stage, only the survival of patients with stage III disease was significantly different between the two groups (P = 0.044).
CONCLUSION Adherence to the ERAS protocol improves both the short-term outcomes and the 5-year overall survival and cancer-specific survival of patients after laparoscopic gastrectomy.
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Affiliation(s)
- Yu-Long Tian
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
| | - Shou-Gen Cao
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
| | - Xiao-Dong Liu
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
| | - Ze-Qun Li
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
| | - Gan Liu
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
| | - Xing-Qi Zhang
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
| | - Yu-Qi Sun
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
| | - Xin Zhou
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
| | - Dao-Sheng Wang
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
| | - Yan-Bing Zhou
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
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Cao S, Zheng T, Wang H, Niu Z, Chen D, Zhang J, Lv L, Zhou Y. Enhanced Recovery after Surgery in Elderly Gastric Cancer Patients Undergoing Laparoscopic Total Gastrectomy. J Surg Res 2020; 257:579-586. [PMID: 32927324 DOI: 10.1016/j.jss.2020.07.037] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 05/08/2020] [Accepted: 07/11/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the effects of the enhanced recovery after surgery (ERAS) program versus conventional perioperative care on the short-term postoperative outcomes among elderly patients with gastric cancer who are undergoing laparoscopic total gastrectomy. METHODS Elderly patients with gastric cancer (age ≥ 65 y) who are undergoing laparoscopic total gastrectomy were randomized to ERAS or conventional perioperative care groups. Short-term postoperative outcomes, including postoperative hospital stay, mortality, complications, readmission rate, and reoperation rate were compared between the two groups. In addition, blood samples were taken preoperatively (baseline) and on postoperative days 1, 3, and 5. Systemic human leukocyte antigen (HLA)-DR expression on monocytes and C-reactive protein (CRP) were analyzed. RESULTS Of the 171 eligible patients, 85 patients were assigned to receive ERAS program treatment (ERAS group) and 86 patients to receive conventional care (conventional group). The patients' characteristics were comparable. Postoperative hospital stay was shorter in the ERAS group than in the conventional group (11 [7-11] versus 13 [8-20] d, P < 0.001). Hospital mortality, overall morbidity, morbidity ≥ Clavien-Dindo (C-D) grade II, readmission rate, and reoperation rate did not show significant differences between the two groups. However, morbidity ≥ C-D grade IIIa was lower in the ERAS group than that in the conventional group (8.2% versus 18.6%, P = 0.047). The ERAS program shortened the number of days to postoperative first flatus, first defecation, semifluid diet, and soft bland diet. Moreover, the ERAS program increased the HLA-DR expression on monocytes and decreased the CRP levels on postoperative days 1, 3, and 5. CONCLUSIONS The ERAS program was feasible and effective for elderly patients with gastric cancer who are undergoing laparoscopic total gastrectomy. The benefits of ERAS were associated with improvement of impaired immune function and suppression of inflammatory reaction.
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Affiliation(s)
- Shougen Cao
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Shandong, China
| | - Taohua Zheng
- Liver Disease Center, Affiliated Hospital of Qingdao University, Shandong, China
| | - Hao Wang
- Department of General Surgery, Dongying People's Hospital, Shandong, China
| | - Zhaojian Niu
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Shandong, China
| | - Dong Chen
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Shandong, China
| | - Jian Zhang
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Shandong, China
| | - Liang Lv
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Shandong, China
| | - Yanbing Zhou
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Shandong, China.
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Ligibel JA, Schmitz KH, Berger NA. Sarcopenia in aging, obesity, and cancer. Transl Cancer Res 2020; 9:5760-5771. [PMID: 33163373 PMCID: PMC7643855 DOI: 10.21037/tcr-2019-eaoc-05] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 06/03/2020] [Indexed: 12/25/2022]
Abstract
Sarcopenia, defined as loss of muscle mass, strength and physical performance, is a hallmark of aging and is invariably associated with perturbation of amino acid metabolism, increased muscle protein catabolism relative to anabolism, and loss of muscle fibers. Sarcopenia may be associated with general loss of body mass, or it may also occur along with obesity [sarcopenic obesity (SO)]. Although sarcopenia is associated with multiple comorbidities in older adults, its effects may even be more severe in patients with malignant disease where it has been shown to contribute to poor surgical outcomes, increased chemotherapy toxicity associated with both cytotoxic and targeted agents, as well as adversely impacting survival. While development of sarcopenia is a common age-related phenomenon, the associated catabolic processes appear to be promoted by physical inactivity, inadequate nutrition, and systemic low-grade inflammation, as well as intrinsic muscle and molecular changes, including mitochondrial dysfunction and impaired muscle stem cell regenerative capacity. Increased physical activity and adequate protein intake can reduce incidence and severity of sarcopenia in cancer patients, but many older cancer patients do not meet physical activity and nutrition recommendations, and cancer treatment can make it more difficult to make favorable lifestyle changes. Sarcopenia is discussed in terms of its adverse clinical consequences in older subjects and particularly, in older patients with cancer. Contributions of lifestyle, molecular, and cellular factors are likewise reviewed with suggestions for interventions to improve sarcopenia and its comorbid sequalae.
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Affiliation(s)
- Jennifer A. Ligibel
- Division of Women’s Cancers, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Kathryn H. Schmitz
- Department Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Nathan A. Berger
- Department Medicine, Biochemistry, Oncology, Genetics & Genome Sciences, Center for Science, Health and Society, Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Swaminathan N, Kundra P, Ravi R, Kate V. ERAS protocol with respiratory prehabilitation versus conventional perioperative protocol in elective gastrectomy- a randomized controlled trial. Int J Surg 2020; 81:149-157. [PMID: 32739548 DOI: 10.1016/j.ijsu.2020.07.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/09/2020] [Accepted: 07/13/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Several studies have investigated the efficacy of enhanced recovery programs in patients undergoing gastrectomy. The role of prehabilitation in these programs has not been evaluated in this subset of patients. This study incorporated incentive spirometry as a type of respiratory prehabilitation in the Enhanced Recovery After Surgery (ERAS) protocol for gastrectomy. METHODS In this single-center, prospective, open-labeled randomized controlled trial, 58 patients were randomized into two groups - a conventional perioperative care group and an ERAS group. The patients in the ERAS group received a supervised regimen of preoperative volume-oriented incentive spirometry as respiratory prehabilitation in addition to other ERAS care elements. The length of hospitalization (LOH) was assessed as the primary outcome, while the postoperative peak expiratory flow rate (PEFR) and the incidence of surgical and pulmonary complications were the secondary outcomes. RESULTS The patients in the ERAS group had a shorter median LOH compared to the conventional group (11 days vs 13 days, p = 0.003). The patients in the ERAS group also had smaller fall in postoperative PEFR from baseline, which was significant on the second postoperative day (p = 0.011). None of the patients were found to have anastomotic leaks. The incidence of surgical complications was comparable between the groups (p = 0.137). CONCLUSION ERAS protocol reduced the duration of hospitalization without increasing the complications compared to conventional perioperative protocol. Respiratory prehabilitation in the form of a supervised schedule of incentive spirometry helped in the preservation of lung functions in the postoperative period.
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Affiliation(s)
- Nagalakshmi Swaminathan
- Department of Anaesthesiology & Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006, India
| | - Pankaj Kundra
- Department of Anaesthesiology & Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006, India.
| | - Ramya Ravi
- Department of Anaesthesiology & Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006, India
| | - Vikram Kate
- Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006, India
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Tian Y, Cao S, Li L, He Q, Xia L, Jiang L, Ding Y, Wang X, Wang H, Mao W, Hui X, Shi Y, Zhang H, Chu X, Kehlet H, Zhou Y. Effects of perioperative enhanced recovery after surgery pathway management versus traditional management on the clinical outcomes of laparoscopic-assisted radical resection of distal gastric cancer: study protocol for a randomized controlled trial. Trials 2020; 21:369. [PMID: 32357913 PMCID: PMC7193340 DOI: 10.1186/s13063-020-04272-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 03/20/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The incidence of gastric cancer in East Asia is much higher than the international average. Therefore, improving the prognosis of patients and establishing effective clinical pathways are important topics for the prevention and treatment of gastric cancer. At present, the enhanced recovery after surgery (ERAS) pathway is widely used in the field of gastric surgery. Many randomized controlled trial (RCT) studies have proven that the ERAS regimen can improve the short-term clinical outcomes of patients with gastric cancer. However, a prospective study on the effect of the ERAS pathway on the prognosis of patients with gastric cancer has not yet been reported. This trial aims to confirm whether the ERAS pathway can improve the disease-free survival and overall survival of patients undergoing laparoscopic-assisted radical resection for distal gastric cancer. METHODS/DESIGN This study is a prospective, multicentre RCT. This experiment will consist of two groups - an experimental group and a control group - randomly divided in a 1:1 ratio. The perioperative period of the experimental group will be managed according to the ERAS pathway and that of the control group will be managed according to the traditional management mode. An estimated 400 patients will be enrolled. The main endpoint for comparison is the 3-year overall survival and disease-free survival between the two groups. DISCUSSION The results of this RCT should clarify whether the ERAS pathway is superior to traditional treatment on inflammatory indexes, short-term clinical outcome and survival for laparoscopic-assisted radical resection of distal gastric cancer. It is hoped that our data will provide evidence that the ERAS pathway improves survival in patients with gastric cancer. TRIAL REGISTRATION Chinese Clinical Trial Registry, CHiCTR1900022438. Registered on 11 April 2019.
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Affiliation(s)
- Yulong Tian
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, No. 16 Jiangsu Road, Qingdao, China
| | - Shougen Cao
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, No. 16 Jiangsu Road, Qingdao, China
| | - Leping Li
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital, Jinan, China
| | - Qingsi He
- Department of Gastrointestinal Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Lijian Xia
- Department of Gastrointestinal Surgery, Qianfoshan Hospital of Shandong Province, Jinan, China
| | - Lixin Jiang
- Department of Gastrointestinal Surgery, Yantai Yuhuangding Hospital, Yantai, China
| | - Yinlu Ding
- Department of Gastrointestinal Surgery, Second Hospital of Shandong University, Jinan, China
| | - Xinjian Wang
- Department of Gastrointestinal Surgery, Weihai Central Hospital, Weihai, China
| | - Hao Wang
- Department of Gastrointestinal Surgery, Dongying People's Hospital, Dongying, China
| | - Weizheng Mao
- Department of Gastrointestinal Surgery, Qingdao Municipal Hospital, Qingdao, China
| | - Xizeng Hui
- Department of Gastrointestinal Surgery, Rizhao People's Hospital, Rizhao, China
| | - Yiran Shi
- Department of Oncological Surgery, Weifang People's Hospital, Weifang, China
| | - Huanhu Zhang
- Department of Gastrointestinal Surgery, Weihai Municipal Hospital, Weihai, China
| | - Xianqun Chu
- Department of Gastrointestinal Surgery, Jining People's Hospital, Jining, China
| | - Henrik Kehlet
- Section of Surgical Pathophysiology 4074, Rigshospitalet Copenhagen University, Copenhagen, Denmark
| | - Yanbing Zhou
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, No. 16 Jiangsu Road, Qingdao, China.
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Global updates in the treatment of gastric cancer: a systematic review. Part 2: perioperative management, multimodal therapies, new technologies, standardization of the surgical treatment and educational aspects. Updates Surg 2020; 72:355-378. [PMID: 32306277 DOI: 10.1007/s13304-020-00771-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 04/11/2020] [Indexed: 12/24/2022]
Abstract
Gastric cancer is the fifth malignancy and the third cause of cancer death worldwide, according to the global cancer statistics presented in 2018. Its definition and staging have been revised in the eight edition of the AJCC/TNM classification, which took effect in 2018. Novel molecular classifications for GC have been recently established and the process of translating these classifications into clinical practice is ongoing. The cornerstone of GC treatment is surgical, in a context of multimodal therapy. Surgical treatment is being standardized, and is evolving according to new anatomical concepts and to the recent technological developments. This is leading to a massive improvement in the use of mini-invasive techniques. Mini-invasive techniques aim to be equivalent to open surgery from an oncologic point of view, with better short-term outcomes. The persecution of better short-term outcomes also includes the optimization of the perioperative management, which is being implemented on large scale according to the enhanced recovery after surgery principles. In the era of precision medicine, multimodal treatment is also evolving. The long-time-awaited results of many trials investigating the role for preoperative and postoperative management have been published, changing the clinical practice. Novel investigations focused both on traditional chemotherapeutic regimens and targeted therapies are currently ongoing. Modern platforms increase the possibility for further standardization of the different treatments, promote the use of big data and open new possibilities for surgical learning. This systematic review in two parts assesses all the current updates in GC treatment.
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Nakanishi K, Kanda M, Sakamoto J, Kodera Y. Is the measurement of drain amylase content useful for predicting pancreas-related complications after gastrectomy with systematic lymphadenectomy? World J Gastroenterol 2020; 26:1594-1600. [PMID: 32327908 PMCID: PMC7167417 DOI: 10.3748/wjg.v26.i14.1594] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 01/13/2020] [Accepted: 03/22/2020] [Indexed: 02/06/2023] Open
Abstract
Many studies investigating postoperative pancreatic fistula (POPF) after gastrectomy, including studies measuring drain amylase content (D-AMY) as a predictive factor have been reported. This article reviews previous studies and looks to the future of measuring D-AMY in patients after gastrectomy. The causes of pancreatic fluid leakage are; the parenchymal and/or thermal injury to the pancreas, and blunt injury to the pancreas by compression and retraction. Measurement of D-AMY to predict POPF has become common in clinical practice after pancreatic surgery and was later extended to the gastric surgery. Several studies have reported associations between D-AMY and POPF after gastrectomy, and the high value of D-AMY on postoperative day (POD) 1 was an independent risk factor. To improve both sensitivity and specificity, attempts have been made to enhance the predictive accuracy of factors on POD 1 as well as on POD 3 as combined markers. Although several studies have shown a high predictive ability of POPF, it has not necessarily been exploited in clinical practice. Many problems remain unresolved; ideal timing for measurement, optimal cut-off value, and means of intervention after prediction. Prospective clinical trial could be imperative in order to develop D-AMY measurement in common clinical practice for gastric surgery.
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Affiliation(s)
- Koki Nakanishi
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Mitsuro Kanda
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | | | - Yasuhiro Kodera
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
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Jang A, Jeong O. Tolerability of early oral nutrition and factors predicting early oral nutrition failure after gastrectomy. Clin Nutr 2020; 39:3331-3336. [PMID: 32146072 DOI: 10.1016/j.clnu.2020.02.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 02/07/2020] [Accepted: 02/12/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND & AIMS Many studies have suggested the feasibility and safety of early oral nutrition after gastrectomy; however, the tolerability of early oral nutrition has rarely been investigated. This study aimed to investigate the tolerability of early oral nutrition and factors affecting early oral nutrition failure after gastrectomy. METHODS We retrospectively reviewed 565 patients with gastric cancer who had undergone gastrectomy and who had received oral nutrition on postoperative day 1. Failure of early oral nutrition was defined as cessation of at least one meal for any reason. Preoperative clinical information and operative factors were analyzed concerning an association with early oral nutrition failure. RESULTS The tolerability of early oral nutrition after gastrectomy was 74.7%. Of 565 patients, 72 (12.7%) failed early oral nutrition due to adverse gastrointestinal symptoms, 52 (9.2%) failed due to gastric stasis or ileus, and 19 (3.4%) patients failed due to other postoperative complications. In the univariate analysis, age (≥70 years), male sex, preoperative tumor obstruction, remnant stomach cancer, open surgery, operating time (≥4 h), and an advanced preoperative stage were associated with failed early oral nutrition. Multivariable analysis of these factors revealed that male sex, preoperative tumor obstruction, operating time, and advanced preoperative stage were independent predictive factors for early oral nutrition failure after gastrectomy. CONCLUSIONS The tolerability of early oral nutrition after gastrectomy was comparable to that of other gastrointestinal surgeries. A tailored approach for postoperative oral nutrition is required based on identified risk factors for early oral nutrition failure.
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Affiliation(s)
- Aelee Jang
- Department of Nursing, University of Ulsan, Ulsan, South Korea
| | - Oh Jeong
- Department of Surgery, Chonnam National University Medical School, South Korea.
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Roh CK, Son SY, Lee SY, Hur H, Han SU. Clinical pathway for enhanced recovery after surgery for gastric cancer: A prospective single-center phase II clinical trial for safety and efficacy. J Surg Oncol 2020; 121:662-669. [PMID: 31930513 DOI: 10.1002/jso.25837] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Accepted: 01/02/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND We aimed to evaluate the safety and efficacy of a clinical pathway (CP) for enhanced recovery after surgery (ERAS) in gastric cancer patients, including early oral feeding and discharge on postoperative day 4. METHODS We performed a prospective, single-center, phase II clinical trial. Based on proposed indications for an ERAS CP in our retrospective study, we enrolled 133 patients younger than 65 years who were undergoing minimally invasive subtotal gastrectomy. The primary endpoint was the ERAS CP completion rate. Secondary endpoints included complication, mortality, hospital stay, and readmission. RESULTS Among 133 patients, six patients were dropped out from this study. The ERAS CP completion rate (77.2%, 98 of 127) was comparable to the historical control group that completed a conventional CP (85.4%, P = .085). The postoperative complication incidence (13.4%, 15 of 127) was also similar to that of the conventional CP group (9.5%, P = .174). We identified reduced hospital stays (4.7 ± 1.3 vs 7.2±2.3 days; P < .001) and lower hospital costs ($7771 vs 8539; P < .001) in the ERAS CP group compared with the conventional CP group. CONCLUSIONS An ERAS CP can be safely and effectively adopted for patients with gastric cancer without increasing the complication rate and could shorten hospital stays. TRIAL REGISTRATION ClinicalTrials.gov (NCT01642953).
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Affiliation(s)
- Chul Kyu Roh
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Sang-Yong Son
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Sook Young Lee
- Department of Anesthesiology, Ajou University School of Medicine, Suwon, Korea
| | - Hoon Hur
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Sang-Uk Han
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
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Güner A. The efficacy of clinical pathway in gastric cancer surgery. Turk J Surg 2020; 36:39-47. [PMID: 32637874 PMCID: PMC7315462 DOI: 10.5578/turkjsurg.4547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 11/04/2019] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Clinical pathways are useful tools for surgical quality improvement and better peri-operative clinical outcomes for patients undergoing major surgery. This study aimed to evaluate the influence of clinical pathway on early postoperative outcomes for gastric cancer patients. MATERIAL AND METHODS The study was designed as a retrospective cohort observational study. Patients who had undergone curative gastrectomy for gastric cancer were evaluated by using the gastric cancer database, which was prospectively maintained. The patients were divided into two groups based on the date when the clinical pathway was first used: The control group (May 2015-May 2016) and the clinical pathway group (June 2016-December 2017). Early postoperative outcomes including the length of hospital stay, start of the day of diet, and 30-day complications including reoperation, and operative mortality were compared after propensity score matching. RESULTS A total of 101 patients were analyzed, and the data of 70 patients (35 patients in each group) were compared after matching. Clinical pathway group demonstrated shorter hospital stay, earlier nasogastric tube removal, and start of earlier liquid/soft diet. Overall complication rate was lower in the clinical pathway group, while there was no statistically significant difference in major complication rates. No statistically significant difference was observed between the groups in terms of reoperation and operative mortality. CONCLUSION Clinical pathway may shorten the postoperative length of hospital stay and reduce the overall complication rate without increasing major morbidity in patients undergoing elective gastric cancer surgery.
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Affiliation(s)
- Ali Güner
- Department of General Surgery, Karadeniz Technical University School of Medicine, Trabzon, Turkey
- Department of Biostatistics and Medical Informatics, Karadeniz Technical University Institute of Medical Science, Trabzon, Turkey
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Nakagawa M. ASO Author Reflections: Feasibility and Safety of Early Oral Intake and Discharge After Total or Proximal Gastrectomy: An Analysis of Consecutive Cases Without Exclusion Criteria. Ann Surg Oncol 2020; 27:822-823. [PMID: 31907747 DOI: 10.1245/s10434-019-08173-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Masatoshi Nakagawa
- Department of Gastrointestinal Surgery, Tokyo Medical and Dental University, Tokyo, Japan.
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The application of enhanced recovery after surgery for upper gastrointestinal surgery: Meta-analysis. BMC Surg 2020; 20:3. [PMID: 31900149 PMCID: PMC6942370 DOI: 10.1186/s12893-019-0669-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 12/19/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Although enhanced recovery after surgery (ERAS) has made great progress in the field of surgery, the guidelines point to the lack of high-quality evidence in upper gastrointestinal surgery. METHODS Randomized controlled trials in four electronic databases that involved ERAS protocols for upper gastrointestinal surgery were searched through December 12, 2018. The primary endpoints were lung infection, urinary tract infection, surgical site infection, postoperative anastomotic leakage and ileus. The secondary endpoints were postoperative length of stay, the time from end of surgery to first flatus and defecation, and readmission rates. Subgroup analysis was performed based on the type of surgery. RESULTS A total of 17 studies were included. The results of the meta-analysis indicate that there was a decrease in rates of lung infection (RR = 0.50, 95%CI: 0.33 to 0.75), postoperative length of stay (MD = -2.53, 95%CI: - 3.42 to - 1.65), time until first postoperative flatus (MD = -0.64, 95%CI: - 0.84 to - 0.45) and time until first postoperative defecation (MD = -1.10, 95%CI: - 1.74 to - 0.47) in patients who received ERAS, compared to conventional care. However, other outcomes were not significant difference. There was no significant difference between ERAS and conventional care in rates of urinary tract infection (P = 0.10), surgical site infection (P = 0.42), postoperative anastomotic leakage (P = 0.45), readmissions (P = 0.31) and ileus (P = 0.25). CONCLUSIONS ERAS protocols can reduce the risk of postoperative lung infection and accelerating patient recovery time. Nevertheless, we should also consider further research ERAS should be performed undergoing gastrectomy and esophagectomy.
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Miao YM, Wang J, Liu JE, Li L. Nutritional management of patients undergoing laparoscopic surgery for gastric cancer based on the concept of rapid rehabilitation. Shijie Huaren Xiaohua Zazhi 2019; 27:1349-1355. [DOI: 10.11569/wcjd.v27.i22.1349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
As a common malignant tumor, patients with gastric cancer (GC) are prone to malnutrition during the development and treatment of the disease. Fast track surgery (FTS), as a perioperative medical concept based on evidence-based medicine, plays an important role in nutrition management, including preoperative malnutrition screening and treatment, preoperative nutritional management, postoperative early oral feeding, accelerated promotion of gastrointestinal function recovery, and nutritional support. Based on a series of small sample studies, the safety and importance of FTS in laparoscopic nutrition management of GC are gradually emerging, but clinical implementation is difficult. This article will review the research progress of FTS in the field of laparoscopic nutrition management of GC in the past decade.
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Affiliation(s)
- Ying-Ming Miao
- Department of Nursing, Second Affiliated Hospital of Hainan Medical College, Haikou 570100, Hainan Province, China
| | - Jie Wang
- Department of Nursing, Second Affiliated Hospital of Hainan Medical College, Haikou 570100, Hainan Province, China
| | - Jun-Er Liu
- Department of Nursing, Second Affiliated Hospital of Hainan Medical College, Haikou 570100, Hainan Province, China
| | - Long Li
- Department of Nursing, Second Affiliated Hospital of Hainan Medical College, Haikou 570100, Hainan Province, China
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Enhanced recovery after surgery (ERAS) versus standard recovery for elective gastric cancer surgery: A meta-analysis of randomized controlled trials. Surg Oncol 2019; 32:75-87. [PMID: 31786352 DOI: 10.1016/j.suronc.2019.11.004] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 11/03/2019] [Accepted: 11/17/2019] [Indexed: 02/08/2023]
Abstract
Enhanced recovery after surgery (ERAS) protocols have been effective in improving postoperative recovery after major abdominal surgeries including colorectal cancer surgery, however its impact after gastric cancer surgery is unclear. A systematic review and meta-analysis was conducted to evaluate the effect of ERAS after gastric cancer surgery. Medline, EMBASE, CENTRAL, and PubMed was searched from database inception to December 2018. Randomized controlled trials (RCTs) comparing ERAS versus standard care in gastric cancer surgery were included. Outcomes included the postoperative length of stay (LOS), hospital costs, time to first flatus, defecation, oral intake, and ambulation after surgery, and complications. Pooled estimates were calculated using random-effects meta-analysis. The GRADE approach assessed overall quality of evidence. 18 RCTs involving 1782 patients were included. ERAS significantly reduced the LOS (Mean Difference (MD) -1.78 days, 95%CI -2.17 to -1.40, P < 0.0001), reduced hospital costs (MD -650 U S. dollars, 95%CI -840 to -460, P < 0.0001), and reduced time to first flatus, defecation, ambulation, and oral intake. ERAS had significantly lower rates of pulmonary infections (Risk Ratio (RR) 0.48, 95%CI 0.28 to 0.82, P = 0.007), but not surgical site infections, anastomotic leaks, and postoperative complications. However, ERAS significantly increased readmissions (RR 2.43, 95%CI 1.09 to 5.43, P = 0.03). The quality of evidence was low to moderate for all outcomes. Implementation of an ERAS protocol may reduce LOS, costs, and time to return of function after gastric cancer surgery compared to conventional recovery. However, ERAS may increase the number of postoperative readmissions, albeit with no impact on the rate of postoperative complications.
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Nakagawa M, Tokunaga M, Aburatani T, Sato Y, Matsuyama T, Nakajima Y, Kinugasa Y. Feasibility and Safety of Early Oral Intake and Discharge After Total or Proximal Gastrectomy: An Analysis of Consecutive Cases Without Exclusion Criteria. Ann Surg Oncol 2019; 27:812-821. [DOI: 10.1245/s10434-019-08072-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Indexed: 12/13/2022]
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