Whole-course flexible management model for endoscopic submucosal dissection-treated patients for early digestive tract cancer or pre-cancerous lesions: Efficacy and quality-of-life-impact

Abstract

BACKGROUND

Minimally invasive surgery for patients with early digestive tract cancer (DTC) or precancerous lesions (PCLs) may induce perioperative adverse events (AEs) and negative emotions, potentially hindering postoperative recovery. Optimizing clinical management is therefore crucial.

AIM

To evaluate the effect of a whole-course flexible management model on patients undergoing endoscopic submucosal dissection (ESD) for early DTC or PCLs, and its impact on patients’ quality of life.

METHODS

Between December 2018 and December 2021, 92 patients undergoing ESD for early DTC or PCLs were enrolled, including 45 patients receiving conventional management (regular group) and 47 patients receiving whole-course flexible intervention management (intervention group). Perioperative indicators, including intraoperative bleeding, operation time, and hospitalization duration, as well as the incidence of AEs (abdominal pain, abdominal distension, bleeding, infection), scores on the Self-Rating Anxiety Scale, Self-Rating Depression Scale, Numeric Rating Scale, Pittsburgh Sleep Quality Index, and Short-Form 36 Health Survey, and nursing satisfaction, were compared between groups.

RESULTS

Compared with the regular group, the intervention group demonstrated significantly lower intraoperative bleeding, shorter operation time and hospitalization time, and a lower overall incidence of AEs (8.51% vs 24.44%). Post-intervention, Self-Rating Anxiety Scale, Self-Rating Depression Scale, Numeric Rating Scale, and Pittsburgh Sleep Quality Index scores were significantly lower in the intervention group than in both baseline and the regular group, while Short-Form 36 Health Survey scores and nursing satisfaction were significantly higher (95.74% vs 75.56%).

CONCLUSION

The whole-course flexible management model exerts a beneficial effect on patients undergoing ESD for early DTC or PCLs, improving surgical outcomes, reducing AEs, alleviating negative emotions and pain, and enhancing sleep quality, quality of life, and nursing satisfaction.

Key Words: Whole-course flexible management model; Endoscopic submucosal dissection; Early digestive tract cancer; Pre-cancerous lesions; Quality of life

Core Tip: This study comparatively analyzed the intervention effects and quality-of-life outcomes of the whole-course flexible management model vs the conventional management model in patients with early digestive tract cancer or precancerous lesions. The analyses indicated that the whole-course flexible management model offered greater clinical benefits than the conventional approach, including enhanced surgical safety, accelerated recovery, reduced negative emotions, alleviated pain, and improved sleep quality and overall quality of life, accompanied by higher nursing satisfaction.

INTRODUCTION

Early digestive tract cancer (DTC) refers to early-stage malignancies occurring in the upper digestive tract, including the esophagus and stomach, as well as in the lower digestive tract, such as the small intestine and rectum[1]. The incidence of early DTC has continued to increase owing to ongoing changes in lifestyle and dietary structure, making it one of the most common malignant neoplastic diseases in clinical practice[2]. In response to this increasingly serious trend, national cancer screening programs have been implemented in certain countries with a high incidence of early DTC[3]. Evidence has demonstrated that early screening and timely treatment are effective clinical strategies for controlling the progression of early DTC and precancerous lesions (PCLs)[4]. Endoscopic resection is commonly adopted for the treatment of early DTC[5], while minimally invasive techniques, including endoscopic mucosal resection and endoscopic submucosal dissection (ESD), have also been developed[6]. However, perioperative patients are susceptible to adverse events (AEs) and negative emotions (NEs), which may aggravate the disease condition and impair postoperative rehabilitation following ESD[7].

The whole-process flexible management model is an innovative nursing approach derived from the humanized nursing management model[8]. Centered on patients’ needs, this model emphasizes respect for patients’ habits, prioritization of emotional needs, and adaptation to patients’ psychological and behavioral characteristics, with the aim of optimizing the medical experience[9]. Unlike conventional rigid nursing interventions, this approach is characterized by non-mandatory and non-dogmatic management principles[10]. The whole-process flexible management model encourages the active participation of all caregivers in nursing management, thereby increasing the flexibility of nursing plans and substantially enhancing caregivers’ enthusiasm[11]. High compatibility with humanistic nursing care has also been demonstrated. Humanistic nursing care has been widely developed and applied in intensive care, pediatrics, and other medical fields, with multidimensional applications in perioperative management, psychological support, lifestyle intervention, and comfortable environment design, thereby providing theoretical support for the promotion of the whole-process flexible management model in perioperative nursing practice[12,13]. In previous clinical practice, the whole-course flexible management model has mainly been applied in obstetrics and has consistently been shown to improve patient satisfaction[14]. Favorable nursing outcomes have also been reported in studies involving spinal surgery patients managed with the whole-process flexible management model[15].

Although substantial clinical research has focused on early DTC and PCLs, limited attention has been given to perioperative nursing care for patients undergoing ESD. Accordingly, the present study analyzed the effects of the whole-course flexible management model on perioperative safety in patients with early DTC and PCLs treated with ESD, as well as its influence on NEs, pain, and quality of life (QoL), with the aim of providing a more effective nursing strategy for clinical practice.

MATERIALS AND METHODS

Patient information

This study included 92 patients with early DTC or PCLs who underwent ESD between December 2018 and December 2021. Non-randomized grouping was based on the management approach actually received, resulting in a regular group of 45 patients receiving conventional management and an intervention group of 47 patients receiving whole-course flexible intervention management. The implementation of interventions was not influenced by the personal preferences of the authors or attending physicians. In the regular group, the male-to-female ratio and mean age were 29:16 and 61.87 ± 11.67 years, respectively, while in the intervention group, the corresponding values were 27:20 and 60.00 ± 10.86 years. No significant differences were observed between the two groups in baseline characteristics (P > 0.05).

All included patients were diagnosed using magnification endoscopy, endoscopic ultrasonography, and pathological confirmation, and met the criteria for early DTC or PCLs. Patients also fulfilled indications for ESD, and demonstrated complete clinical data and high compliance. Exclusion criteria encompassed: Concurrent surgeries, other malignant tumors, coagulation disorders or autoimmune system defects, and mental illness or cognitive dysfunction. The study received approval from the Ethics Committee of Sanmen People’s Hospital, No. 2025-107.

Methods

The routine management model was implemented in the regular group. Health education was provided to patients after admission. Relevant equipment and supplies required for the operation were adequately prepared by medical staff before surgery. The results of preoperative laboratory examinations, including blood routine, coagulation function, and liver and kidney function, were evaluated to determine each patient’s general condition. In addition, medical staff explained preoperative precautions, surgical procedures, and matters requiring patient cooperation, while postoperative nursing was carried out strictly in accordance with the doctor’s instructions. The entire nursing process conformed to the clinical nursing practice guidelines.

The intervention group received the flexible intervention management model. (1) The nurse in charge provided continuous nursing care throughout the whole process, offered psychological support during the operation, responded promptly to patients’ doubts and concerns, and alleviated their Nes; (2) In cases of intraoperative bleeding, timely wound irrigation was performed with 8% ice norepinephrine saline, and the nurse assisted the doctor in electrocoagulating the bleeding site. After complete lesion resection, all small vessels on the wound surface were treated with hemostatic forceps to prevent active vascular bleeding; (3) Patients underwent fasting for 24 hours after surgery, followed by a liquid diet that was gradually changed to soft food after 72 hours. The diet was primarily light, nutritious, and easy to digest, while food intake was regulated through small and frequent meals; (4) Since postoperative pain may induce nervousness, anxiety, fear, and other NEs, psychological counseling was provided by nursing staff to strengthen patients’ confidence in overcoming the disease and encourage active cooperation with nursing care; (5) Disease-related education was delivered to patients and their families through knowledge lectures to improve understanding of the differences between early-stage and advanced cancer. In addition, health education was conducted through WeChat, multimedia courseware, videos, and other educational tools; and (6) Follow-up was conducted at 1 week, 1 month, 3 months, 6 months, and 12 months after discharge to assess patients’ physical condition, provide health guidance, and remind them of timely return visits. Nursing staff received standardized training before the implementation of intervention measures to ensure maximum consistency during the intervention process.

Evaluation indexes

(1) Perioperative indicators: Perioperative indicators of the two groups, including intraoperative bleeding volume, operation time (OT), and hospitalization time, were observed and compared; (2) Safety: Cases of AEs, including abdominal pain, abdominal distension, bleeding, and infection, were mainly observed and recorded, and the corresponding incidence rates as well as the overall incidence were calculated; (3) NEs: The Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS) were used before and after nursing intervention to evaluate patients’ anxiety and depression. Both scales contain 20 items with a total score of 80 points, and higher scores indicate more severe anxiety and depression; (4) Pain and sleep quality: Pain severity was assessed using the Numerical Rating Scale (NRS) at 6 hours and 72 hours postoperatively. The NRS score ranges from 0 to 10 points, with higher scores indicating more severe pain. The evaluation criteria were as follows: 0, no pain; 1-3, mild pain; 4-6, moderate pain; and 7-10, severe pain. Sleep quality was evaluated using the Pittsburgh Sleep Quality Index (PSQI; score range: 0-21) at 6 hours and 72 hours after surgery, with higher scores indicating more severe sleep disturbance; (5) QoL: The Short-Form 36 Item Health Survey was adopted to evaluate patients’ QoL before nursing and one week after nursing. The assessed dimensions included vitality (VT), social functioning (SF), role emotional, mental health, physical functioning, role physical, bodily pain, and general health. The total score ranged from 0 to 100 points, with higher scores indicating better QoL; and (6) Nursing satisfaction: Patient satisfaction with nursing care was evaluated after nursing using the Patient Satisfaction Questionnaire Short Form, with responses categorized as very satisfied, relatively satisfied, satisfied, uncertain, or dissatisfied. Total satisfaction was calculated as follows: (Very satisfied + relatively satisfied + satisfied cases)/total number of cases × 100%.

Statistical analysis

Measurement data are expressed as mean ± SD, while count data are presented as percentages (%). All data were analyzed using SPSS 18.0 software. Inter-group comparisons of measurement data and count data were performed using the t-test and χ²-test, respectively, with P < 0.05 considered statistically significant.

RESULTS

Baseline data of patients under two management models

The two groups were comparable in terms of gender, mean age, body mass index, education level, and lesion diameter (P > 0.05; Table 1).

Table 1 Baseline data of patients under two management models, n (%)/mean ± SD.

Categories	Regular group (n = 45)	Intervention group (n = 47)	t/χ2 value	P value
Sex			0.473	0.492
Male	29 (64.44)	27 (57.45)
Female	16 (35.56)	20 (42.55)
Average age (years)	61.87 ± 11.67	60.00 ± 10.86	0.796	0.428
Body mass index (kg/m2)	22.09 ± 2.57	22.38 ± 2.11	0.593	0.555
Educational level			0.416	0.812
Junior high school or below	23 (51.11)	25 (53.19)
Senior high school	14 (31.11)	12 (25.53)
Graduate or above	8 (17.78)	10 (21.82)
Lesion diameter (mm)	10.62 ± 1.96	10.48 ± 2.04	0.545	0.587

Influence of two management models on perioperative indicators of patients

To investigate the effects of the two management models on surgical outcomes in patients undergoing ESD for early DTC or PCLs, perioperative indicators including intraoperative bleeding volume, OT, and hospitalization time were evaluated in both groups (Figure 1). In the regular and intervention groups, the intraoperative bleeding volume was 107.96 ± 22.76 mL and 53.89 ± 14.49 mL, the OT was 100.24 ± 19.08 minutes and 62.74 ± 14.35 minutes, and the hospitalization time was 12.73 ± 2.63 days and 9.26 ± 2.17 days, respectively. These findings indicated that the intervention group had lower intraoperative bleeding volume as well as shorter OT and hospitalization time compared with the regular group (P < 0.05).

Figure 1 Perioperative indicators. A: Effects of the two management models on intraoperative bleeding volume; B: Effects of the two management models on operation time; C: Effects of the two management models on hospitalization time. ^aP < 0.05.

Influence of two management models on patient safety

Subsequently, the incidences of abdominal pain, abdominal distension, bleeding, and infection were analyzed in both groups to evaluate the effects of the two management models on postoperative safety in patients with early DTC and PCLs treated with ESD (Table 2). Statistical analysis demonstrated a significantly lower overall incidence of AEs in the intervention group than in the regular group (8.51% vs 24.44%, P < 0.05).

Table 2 Impacts of two management models on patient safety, n (%).

Categories	Regular group (n = 45)	Intervention group (n = 47)	χ2 value	P value
Abdominal pain	3 (6.67)	0 (0.00)
Abdominal distension	2 (4.44)	1 (2.13)
Bleeding	4 (8.89)	2 (4.26)
Infection	2 (4.44)	1 (2.13)
Total occurrence	11 (24.44)	4 (8.51)	4.277	0.039

Influence of two management models on patients’ NEs

Furthermore, SAS and SDS scores were analyzed before and after nursing intervention to evaluate the effects of the two management models on NEs in patients with early DTC and PCLs treated with ESD (Figure 2). Before nursing, the SAS scores were 58.87 ± 7.24 in the regular group and 59.83 ± 8.27 in the intervention group, which decreased to 54.02 ± 7.23 and 46.07 ± 6.44, respectively, after nursing. Regarding SDS scores, the values in the regular and intervention groups were 52.98 ± 8.74 and 51.37 ± 10.20 before nursing, and 47.50 ± 5.48 and 41.57 ± 7.58 after nursing, respectively. No significant differences in SAS or SDS scores were observed between the two groups before nursing (P > 0.05), whereas significant reductions were identified after nursing in both groups (P < 0.05). In addition, lower SAS and SDS scores were observed in the intervention group compared with the regular group after nursing (P < 0.05).

Figure 2 Self-Rating Anxiety Scale and Self-Rating Depression Scale scores. A: Effects of the two management models on Self-Rating Anxiety Scale scores; B: Effects of the two management models on Self-Rating Depression Scale scores. ^aP < 0.05 vs before nursing, ^cP < 0.05 vs the regular group. SAS: Self-Rating Anxiety Scale; SDS: Self-Rating Depression Scale.

Influences of two management models on patients’ pain and sleep quality

The effects of the two management models on patients’ pain and sleep quality were evaluated by analyzing NRS and PSQI scores at different postoperative time points (Figure 3). In both groups, NRS scores decreased from 6 hours to 72 hours after surgery (regular group: 4.37 ± 1.29 points to 3.57 ± 1.38 points; intervention group: 4.46 ± 1.68 points to 2.26 ± 1.16 points). Regarding PSQI scores, the values at 6 hours postoperatively were 11.51 ± 2.59 points in the regular group and 9.89 ± 2.56 points in the intervention group, which declined to 8.64 ± 2.59 points and 6.06 ± 2.31 points, respectively, at 72 hours after surgery. No significant difference in NRS scores was identified between the two groups at 6 hours postoperatively (P > 0.05), whereas significantly lower scores were observed at 72 hours after surgery (P < 0.05), with the intervention group showing lower NRS scores than the regular group (P < 0.05). As for PSQI scores, lower values were observed in the intervention group than in the regular group at 6 hours postoperatively (P < 0.05). Both groups exhibited significant reductions in PSQI scores at 72 hours after surgery compared with those at 6 hours postoperatively (P < 0.05), and the intervention group maintained lower PSQI scores at postoperative 72 hours (P < 0.05).

Figure 3 Numeric Rating Scale and Pittsburgh Sleep Quality Index scores. A: Effects of the two management models on Numeric Rating Scale scores; B: Effects of the two management models on Pittsburgh Sleep Quality Index scores. ^aP < 0.05, ^bP < 0.05 vs 6 hours post-operation, and ^cP < 0.05 vs the regular group.

Influence of two management models on patients’ QoL

The influence of the two management models on the QoL of patients undergoing ESD for early DTC and PCLs was further evaluated using Short-Form 36 Health Survey scores after nursing (Figure 4). The intervention group demonstrated significantly higher scores in VT (67.64 ± 12.98 points vs 61.40 ± 10.23 points), SF (67.98 ± 8.87 points vs 64.91 ± 8.69 points), role emotional (72.19 ± 6.73 points vs 63.93 ± 6.32 points), mental health (64.51 ± 5.78 points vs 59.71 ± 5.91 points), physical functioning (72.00 ± 8.27 points vs 67.82 ± 8.74 points), role physical (56.74 ± 6.86 points vs 53.76 ± 5.61 points), bodily pain (75.83 ± 8.40 points vs 70.47 ± 6.57 points), and general health (66.19 ± 9.84 points vs 58.53 ± 6.83 points) compared with the regular group (P < 0.05).

Figure 4 Short-Form 36 Item Health Survey scores. A: Effects of the two management models on vitality; B: Effects of the two management models on social functioning; C: Effects of the two management models on role emotional; D: Effects of the two management models on mental health; E: Effects of the two management models on physical functioning; F: Effects of the two management models on role physical; G: Effects of the two management models on bodily pain; H: Effects of the two management models on general health. ^aP < 0.05. VT: Vitality; SF: Social functioning; RE: Role emotional; MH: Mental health; PF: Physical functioning; RP: Role physical; BP: Bodily pain; GH: General health.

Influence of two management models on patients’ nursing satisfaction

To evaluate the effects of the two management models on nursing satisfaction among patients with early DTC or PCLs treated with ESD, nursing satisfaction scores after nursing were analyzed. Higher nursing satisfaction was observed in the intervention group than in the regular group (95.74% vs 75.56%; P < 0.05; Table 3).

Table 3 Influence of two management models on patients’ nursing satisfaction, n (%).

Categories	Regular group (n = 45)	Intervention group (n = 47)	χ2 value	P value
Very satisfied	14 (31.11)	23 (48.94)
Relatively satisfied	12 (26.67)	15 (31.91)
Satisfied	8 (17.78)	7 (14.89)
Uncertain	0 (0.00)	0 (0.00)
Dissatisfied	11 (24.44)	2 (4.26)
Nursing satisfaction	34 (75.56)	45 (95.74)	7.723	0.006

DISCUSSION

Relevant data indicate that among early DTC cases, the incidences of gastric cancer and colorectal cancer are 10.79% and 9.74%, respectively, with a continuously increasing trend that poses a serious challenge to public health[16]. Radical surgery remains the first-line treatment for early DTC and PCLs. Although considerable progress has been achieved in this field, surgical stress responses, operative procedures, and anesthetic agents continue to influence postoperative complications and metastasis[17,18]. In addition to the inevitable decline in QoL during treatment, patients frequently experience substantial stress, anxiety, and psychological imbalance, all of which are associated with survival outcomes[19,20]. Under such circumstances, the present study adopted the whole-course flexible management model as the focus of investigation, with the aim of optimizing perioperative clinical management and improving the QoL of patients with early DTC and PCLs.

Perioperative indicators were initially analyzed, and the results demonstrated that patients receiving whole-course flexible management exhibited significantly lower intraoperative bleeding volume as well as shorter OT and hospitalization time compared with those receiving conventional management. These findings suggest that the whole-course flexible management model can improve surgical outcomes and accelerate postoperative rehabilitation in patients with early DTC and PCLs undergoing ESD, which is consistent with the findings reported by Zhang and Pan[21] regarding postoperative nursing intervention strategies for colon cancer. Such improvements may be attributed to the continuous involvement of the nurse in charge throughout the perioperative period and close cooperation with physicians in the timely management of intraoperative bleeding, including norepinephrine saline irrigation, electrocoagulation hemostasis, and pretreatment of small blood vessels, thereby effectively reducing intraoperative blood loss. In addition, reductions in intraoperative bleeding together with improved emotional stability achieved through psychological nursing may decrease the need for repeated hemostatic procedures, consequently shortening the OT. Postoperatively, comprehensive diet management, psychological counseling, and continuous follow-up may further reduce the risk of complications and promote rehabilitation, ultimately shortening hospitalization time. High-quality, precise, and comprehensive perioperative care plays a pivotal role in preventing AEs. In this study, the incidence of each AE, including bleeding and infection, was recorded in both groups. Analysis showed that the overall AE rate was significantly lower in the intervention group compared with the regular group (8.51% vs 24.44%), indicating that the whole-course flexible management model provides high safety and effectiveness in preventing postoperative complications. This outcome may be related to the comprehensive measures implemented in the whole-course flexible management model, which ensure thorough treatment of small blood vessels in the wound and timely hemostasis of active bleeding points during surgery, thereby reducing postoperative bleeding risk. Postoperative fasting combined with gradual dietary progression helps minimize wound stimulation, and systematic follow-up with health guidance after discharge enables early identification and timely intervention for potential issues, effectively reducing the occurrence of AEs such as bleeding and infection. The SAS and SDS were further used to evaluate patients’ NEs during treatment. Results showed significant alleviation of NEs in both groups after intervention, with markedly greater improvement in the intervention group, demonstrating that the whole-course flexible management model exerts a stronger effect in mitigating patients’ NEs. This effect is partly attributed to the various strategies incorporated into the model. Continuous psychological support from supervising nurses, prompt responses to patients’ questions, emotional soothing, and educational measures such as knowledge lectures and multimedia resources helped patients understand the differences between early-stage and advanced-stage cancers, build confidence, and more effectively relieve anxiety and depression. In a study on postoperative emotions in rectal cancer, Li et al[22] confirmed the positive effect of a flexible nursing model on patients’ emotional improvement, which is consistent with the findings of the present study. The results further indicated that the whole-course flexible management model exerted a more pronounced effect on alleviating patients’ pain and improving sleep quality. It is speculated that the significant reduction in postoperative pain and relief of NEs contributed to improved sleep quality, potentially exerting a positive influence on overall QoL. Consequently, differences between the two intervention models were evaluated across eight dimensions of QoL. The intervention group demonstrated significantly better performance in all aspects, including VT and SF, confirming that the whole-course flexible management model can comprehensively enhance patients’ QoL during treatment, in line with the findings of Hanna et al[23] regarding QoL in patients with DTC. This comprehensive improvement may result from the combination of reduced intraoperative bleeding, shorter operation and hospitalization times, decreased postoperative AEs, alleviated NEs, meticulous dietary management, continuous follow-up, and health guidance, which collectively support patients physically, psychologically, and socially. Furthermore, the whole-course flexible management model contributed to markedly higher overall nursing satisfaction among patients with early DTC or PCLs treated by ESD. This effect may be attributed to several factors: The supervising nurse assumes full responsibility throughout the process, promptly addresses doubts and soothes emotions during and after surgery, implements careful and standardized dietary management, provides diverse health education, and ensures long-term regular follow-ups after discharge. These measures deliver comprehensive care and support, thereby significantly enhancing nursing satisfaction.

Several limitations of this study should be acknowledged. First, the sample may lack sufficient representativeness, as only 92 cases from a single center were included; a multi-center analysis would enhance sample generalizability. Second, the economic implications of the two management models were not assessed, and such an evaluation could provide valuable insights for clinical implementation of the whole-course flexible management model. Finally, the long-term prognostic impact of the two models remains unclear; future prospective studies could clarify potential long-term benefits associated with this approach.

CONCLUSION

In conclusion, the whole-course flexible management model demonstrates remarkable efficacy in patients undergoing ESD for early DTC and PCLs. It effectively improves surgical outcomes, reduces the incidence of AEs, and exhibits a favorable safety profile. In addition, it significantly mitigates NEs, alleviates pain, enhances sleep and overall QoL, and increases nursing satisfaction during the perioperative period, representing an effective and clinically valuable nursing strategy for the management of patients with early DTC and PCLs treated by ESD.