Allowing Normal Food at Will After Major Upper Gastrointestinal Surgery Does Not Increase Morbidity: A Randomized Multicenter Trial

Consensus guidelines for enhanced recovery after gastrectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations

BACKGROUND

Application of evidence-based perioperative care protocols reduces complication rates, accelerates recovery and shortens hospital stay. Presently, there are no comprehensive guidelines for perioperative care for gastrectomy.

METHODS

An international working group within the Enhanced Recovery After Surgery (ERAS®) Society assembled an evidence-based comprehensive framework for optimal perioperative care for patients undergoing gastrectomy. Data were retrieved from standard databases and personal archives. Evidence and recommendations were classified according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system and were discussed until consensus was reached within the group. The quality of evidence was rated 'high', 'moderate', 'low' or 'very low'. Recommendations were graded as 'strong' or 'weak'.

RESULTS

The available evidence has been summarized and recommendations are given for 25 items, eight of which contain procedure-specific evidence. The quality of evidence varies substantially and further research is needed for many issues to improve the strength of evidence and grade of recommendations.

CONCLUSION

The present evidence-based framework provides comprehensive advice on optimal perioperative care for the patient undergoing gastrectomy and facilitates multi-institutional prospective cohort registries and adequately powered randomized trials for further research.

Short hospital stays after laparoscopic gastric surgery under an Enhanced Recovery After Surgery (ERAS) pathway: experience at a single center

Introduction

Recently, first reports on benefits from Enhanced Recovery After Surgery (ERAS) pathway in patients undergoing gastric surgery have appeared. It seems that maximal reduction of unfavorable surgery-induced trauma in patients with gastric malignancy via ERAS protocol combined with minimally invasive techniques can improve outcomes.

Objective

The aim of this study was to determine the influence of laparoscopic surgery and ERAS protocol in oncological gastric surgery on early outcomes.

Materials and methods

Prospective analysis involved 28 patients (18 female and 10 male) with gastric malignancy who underwent laparoscopic gastric resection between 2009 and 2013. Gastric tumors (gastrointestinal stromal tumors or adenocarcinoma) were the indication for the surgery. A total of 17 patients underwent laparoscopic local excision, and 11 patients with adenocarcinoma or multiple neuroendocrine tumors underwent laparoscopic D2 total gastrectomy. Perioperative care was based on ERAS principles. Length of hospital stay, postoperative course, perioperative complications, and readmission rates were analyzed.

Results

There was one conversion in the gastrectomy group. All patients were mobilized on the day of surgery. Oral fluids were introduced on day 0 and were well tolerated. Full hospital diet was started on day 2 in all patients, but was well tolerated in only 18 of them. One postoperative complication requiring reoperation was noted. The length of stay after gastrectomy and gastric wedge resection was 4.6 (2–6) and 3.3 (2–6) days, respectively. No readmissions were noted in the entire group.

Conclusions

The implementation of ERAS protocol to clinical practice in combination with laparoscopy in patients with gastric tumors can result in improved postoperative care quality, shortening of hospital stay, and quicker return to normal activity.

Study protocol for the nutritional route in oesophageal resection trial: a single-arm feasibility trial (NUTRIENT trial)

INTRODUCTION

The best route of feeding for patients undergoing an oesophagectomy is unclear. Concerns exist that early oral intake would increase the incidence and severity of pneumonia and anastomotic leakage. However, in studies including patients after many other types of gastrointestinal surgery and in animal experiments, early oral intake has been shown to be beneficial and enhance recovery. Therefore, we aim to determine the feasibility of early oral intake after oesophagectomy.

METHODS AND ANALYSIS

This study is a feasibility trial in which 50 consecutive patients will start oral intake directly following oesophagectomy. Primary outcomes will be the frequency and severity of anastomotic leakage and (aspiration) pneumonia. Clinical parameters will be registered prospectively and nutritional requirements and intake will be assessed by a dietician. Surgical complications will be registered.

ETHICS AND DISSEMINATION

Approval for this study has been obtained from the Medical Ethical Committee of the Catharina Hospital Eindhoven and the study has been registered at the Dutch Trial Register, NTR4136. Results will be published and presented at international congresses.

DISCUSSION

We hypothesise that the oral route of feeding is safe and feasible following oesophagectomy, as has been shown previously for other types of gastrointestinal surgery. It is expected that early oral nutrition will result in enhanced recovery. Furthermore, complications related to artificial feeding, such as jejunostomy tube feeding, are believed to be reduced. However, (aspiration) pneumonia and anastomotic leakage are potential risks that are carefully monitored.

TRIAL REGISTRATION NUMBER

NTR4136.

Enhanced recovery (ERAS) protocol in patients undergoing laparoscopic total gastrectomy

INTRODUCTION

Laparoscopic technique combined with the ERAS (Enhanced Recovery after Surgery) protocol enables a shorter hospital stay and a lower complication rate. Although it has been widely used in many patients undergoing elective abdominal surgery, especially in patients with colorectal cancer, there are only a few papers describing laparoscopic total gastrectomy and the enhanced recovery protocol in patients with gastric cancer. Minimally invasive gastrectomy is still an uncommon procedure, mostly because of its difficulty.

AIM

To present the preliminary results of treatment of patients with gastric neoplasms who underwent laparoscopic gastrectomy D2 with perioperative care according to ERAS principles.

MATERIAL AND METHODS

Eleven patients (5 male and 6 female, age 52-77 years) underwent laparoscopic D2 gastrectomy with intracorporeal esophagojejunal anastomosis. In all patients the ERAS protocol was implemented. We analyzed operation time, complications and hospital stay. Additionally we focused on operative technique as well as the perioperative care protocol.

RESULTS

The mean duration of the procedure was 245 min. There was 1 conversion due to unclear tumor infiltration. Mean hospital stay was 4.6 days. One postoperative complication (central venous catheter sepsis) was reported. Histological analysis confirmed the tentative diagnosis (R0 resection) in 10/11 patients. There were no readmissions.

CONCLUSIONS

Laparoscopic gastrectomy is a valuable alternative to the classical approach and combined with the ERAS protocol can result in reduced hospital stay. However, due to the small group of patients it is difficult to adequately assess the incidence of early and late complications of the laparoscopic procedures; therefore further research is needed.

Early initiation of oral feeding following upper gastrointestinal tumor surgery: a randomized controlled trial

OBJECTIVES

Despite increasing trends toward the early initiation of oral feeding after gastrointestinal (GI) surgeries, current evidence has not been convincing. The present randomized clinical trial aimed to compare the clinical outcomes of early oral feeding (EOF) with late oral feeding (LOF) following surgery for upper GI tumors.

METHODS

One hundred and nine consecutive patients with esophageal or gastric tumors undergoing surgical resection in two hospitals in Tehran, Iran, were enrolled in this prospective randomized controlled trial, and were randomly assigned to a group starting EOF on the first postoperative day and another group that remained nil by mouth until the return of bowel sounds (LOF group). The clinical and surgical outcomes were compared between the two groups.

RESULTS

The clinical outcomes were significantly better in the patients in the EOF group (p < 0.05). Repeated nil per os (14.8 vs. 30.9 %) and re-hospitalization (1.8 vs. 7.3 %) were more common in LOF group (p < 0.0001). Additionally, gas passage, nasogastric tube (NGT) discharge, a decrease in intravenous serum to less than 1000 ml per day, the time to start a soft diet and hospital discharge following surgery occurred significantly earlier in the EOF group than in the LOF group (p < 0.0001).

CONCLUSION

Early oral feeding after the surgical resection of esophageal and gastric tumors is safe, and is associated with favorable early in-hospital outcomes and a sooner return to physiological GI function and hospital discharge.

Early oral feeding following thoracolaparoscopic oesophagectomy for oesophageal cancer

OBJECTIVES

Nil-by-mouth with enteral tube feeding is widely practised for several days after resection and reconstruction of oesophageal cancer. This study investigates early changes in postoperative gastric emptying and the feasibility of early oral feeding after thoracolaparoscopic oesophagectomy for patients with oesophageal cancer.

METHODS

Between January 2013 and August 2013, gastric emptying of liquid food and the feasibility of early oral feeding after thoracolaparoscopic oesophagectomy was investigated in 68 patients. Sixty-five patients previously managed in the same unit who routinely took liquid food 7 days after thoracolaparoscopic oesophagectomy served as controls.

RESULTS

The mean preoperative half gastric emptying time (GET1/2) was 66.4 ± 38.4 min for all 68 patients, and the mean GET1/2 at postoperative day (POD) 1 and POD 7 was statistically significantly shorter than preoperative GET1/2 (23.9 ± 15.7 min and 24.1 ± 7.9 min, respectively, both P-values <0.001). Of the 68 patients who were enrolled to analyse the feasibility of early oral feeding, 2 (3.0%) patients could not take food as early as planned. The rate of total complication was 20.6% (14/68) and 29.2% (19/65) in the early oral feeding group and the late oral feeding group, respectively (P = 0.249). Compared with the late oral feeding group, time to first flatus and bowel movement was significantly shorter in the early oral feeding group.

CONCLUSIONS

Compared with preoperative gastric emptying, early postoperative gastric emptying for liquid food after oesophagectomy is significantly faster. Postoperative early oral feeding in patients with thoracolaparoscopic oesophagectomy is feasible and safe.

Perioperative nutrition: what is the current landscape?

Poor nutrition status has long been linked to increases in postoperative complications and adverse outcomes for the patient undergoing elective surgery. While optimal planning for nutrition therapy should be comprehensive spanning throughout the perioperative period, recent advances have focused on the concept of "prehabilitation" to best prepare the patient prior to the insult of surgery. Adding immune/metabolic modulating formulas the week of surgery with carbohydrate drinks to optimize glycogen deposition immediately prior to surgery, enhances patient recovery and return to baseline function. Such nutrition strategies should now be combined with a host of other practices (such as smoking cessation, weight loss, glucose control, and specialized exercise program) as part of a structured protocol to maximize patients' chances for a full and rapid recovery from their elective surgical procedure.

Early oral feeding versus traditional postoperative care after abdominal emergency surgery: a randomized controlled trial

BACKGROUND

Early oral feeding (EOF) has been demonstrated to be safe and beneficial after abdominal elective surgery. The aim of this randomized controlled trial is to assess the safety and benefits of EOF compared to traditional postoperative care (TPC) after abdominal emergency surgery.

METHODS

Patients assigned to the EOF group commenced a soft diet within 24 h after surgery. In the TPC group, a liquid diet was commenced upon passage of flatus or stool and then advanced to soft food. The primary endpoint was the complication rate. Secondary endpoints were severity of complications, mortality, gastrointestinal leaks, surgical-site infection, reoperation, diet intolerance, time to first flatus and stool, amount of food intake, postoperative discomfort, hospital stay, weight loss at the 15th postoperative day and incisional hernias.

RESULTS

A total of 295 patients assigned to EOF (n = 148) or TPC (n = 147) were analyzed. No significant differences were seen in the complications rates (EOF 45.3 % vs. TPC 37.4 %; p = 0.1). There was a significantly higher rate of vomiting with EOF (EOF 13.5 % vs. TPC 6.1 %; p = 0.03), with no differences in nasogastric tube reinsertion. EOF patients' food intake was proportionally lower for the first three meals than that of TPC patients (p < 0.01). Postoperative discomfort survey revealed more hunger in the TPC group (p < 0.01). There were no differences in postoperative ileus or length of hospital stay.

CONCLUSIONS

EOF was safe after abdominal emergency surgery. EOF was associated with more vomiting (treated easily and without patient discomfort) and less hunger than with TPC. No other EOF-related benefits could be demonstrated during this trial.

The safety and feasibility of early postoperative oral nutrition on the first postoperative day after gastrectomy for gastric carcinoma

BACKGROUND

Unlike the wide acceptance of early enteral nutrition after colorectal surgery, little information is available regarding the feasibility of immediate oral nutrition after gastric cancer surgery. This study evaluated the feasibility and safety of oral nutrition on the first postoperative day after gastrectomy.

METHODS

From September 2010 to March 2011, 74 consecutive gastric cancer patients received an oral diet on the first postoperative day after gastrectomy. Surgical outcomes, including hospital stay, morbidity, and mortality, were compared with a conventional diet group (n = 96, before September 2010), in which an oral diet was started on the third or fourth postoperative day.

RESULTS

No significant differences were found in the clinicopathological characteristics or operation types between the two groups. Average diet start times in the early diet (ED) and conventional diet (CD) groups were 1.8 and. 3.2, respectively (p < 0.001). The mean hospital stay was significantly shorter in the ED group (7.4 vs. 8.9 days, p = 0.004). There was no significant difference in postoperative morbidity (p = 0.947) between the two groups. Gastrointestinal-related complications, such as anastomosis leakage or postoperative ileus, were also similar in the two groups. Overall compliance to early oral nutrition in the ED group was 78.5 %, and an old age (≥70 years) was found to affect the compliance to early postoperative oral nutrition.

CONCLUSIONS

Postoperative oral nutrition is safe and feasible on the first postoperative day after gastrectomy. However, elderly patients require careful monitoring when applying early oral nutrition after gastrectomy.

Enhanced recovery for esophagectomy: a systematic review and evidence-based guidelines

OBJECTIVE

This article aims to provide the first systematic review of enhanced recovery after surgery (ERAS) programs for esophagectomy and generate guidelines.

BACKGROUND

ERAS programs use multimodal approaches to reduce complications and accelerate recovery. Although ERAS is well established in colorectal surgery, experience after esophagectomy has been minimal. However, esophagectomy remains an extremely high-risk operation, commonly performed in patients with significant comorbidities. Consequently, ERAS may have a significant role to play in improving outcomes. No guidelines or reviews have been published in esophagectomy.

METHODS

We undertook a systematic review of the PubMed, EMBASE, and the Cochrane databases in July 2012. The literature was searched for descriptions of ERAS in esophagectomy. Components of successful ERAS programs were determined, and when not directly available for esophagectomy, extrapolation from related evidence was made. Graded recommendations for each component were then generated.

RESULTS

Six retrospective studies have assessed ERAS for esophagectomy, demonstrating favorable morbidity, mortality, and length of stay. Methodological quality is, however, low. Overall, there is little direct evidence for components of ERAS, with much derived from nonesophageal thoracoabdominal surgery.

CONCLUSIONS

ERAS in principle seems logical and safe for esophagectomy. However, the underlying evidence is poor and lacking. Despite this, a number of recommendations for practice and research can be made.

Clinical effects of early postoperative oral feeding versus traditional oral feeding after bilioenteric anastomosis

AIM: To explore the security and feasibility of early postoperative oral feeding in patients after bilioenteric anastomosis.

METHODS: A randomized controlled trial was performed on 78 patients who underwent bilioenteric anastomosis from January 2010 to December 2012 at the First Affiliated Hospital of Kunming Medical University. The patients were randomized into two groups: early oral feeding (EOF group, n = 42) and traditional oral feeding (TOF group, n = 36). The length of postoperative hospital stay, time to first flatus and defecation, nutritional status and postoperative complications were compared.

RESULTS: The EOF group was associated with significantly shorter post-operative hospital stay, time to first flatus and defecation compared with the TOF group (P < 0.05 for all). The levels of albumin, prealbumin and lymphocyte count were significantly higher in the EOF group than in the TOF group on postoperative days 3 and 7 (P < 0.05 for all). There were no significant differences in patient characteristics and other postoperative complications between the two groups (P > 0.05 for all).

CONCLUSION: Early oral feeding after bilioenteric anastomosis is safe and beneficial, and leads to faster recovery of bowel function and shorter postoperative hospital stay without increasing postoperative complications.

A single surgeon's series of transthoracic oesophageal resections

INTRODUCTION

Significant controversy persists over the optimum surgical management of oesophageal carcinoma. The authors report on a consecutive personal series of open transthoracic oesophageal resections.

METHODS

Data relating to resections performed between mid-1993 and the end of 2010 were analysed. Patient and tumour assessment evolved over this period. Preoperative chemotherapy in appropriate cases was introduced in 2002. A laparotomy and right lateral thoracotomy approach (Ivor-Lewis) was used. In all cases the pylorus was not interfered with, no attempt was made to perform a radical lymphadenectomy but surgical strategy was focused on producing an R0 resection and a hand sewn anastomosis was fashioned.

RESULTS

A total of 165 resections were performed; 130 patients (80%) were male. The median age was 66 years (range: 31-82 years). Eighty per cent had an adenocarcinoma. Sixty-four per cent of the tumours were T3/T4 and sixty-two per cent node positive. Forty patients (24%) had an involved circumferential resection margin (CRM). Five patients (3.0%) had no resection and a quarter (26%) developed morbidity of some form. There was one clinical anastomotic leak (0.6%) and three benign strictures requiring dilation (1.8%). In-hospital mortality was 3.0% (5 patients). Disease specific survival at one, two and five years was 77%, 42% and 36% respectively. Neither CRM involvement nor preoperative chemotherapy influenced survival significantly. No patient required intervention to disrupt the pylorus.

CONCLUSIONS

Excellent outcomes are achievable following open transthoracic oesophagectomy without radical lymphadenectomy using a hand sewn gastro-oesophageal anastomosis and without disrupting the pylorus.

Jejunostomy tube feeding in patients undergoing esophagectomy

BACKGROUND

Surgical jejunostomy tubes are a routine part of elective esophagectomies in patients with carcinomas and provide a route for nutritional support in those who experience complications. We wished to determine how frequently oral intake is delayed and the amount of nutrition delivered via the jejunostomy tube.

METHODS

We reviewed the charts of all adults undergoing esophagectomy for carcinoma between January 2000 and June 2008. We determined the proportion of patients unable to resume oral nutrition after 8 days and the amount of nutrition delivered in each of the 8 days.

RESULTS

In all, 111 patients underwent elective esophagectomy for carcinoma, and 103 had a jejunostomy tube placed. The mean age was 67 ± 10.8 years. The median time to oral intake was 7 (interquartile range 7-11) days. Seventy-four (67%) patients resumed oral intake within 8 days. The mean nutrition delivered by jejunostomy within the first 8 days as a percentage of the target was 45.6% (95% confidence interval 41.2%-49.9%). Six (5.4%) patients experienced complications attributable solely to the jejunostomy tube; 3 (2.9%) required surgery. Forty (38.8%) patients had abdominal issues serious enough to warrant delaying the progression of feeding.

CONCLUSION

Two-thirds of patients undergoing elective esophagectomy were tolerating oral intake by the end of the eighth postoperative day, and less than half of the target nutrition was delivered over the first 8 days. We now selectively place surgical jejunostomy tubes in patients undergoing elective esophagectomies.

Economic impact of an enhanced recovery pathway for oesophagectomy

BACKGROUND

Data are lacking to support the cost-effectiveness of enhanced recovery pathways (ERP) for oesophagectomy. The aim of this study was to investigate the impact of an ERP on medical costs for oesophagectomy.

METHODS

This study investigated all patients undergoing elective oesophagectomy between June 2009 and December 2011 at a single high-volume university hospital. From June 2010, all patients were enrolled in an ERP. Clinical outcomes were recorded for up to 30 days. Deviation-based cost modelling was used to compare costs between the traditional care and ERP groups.

RESULTS

A total of 106 patients were included (47 traditional care, 59 ERP). There were no differences in patient, pathological and operative characteristics between the groups. Median length of hospital stay (LOS) was lower in the ERP group (8 (interquartile range 7-18) days versus 10 (9-18) days with traditional care; P = 0·019). There was no difference in 30-day complication rates (59 per cent with ERP versus 62 per cent with traditional care; P = 0·803), and the 30-day or in-hospital mortality rate was low (3·8 per cent, 4 of 106). Costs in the on-course and minor-deviation groups were significantly lower after implementation of the ERP. The pathway-dependent cost saving per patient was €1055 and the overall cost saving per patient was €2013. One-way sensitivity analysis demonstrated that the ERP was cost-neutral or more costly only at extreme values of ward, operating and intensive care costs.

CONCLUSION

A multidisciplinary ERP for oesophagectomy was associated with cost savings, with no increase in morbidity or mortality.

Strategies to reduce pulmonary complications after esophagectomy

Esophagectomy, the surgical removal of all or part of the esophagus, is a surgical procedure that is associated with high morbidity and mortality. Pulmonary complications are an especially important postoperative problem. Therefore, many perioperative strategies to prevent pulmonary complications after esophagectomy have been investigated and introduced in daily clinical practice. Here, we review these strategies, including improvement of patient performance and technical advances such as minimally invasive surgery that have been implemented in recent years. Furthermore, interventions such as methylprednisolone, neutrophil elastase inhibitor and epidural analgesia, which have been shown to reduce pulmonary complications, are discussed. Benefits of the commonly applied routine nasogastric decompression, delay of oral intake and prophylactic mechanical ventilation are unclear, and many of these strategies are also evaluated here. Finally, we will discuss recent insights and new developments aimed to improve pulmonary outcomes after esophagectomy.

Early Oral Feeding in Pediatric Intestinal Anastomosis

A prospective nonrandomized study of 31 children aged <16 years over a period of 14 months was conducted to evaluate the effects of early oral feeding (EOF) in children with intestinal anastomosis. Patients undergoing elective or emergency intestinal anastomosis below the ligament of Trietz with no contamination were included while contaminated cases and neonatal atresias were excluded. First feed was the direct oral feed started within 24 h, usually the morning after surgery. Liquid feeds were started initially and increased at 4 hourly increments to appropriate feed for age. Time to full feeds was recorded. Patients were monitored for vomiting, abdominal distension, and signs of leak. Time to first stool and length of hospital stay were recorded. Median age of patient was 12 months. Mean time to first feed was 16 h, and mean time to full feeds was 36 h. Four of the 31 patients had delayed tolerance to feed, either due to vomiting or distension, which was transient and resolved spontaneously in three patients and due to prolonged ileus in the fourth patient. None of the patients had leaks. Most of the patients were discharged by postoperative day 3 (83 %). Early enteral feeding in pediatric intestinal anastomosis can be safely started without looking for traditional markers of return of bowel activity. It lowers hospital stay with no adverse effects. Generalization of this concept to selected emergency and neonatal surgeries can be considered, but needs further randomized control trial to validate.

Pancreatic surgery: indications, complications, and implications for nutrition intervention

Pancreatic surgery is a complicated procedure leaving postoperative patients with an altered gastrointestinal (GI) anatomy and a potential for further surgical complications such as leaks and fistulas. Beyond surgical complications, these patients are prone to delayed gastric emptying, fat malabsorption, and hyperglycemia, with early satiety and poor appetite further compromising nutrition status. Many of these patients are malnourished prior to this major surgical procedure, and significant weight loss is common postoperatively. Does this affect their outcome? There seems to be a lack of consensus in this patient population regarding how to optimize nutrition and limit potential deleterious effects of this surgery. It is important to first understand the underlying disease condition and the effects to the gland, different forms of surgery with subsequent GI alterations, and common surgical and digestive complications. Once this is reviewed, existing nutrition support literature will be explored in attempts to determine the best nutrition management in this patient population.

Systematic review of five feeding routes after pancreatoduodenectomy

BACKGROUND

Current European guidelines recommend routine enteral feeding after pancreato-duodenectomy (PD), whereas American guidelines do not. The aim of this study was to determine the optimal feeding route after PD.

METHODS

A systematic search was performed in PubMed, Embase and the Cochrane Library. Included were studies on feeding routes after PD that reported length of hospital stay (primary outcome).

RESULTS

Of 442 articles screened, 15 studies with 3474 patients were included. Data on five feeding routes were extracted: oral diet (2210 patients), enteral nutrition via either a nasojejunal tube (NJT, 165), gastrojejunostomy tube (GJT, 52) or jejunostomy tube (JT, 623), and total parenteral nutrition (TPN, 424). Mean(s.d.) length of hospital stay was shortest in the oral diet and GJT groups (15(14) and 15(11) days respectively), followed by 19(12) days in the JT, 20(15) days in the TPN and 25(11) days in the NJT group. Normal oral intake was established most quickly in the oral diet group (mean 6(5) days), followed by 8(9) days in the NJT group. The incidence of delayed gastric emptying varied from 6 per cent (3 of 52 patients) in the GJT group to 23.2 per cent (43 of 185) in the JT group, but definitions varied widely. The overall morbidity rate ranged from 43.8 per cent (81 of 185) in the JT group to 75 per cent (24 of 32) in the GJT group. The overall mortality rate ranged from 1.8 per cent (3 of 165) in the NJT group to 5.4 per cent (23 of 424) in the TPN group.

CONCLUSION

There is no evidence to support routine enteral or parenteral feeding after PD. An oral diet may be considered as the preferred routine feeding strategy after PD.

Implementation of an enhanced recovery programme following pancreaticoduodenectomy

OBJECTIVES

The aim of this prospective study was to investigate the implementation of an enhanced recovery after surgery (ERAS) programme following pancreaticoduodenectomy (PD).

METHODS

Patients undergoing PD were managed according to an ERAS protocol. Outcome measures included postoperative mortality, morbidity, hospitalization and 30-day readmission rate. Key protocol targets were: nasogastric tube (NGT) removal [postoperative day (PoD) 1]; resumption of oral fluids (PoD 1); urinary catheter removal (PoD 3); high-dependency unit (HDU) discharge (PoD 3); tolerating diet (PoD 4); drain removal (PoD 5), and hospital discharge (PoD 6).

RESULTS

Data were collected for 50 patients (24 male; median age 67 years). Rates of mortality, morbidity and readmission were 4%, 46% and 4%, respectively. The median length of postoperative hospitalization was 10 days. The proportions of patients achieving key targets were: 78% for NGT removal; 82% for resumption of oral fluids; 48% for urinary catheter removal; 82% for HDU discharge; 86% for tolerating diet; 84% for meeting mobility targets, and 72% for drain removal. One patient was discharged by PoD 6, eight patients by PoD 7, 15 patients by PoD 8 and 26 patients (52%) by PoD 10. Discharge was delayed in 16 patients for social or transport-related reasons.

CONCLUSIONS

The ERAS protocol was implemented safely. Achieving certain targets was challenging. Non-medical causes remain a significant factor in delayed discharge following PD.

[Fast track approach in radical cystectomy]

The origins of the fast track concept in the field of elective colon surgery can be traced back to the beginning of the 1990s. The first studies performed by Kehlet et al. sparked interest in this new form of patient management among physicians and hospital administrators. Different fast track programs for patients undergoing radical cystectomy can be found in the current literature. The goal of the prevailing fast track concepts is to reduce the perioperative burden, optimize postoperative convalescence, decrease the postoperative need for analgesics, lower the postoperative morbidity rate, and shorten hospital stays.

Standards for reporting randomized controlled trials in medical informatics: a systematic review of CONSORT adherence in RCTs on clinical decision support

INTRODUCTION

The Consolidated Standards for Reporting Trials (CONSORT) were published to standardize reporting and improve the quality of clinical trials. The objective of this study is to assess CONSORT adherence in randomized clinical trials (RCT) of disease specific clinical decision support (CDS).

METHODS

A systematic search was conducted of the Medline, EMBASE, and Cochrane databases. RCTs on CDS were assessed against CONSORT guidelines and the Jadad score.

RESULT

32 of 3784 papers identified in the primary search were included in the final review. 181 702 patients and 7315 physicians participated in the selected trials. Most trials were performed in primary care (22), including 897 general practitioner offices. RCTs assessing CDS for asthma (4), diabetes (4), and hyperlipidemia (3) were the most common. Thirteen CDS systems (40%) were implemented in electronic medical records, and 14 (43%) provided automatic alerts. CONSORT and Jadad scores were generally low; the mean CONSORT score was 30.75 (95% CI 27.0 to 34.5), median score 32, range 21-38. Fourteen trials (43%) did not clearly define the study objective, and 11 studies (34%) did not include a sample size calculation. Outcome measures were adequately identified and defined in 23 (71%) trials; adverse events or side effects were not reported in 20 trials (62%). Thirteen trials (40%) were of superior quality according to the Jadad score (≥3 points). Six trials (18%) reported on long-term implementation of CDS.

CONCLUSION

The overall quality of reporting RCTs was low. There is a need to develop standards for reporting RCTs in medical informatics.

Perioperative nutritional management in digestive tract surgery

PURPOSE OF REVIEW

This article reviews the recent research on perioperative nutrition in digestive tract surgery in the light of modern perioperative care principles, that is, enhanced recovery after surgery (ERAS). Four major directions of research emerge: detecting malnutrition, perioperative hyperglycemia/insulin resistance, enteral/parenteral nutrition and immunonutrition.

RECENT FINDINGS

For preoperative nutritional screening/assessment, current data cannot single out superiority for SGA questionnaire, nutritional risk score, Reilly's nutritional risk score or nutritional risk index in the ability to predict nutrition-related complications. The use of ERAS elements to reduce surgical stress and preclude postoperative insulin resistance has recently been clearly linked to reductions in adverse outcomes. There are specific situations in which enteral nutrition is contraindicated and criterias for preoperative and postoperative parenteral nutrition in undernourished patients are defined in guidelines recently available. Several controlled randomized studies and systematic reviews indicate that immune nutrition formulas reduce both morbidity and length of stay after major abdominal surgery.

SUMMARY

To reduce surgical stress, insulin resistance, unnecessary protein losses and postoperative complications, the use of an ERAS protocol is important. Current data shows that the use of perioperative immunonutrition diets for major abdominal surgery is beneficial. Further research on nutritional assessment tools to predict who is at risk for postoperative complications is needed.

Feasibility study of early oral intake after gastrectomy for gastric carcinoma

Purpose

Despite the compelling scientific and clinical data supporting the use of early oral nutrition after major gastrointestinal surgery, traditional bowel rest and intravenous nutrition for several postoperative days is still being used widely after gastric cancer surgery.

Materials and Methods

A phase II study was carried out to evaluate the feasibility and safety of postoperative early oral intake (water intake on postoperative days (POD) 1-2, and soft diet on POD 3) after a gastrectomy. The primary outcome was morbidity within 30 postoperative days, which was targeted at <25% based on pilot study data.

Results

The study subjects were 90 males and 42 females with a mean age 61.5 years. One hundred and four (79%) and 28 (21%) patients underwent a distal and total gastrectomy, respectively. The postoperative morbidity rate was within the targeted range (15.2%, 95% CI, 10.0~22.3%), and there was no hospital mortality. Of the 132 patients, 117 (89%) successfully completed a postoperative early oral intake regimen without deviation; deviation in 10 (8%) due to gastrointestinal symptoms and in five (4%) due to the management of postoperative complications. The mean times to water intake and a soft diet were 1.0±0.2 and 3.2±0.7 days, respectively, and the mean hospital stay was 10.0±6.1 days.

Conclusions

Postoperative early oral intake after a gastrectomy is feasible and safe, and can be adopted as a standard perioperative care after a gastrectomy. Nevertheless, further clinical trials will be needed to evaluate the benefits of early oral nutrition after upper gastrointestinal surgery.

Laparoscopic extraperitoneal rectal cancer surgery: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES)

BACKGROUND

The laparoscopic approach is increasingly applied in colorectal surgery. Although laparoscopic surgery in colon cancer has been proved to be safe and feasible with equivalent long-term oncological outcome compared to open surgery, safety and long-term oncological outcome of laparoscopic surgery for rectal cancer remain controversial. Laparoscopic rectal cancer surgery might be efficacious, but indications and limitations are not clearly defined. Therefore, the European Association for Endoscopic Surgery (EAES) has developed this clinical practice guideline.

METHODS

An international expert panel was invited to appraise the current literature and to develop evidence-based recommendations. The expert panel constituted for a consensus development conference in May 2010. Thereafter, the recommendations were presented at the annual congress of the EAES in Geneva in June 2010 in a plenary session. A second consensus process (Delphi process) of the recommendations with the explanatory text was necessary due to the changes after the consensus conference.

RESULTS

Laparoscopic surgery for extraperitoneal (mid- and low-) rectal cancer is feasible and widely accepted. The laparoscopic approach must offer the same quality of surgical specimen as in open surgery. Short-term outcomes such as bowel function, surgical-site infections, pain and hospital stay are slightly improved with the laparoscopic approach. Laparoscopic resection of rectal cancer is not inferior to the open in terms of disease-free survival, overall survival or local recurrence. Laparoscopic pelvic dissection may impair genitourinary and sexual function after rectal resection, like in open surgery.

CONCLUSIONS

Laparoscopic surgery for mid- and low-rectal cancer can be recommended under optimal conditions. Still, most level 1 evidence is for colon cancer surgery rather than rectal cancer. Upcoming results from large randomised trials are awaited to strengthen the evidence for improved short-term results and equal long-term results in comparison with the open approach.

Early versus traditional postoperative feeding in patients undergoing resectional gastrointestinal surgery: a meta-analysis

BACKGROUND

A meta-analysis evaluating surgical outcomes following nutritional provision provided proximal to the anastomosis within 24 hours of gastrointestinal surgery compared with traditional postoperative management was conducted.

METHODS

Databases were searched to identify randomized controlled trials comparing the outcomes of early and traditional postoperative feeding. Trials involving gastrointestinal tract resection followed by patients receiving nutritionally significant oral or enteral intake within 24 hours after surgery were included for analysis.

RESULTS

Fifteen studies involving a total of 1240 patients were analyzed. A statistically significant reduction (45%) in relative odds of total postoperative complications was seen in patients receiving early postoperative feeding (odds ratio [OR] 0.55; confidence interval [CI], 0.35 -0.87, P = .01). No effect of early feeding was seen with relation to anastomotic dehiscence (OR 0.75; CI, 0.39-1.4, P = .39), mortality (OR 0.71; CI, 0.32-1.56, P = .39), days to passage of flatus (weighted mean difference [WMD] -0.42; CI, -1.12 to 0.28, P = .23), first bowel motion (WMD -0.28; CI, -1.20 to 0.64, P = .55), or reduced length of stay (WMD -1.28; CI, -2.94 to 0.38, P = .13); however, the direction of clinical outcomes favored early feeding. Nasogastric tube reinsertion was less common in traditional feeding interventions (OR 1.48; CI, 0.93-2.35, P = .10).

CONCLUSIONS

Early postoperative nutrition is associated with significant reductions in total complications compared with traditional postoperative feeding practices and does not negatively affect outcomes such as mortality, anastomotic dehiscence, resumption of bowel function, or hospital length of stay.

Perioperative nutrition in abdominal surgery: recommendations and reality

Introduction. Preoperative malnutrition is a major risk factor for increased postoperative morbidity and mortality. Definition and diagnosis of malnutrition and its treatment is still subject for controversy. Furthermore, practical implementation of nutrition-related guidelines is unknown. Methods. A review of the available literature and of current guidelines on perioperative nutrition was conducted. We focused on nutritional screening and perioperative nutrition in patients undergoing digestive surgery, and we assessed translation of recent guidelines in clinical practice. Results and Conclusions. Malnutrition is a well-recognized risk factor for poor postoperative outcome. The prevalence of malnutrition depends largely on its definition; about 40% of patients undergoing major surgery fulfil current diagnostic criteria of being at nutritional risk. The Nutritional Risk Score is a pragmatic and validated tool to identify patients who should benefit from nutritional support. Adequate nutritional intervention entails reduced (infectious) complications, hospital stay, and costs. Preoperative oral supplementation of a minimum of five days is preferable; depending on the patient and the type of surgery, immune-enhancing formulas are recommended. However, surgeons' compliance with evidence-based guidelines remains poor and efforts are necessary to implement routine nutritional screening and nutritional support.

Prospective multicentre randomised controlled trial of early enteral nutrition for patients undergoing major upper gastrointestinal surgical resection

BACKGROUND & AIMS

The evidence in support of Early Enteral Nutrition (EEN) after upper gastrointestinal surgery is inconclusive. The aim of this study was to determine if EEN improved clinical outcomes and shortened length of hospital stay.

METHODS

Open, prospective multicentre randomised controlled trial within a regional UK Cancer Network. One hundred and twenty-one patients with suspected operable upper gastrointestinal cancer (54 oesophageal, 38 gastric, 29 pancreatic) were studied. Patients were randomised to receive EEN (n = 64) or Control management postoperatively (nil by mouth and IV fluid, n = 57). Analysis was based on intention-to-treat and the primary outcome measure was length of hospital stay.

RESULTS

Operative morbidity was less common after EEN (32.8%) than Control management (50.9%, p = 0.044), due to fewer wound infections (p = 0.017), chest infections (p = 0.036) and anastomotic leaks (p = 0.055). Median length of hospital stay was 16 days (IQ = 9) after EEN compared with 19 (IQ = 11) days after Control management (p = 0.023).

CONCLUSIONS

EEN was associated with significantly shortened length of hospital stay and improved clinical outcomes. These findings reinforce the potential benefit of early oral nutrition in principle and as championed within enhanced recovery after surgery programmes, and such strategies deserve further research in the arena of upper GI surgery.

A clinical and economic evaluation of enteral nutrition

MOTIVATION

The American Society of Parenteral and Enteral Nutrition (ASPEN) guidelines advise use of enteral nutrition (EN) for critically ill hospital patients requiring nutritional support, but no studies have comprehensively estimated economic benefits from adherence to this recommendation.

METHODS

We systematically reviewed studies comparing EN to alternative nutritional support therapies among adult, critically ill patients. We reviewed 1200 abstracts, selected 243 for further review, and included 48 studies in our analysis. Most retained studies compared EN and parenteral nutrition (PN). Using meta-analysis, we estimated the absolute impact of EN on adverse event risk and its impact on treatment duration and length of stay. These estimates were converted to population economic impacts by assuming 10% of PN patients are suitable candidates for EN.

RESULTS

Compared to PN, EN reduces the risk of major, potentially life-threatening infections (RR = 0.58, 95% confidence interval [CI] 0.44 to 0.77), the risk of major, potentially life-threatening non-infection events (RR = 0.73, CI 0.59 to 0.91), and suggests a reduction in mortality, although this result did not achieve statistical significance (RR = 0.70, CI 0.45 to 1.09). EN also reduces inpatient length of stay, time in the ICU, and length of nutritional treatment. Compared to PN, EN savings from reduced adverse event risks average nearly $1500 per patient; savings from reduced hospital length of stay amount to nearly $2500 per patient. Shifting 10% of parenterally treated adult patients in the U.S. to EN would save $35 million annually due to reduced adverse events and another $57 million due to shorter hospital stays.

CONCLUSION

The evidence of both clinical and economic gains from EN is consistent with ASPEN guidelines recommending use of EN in critically ill hospital patients when possible.

Multimodal optimization of surgical care shows beneficial outcome in gastrectomy surgery

BACKGROUND

The aim of this trial was to compare multimodal optimization with conventional perioperative management in a consecutive series of patients undergoing gastrectomy procedures.

METHODS

According to randomized controlled studies and conclusions made by meta-analyses in colorectal surgery, optimized perioperative measures were designed and applied in gastrectomy surgery. Thirty-three patients were randomized to the optimized group and 30 patients to a control group. Two groups were treated in 1 center by a single surgical team in different wards. Both groups used patient-controlled intravenous analgesia for postoperative analgesia. The primary end point was length of postoperative hospital stay. Secondary outcomes included bowel function recovery after surgery, perioperative changes of inflammatory factors, glucocorticoid, insulin resistance, and body composition. Perioperative complications and adverse events were also recorded.

RESULTS

The groups were similar in terms of age, sex ratio, and Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM score). The optimized group was associated with a significantly shorter postoperative hospital stay compared with the conventional care group (P < .001). Durations of urinary catheterization and abdominal drainage were also less (P < .001). The diet program in the optimization group was well tolerated and was associated with an earlier recovery of gut function (P < .001). Proinflammatory factors were less elevated and body composition was more stable in the optimized group than in controls. There were no differences in morbidity or mortality between the groups.

CONCLUSIONS

Optimization of care in gastrectomy can shorten postoperative hospital stay and provides multiple beneficial outcomes, including hastening the return of gut function, without increasing morbidity.

Laparoscopic gastric surgery in an enhanced recovery programme

BACKGROUND

Laparoscopy is associated with less pain and organ dysfunction than open surgery. Improved perioperative care (enhanced recovery programmes, fast-track methodology) has also led to reduced morbidity and a shorter hospital stay. The effects of a combination of laparoscopic resection and accelerated recovery have not been examined previously in the context of gastric surgery.

METHODS

This was a prospective study of 32 consecutive patients undergoing laparoscopic gastric resection combined with an enhanced recovery protocol (early oral intake, no drains or nasogastric tubes, no epidural analgesia, use of a urinary catheter for less than 24 h and planned discharge 72 h after surgery). Outcomes included length of hospital stay, intraoperative and postoperative complications, readmission rate and 30-day mortality.

RESULTS

Operative procedures were elective distal or subtotal gastrectomy (22 patients) and total gastrectomy (10). Median length of hospital stay was 4 (range 2-30) days. There were two major complications: postoperative bleeding requiring reoperation and pulmonary embolism. Two patients required readmission, one for a wound abscess and one for treatment of a urinary tract infection. There were no deaths within 30 days.

CONCLUSION

Minimally invasive gastrectomy with enhanced postoperative recovery results in a short hospital stay and low morbidity rate.

Postoperative ileus: Impact of pharmacological treatment, laparoscopic surgery and enhanced recovery pathways

Almost all patients develop postoperative ileus (POI) after abdominal surgery. POI represents the single largest factor influencing length of stay (LOS) after bowel resection, and has great implications for patients and resource utilization in health care. New methods to treat and decrease the length of POI are therefore of great importance. During the past decade, a substantial amount of research has been performed evaluating POI, and great progress has been made in our understanding and treatment of POI. Laparoscopic procedures, enhanced recovery pathways and pharmacologic treatment have been introduced. Each factor has substantially contributed to decreasing the length of POI and thus LOS after bowel resection. This editorial outlines resource utilization of POI, normal physiology of gut motility and pathogenesis of POI. Pharmacological treatment, fast track protocols and laparoscopic surgery can each have significant impact on pathways causing POI. The optimal integration of these treatment options continues to be assessed in prospective studies.

Early postoperative feeding in resectional gastrointestinal surgical cancer patients

Malnutrition is present in the majority of patients presenting for surgical management of gastrointestinal malignancies, due to the effects of the tumour and preoperative anti-neoplastic treatments. The traditional practice of fasting patients until the resumption of bowel function threatens to further contribute to the malnutrition experienced by these patients. Furthermore, the rationale behind this traditional practice has been rendered obsolete through developments in anaesthetic agents and changes to postoperative analgesia practices. Conversely, there is a growing body of literature that consistently demonstrates that providing oral or tube feeding proximal to the anastomosis within 24 h postoperatively, is not only safe, but might be associated with significant benefits to the postoperative course. Early post operative feeding should therefore be adopted as a standard of care in oncology patients undergoing gastrointestinal resections.