Naso-gastric or naso-jejunal decompression after partial distal gastrectomy for gastric cancer. Final results of a multicenter prospective randomized trial

Lessons learned from 150 total gastrectomies for prevention of cancer

BACKGROUND

Prophylactic total gastrectomy (PTG) is performed in carriers of CDH1 pathogenic and likely pathogenic (P/LP) variants and is becoming more frequent with broader use of germline genetic testing. There is an unmet need to standardize care and enhance outcomes among patients undergoing surgery for the prevention of gastric cancer.

METHODS

This was a retrospective analysis of 150 individuals with germline CDH1 P/LP variants who underwent PTG as part of a prospective natural history study from October 2017 to May 2023. All individuals received multidisciplinary, protocolized care before and after total gastrectomy.

RESULTS

A total of 150 asymptomatic patients with germline CDH1 P/LP variants underwent PTG with the aid of a multidisciplinary enhanced recovery after surgery (ERAS) pathway. This study demonstrated that acute major morbidity (Clavien-Dindo grade of ≥3) was low (17/150 [11.3%]) and that the most common complication was anastomotic leak (11/150 [7.3%]) in the setting of a comprehensive preoperative and postoperative care pathway. Nearly all gastrectomy specimens (132/150 [88.0%]) harbored occult signet ring cell lesions on final pathology. There were no gastric cancer recurrences or gastric cancer-related deaths during the study period, with a median overall follow-up of 36 months (IQR, 24-48) from gastrectomy.

CONCLUSION

PTG can be performed with low surgical morbidity in a high-volume center. The delivery of patient-centered care by a multidisciplinary team and the application of an ERAS pathway may improve short-term outcomes. However, interventions that can reduce chronic morbidity associated with total gastrectomy warrant further study.

State of the art of enhanced recovery after surgery (ERAS) protocols in esophagogastric cancer surgery: the Western experience

Enhanced recovery after surgery (ERAS) programs provide a framework to standardize care processes and improve outcomes. The results of this multimodal and multidisciplinary approach based on actions focused on reducing physiological surgical stress in the preoperative, intraoperative, and postoperative periods are beneficial in reducing morbidity and hospital stay, without increasing readmissions across different surgical settings. The implementation of ERAS in resection procedures of esophageal and gastric cancer has been challenging due to the complexity of these surgical techniques and the high risk of complications. Despite the limited evidence of ERAS in esophagectomy operations, systematic reviews and meta-analysis have confirmed a reduction of pulmonary complications and hospital stay without increasing readmissions. In gastrectomy operations, the implementation of ERAS reduces the use of nasogastric tubes and intraabdominal drains, facilitates early diet, and reduces the length of hospital stay, without increasing complications. There is, however, wide heterogeneity and absence of standardization in the number and definition of the ERAS components. The development of ERAS consensus guidelines including procedure-specific components may reduce this variability. Regardless growing evidence of the effectiveness of ERAS, the adherence rate is still low. The commitment of the multidisciplinary team and leadership is critical in the application and refinement of ERAS protocols in parallel with periodic audits. Pre- and post-habilitation methods are emerging concepts to be incorporated in ERAS protocols.

Enhanced recovery after surgery (ERAS) versus standard recovery for gastric cancer patients: The evidences and the issues

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.

Gastric emergencies in older adults: not always the same old story! A tertiary care emergency department observational cohort study

OBJECTIVE

To analyse and compare the clinical outcomes between patients ≥80 years and 65-79 years, who presented to our emergency department (ED) with the two most common gastric emergency (GE) clinical presentation, that is, gastric bleeding and gastric perforation.

DESIGN

Single-centre retrospective cohort study.

PARTICIPANTS

A total of 1011 patients were enrolled: 421 patients aged ≥80 years were compared with a group of 590 patients aged 65-79 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was to compare the overall mortality. Secondary outcomes included major complications, in-hospital length of stay (LOS) and need for surgical procedures.

RESULTS

Patients ≥80 years with GE had different presentations at ED compared with younger patients: they had higher gastrointestinal bleeding (24.9% vs 16.3%, p=0.001), anemisation (14.5% vs 8.8%, p=0.005) and shock (10.9% vs 5.1%, p=0.001) rates. Median LOS, cumulative major complications and mortality rates were similar among the two groups.Multivariate analysis identified shock, gastric malignancy and gastric fistula as independent predictors for survival.

CONCLUSIONS

Patients ≥80 years with GE did not have a higher mortality rate and cumulative major complications as compared to younger elderly patients. Invasive treatments were not associated with a different prognosis in this age group.

Omitting nasogastric tube placement after gastrectomy does not enhance postoperative recovery: a propensity score matched analysis

PURPOSE

Enhanced recovery after surgery (ERAS) program has become the main trend in gastrointestinal surgery. This study aims to investigate factors influencing the decision-making of nasogastric tube (NGT) placement and its safety and efficacy after gastrectomy.

METHODS

We analyzed our prospectively maintained database including 287 patients who underwent elective gastrectomy in our department from January 1 to December 31, 2017. All cases were divided into two groups, namely, the no-NGT group and the NGT group. Logistic regression was used to analyze factors that affected the decision of NGT placement, and propensity score matching (PSM) was later applied to balance those factors for the analysis of safety outcomes between groups.

RESULTS

Multivariate analysis showed resection range (p = 0.004, proximal gastrectomy: OR = 4.555, 95%CI = 1.392-14.905, p = 0.016; total gastrectomy: OR = 1.990, 95%CI = 1.205-3.287, p = 0.009) was the only independent risk factor of NGT placement. NGT was omitted in the majority (58.8%) of distal gastrectomy but only in 42.5% and 25% in total and proximal gastrectomy. After PSM, we found no significant differences between patients with or without NGT in postoperative hospital stay, time to first flatus and defecation, time to fluid and semi-fluid diet, rate of reinsertion, or hospitalization expenditure (p > 0.05, respectively). The incidence of postoperative complications in the two groups were 21.7% and 23.5%, respectively (p = 0.753), and the incidence of major complications was 7.0% and 9.6% (p = 0.472).

CONCLUSION

The decision-making of NGT placement is mainly influenced by the resection range. Omitting NGT is a safe approach in all types of gastrectomy but was not able to enhance the recovery in our practice.

Electroacupuncture for postoperative ileus after laparoscopic surgery on colorectal cancer: study protocol for a randomized controlled trial

BACKGROUND

Postoperative ileus (POI) occurs in almost all patients after abdominal laparoscopic surgery, resulting in complications and increasing the length of hospitalization. Electroacupuncture has been used as an alternative therapy for gastrointestinal dysfunction, but its efficacy for POI is inconclusive. The study is designed to determine whether electroacupuncture can accelerate recovery from POI.

METHODS/DESIGN

This study is a three-arm, randomized controlled trial. A total of 105 patients will be randomized into a group receiving electroacupuncture at Tianshu (ST25), a group receiving electroacupuncture at Zusanli (ST36), or a control group in a 1:1:1 ratio. Patients in the electroacupuncture groups will receive electroacupuncture treatment for 4 days from the first day after surgery. The primary outcome consists of the time to first flatus and the time to first defecation. Secondary outcomes include the time to first tolerance of liquid and semiliquid food; the length of the hospital stay; postoperative pain, nausea, and vomiting; abdominal distension; the time to first get out of bed; and postoperative complications. The outcomes will be assessed by the patients themselves every day during hospitalization. Surgeons, nurses, assessors, and statisticians will be blinded to the group assignments. Patients in the two electroacupuncture groups, but not in the control group, will be blinded to the group assignments. The acupuncturists will not be blinded.

DISCUSSION

The aim of this trial is to provide a nonpharmacological therapy for POI and may provide evidence of the effect of electroacupuncture at ST25 or ST36 on POI.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR1900027466 . Registered on 14 November 2019.

Effects of early oral feeding after radical total gastrectomy in gastric cancer patients

BACKGROUND

Gastric cancer (GC) is a heavy burden in China. Nutritional support for GC patients is closely related to postoperative rehabilitation. However, the role of early oral feeding after laparoscopic radical total gastrectomy in GC patients is unclear and high-quality research evidence is scarce.

AIM

To prospectively explore the safety, feasibility and short-term clinical outcomes of early oral feeding after laparoscopic radical total gastrectomy for GC patients.

METHODS

This study was a prospective cohort study conducted between January 2018 and December 2019 based in a high-volume tertiary hospital in China. A total of 206 patients who underwent laparoscopic radical total gastrectomy for GC were enrolled. Of which, 105 patients were given early oral feeding (EOF group) after surgery, and the other 101 patients were given the traditional feeding strategy (control group) after surgery. Perioperative clinical data were recorded and analyzed. The primary endpoints were gastrointestinal function recovery time and postoperative complications, and the secondary endpoints were postoperative nutritional status, length of hospital stay and expenses, etc.

RESULTS

Compared with the control group, patients in the EOF group had a significantly shorter postoperative first exhaust time (2.48 ± 1.17 d vs 3.37 ± 1.42 d, P = 0.001) and first defecation time (3.83 ± 2.41 d vs 5.32 ± 2.70 d, P = 0. 004). In addition, the EOF group had a significant shorter postoperative hospitalization duration (5.85 ± 1.53 d vs 7.71 ± 1.56 d, P < 0.001) and lower postoperative hospitalization expenses (16.60 ± 5.10 K¥ vs 21.00 ± 7.50 K¥, P = 0.014). On the 5^th day after surgery, serum prealbumin level (214.52 ± 22.47 mg/L vs 204.17 ± 20.62 mg/L, P = 0.018), serum gastrin level (246.30 ± 57.10 ng/L vs 223.60 ± 55.70 ng/L, P = 0.001) and serum motilin level (424.60 ± 68.30 ng/L vs 409.30 ± 61.70 ng/L, P = 0.002) were higher in the EOF group. However, there was no significant difference in the incidence of total postoperative complications between the two groups (P = 0.507).

CONCLUSION

Early oral feeding after laparoscopic radical total gastrectomy can promote the recovery of gastrointestinal function, improve postoperative nutritional status, reduce length of hospital stay and expenses while not increasing the incidence of related complications, which indicates its safety, feasibility and potential benefits for gastric cancer patients.

Current status of the "enhanced recovery after surgery" program in gastric cancer surgery

Since the late 1990s, perioperative care through the enhanced recovery after surgery (ERAS, European Society for Clinical Nutrition and Metabolism [ESPEN]) program has spread. ERAS protocols aim to reduce surgical complications, improving postoperative outcomes and thereby saving resources by addressing various clinical elements through a multidisciplinary approach or based on evidence. In the field of gastric cancer, the philosophy of ERAS has gradually become accepted and, in 2014, consensus guidelines for enhanced recovery after gastrectomy were published. These guidelines consist of "procedure-specific" guidelines and "general (not procedure-specific) enhanced recovery items." In this review, we focused on the procedure-specific guidelines and tried to update the contents of every element of the procedure-specific guidelines. The procedure-specific guidelines consist of the following eight elements: "Preoperative nutrition," "Preoperative oral pharmaconutrition," "Access (of gastrectomy)," "Wound catheters and transversus abdominis plane block," "Nasogastric/Nasojejunal decompression," "Perianastomotic drains," "Early postoperative diet and artificial nutrition," and "Audit." On reviewing papers supporting these elements, it was reconfirmed that the recommendations of the guidelines are pertinent and valid. Four meta-analyses concerning the evaluation of ERAS protocols for gastric cancer were included in this review. Every study showed that the ERAS protocol reduced the cost and duration of hospital stay without increasing surgical complication rates, suggesting that ERAS is effective for gastric cancer surgery. However, it cannot be said that ERAS has achieved full penetration in Japan because most evidence is established in Western countries. Future studies must focus on developing a new ERAS protocols appropriate to Japanese conditions of gastric cancer.

One-day nasogastric tube decompression after distal gastrectomy: a prospective randomized study

PURPOSE

Many surgeons in Japan use 1-day nasogastric tube (NGT) decompression after gastrectomy as a standard procedure. This prospective randomized study aimed to define whether 1-day NGT decompression is necessary after distal gastrectomy.

METHODS

The subjects were 233 patients with gastric cancer, randomized into two groups immediately after distal gastrectomy: one group received 1-day NGT decompression (NGT group, n = 119) and the other did not (no-NGT group, n = 114). The primary outcome measure was postoperative surgery-related and respiratory complications, whereas secondary measures were the postoperative course to recovery and patient complaints.

RESULTS

The incidence of surgery-related complications did not differ significantly between the NGT and no-NGT groups (21.0 and 19.2%, respectively; p = 0.87). The rate of respiratory complications was 6.7% in the NGT group and 7.0% in the no-NGT group (p > 0.99). The time to passage of first flatus and the postoperative hospital stay did not differ between the groups. Twenty-five patients in the NGT group and none in the no-NGT group complained of nasopharyngeal discomfort (p < 0.0001).

CONCLUSION

Considering the physical discomfort caused by the NGT, we believe that routine 1-day NGT decompression is unnecessary after distal gastrectomy.

Current status of management of malignant disease: current management of gastric cancer

Despite a continually decreasing incidence trend, gastric cancer remains a high-risk malignancy. Symptoms are often unspecific, and upper gastrointestinal endoscopy is the key modality for diagnosing early and intermediate-stage disease. Surgeons play a critical role in guiding and managing multiple aspects of gastric cancer diagnosis and care. Potentially curable gastric adenocarcinoma has to be free of distant metastasis and should be staged through endoscopic ultrasound and computed tomography. Early (T1N0) gastric cancer can be considered for endosopic mucosal resection or submucosal dissection. All other M0 stage groups should be evaluated for preoperative chemotherapy or chemoradiation followed by resection through a multidisciplinary approach. Laparoscopic staging, complete (R0) resection, and extended lymphadenectomy (D2 dissection) are critical operative components that optimize curability during gastrectomy. The morbidity potential after gastrectomy remains high; splenectomy and distal pancreatectomy should be avoided if possible to minimize postoperative complications. Laparoscopic gastric cancer resections are increasingly pursued and have not shown disadvantages to open gastrectomy as long as oncologic principles are followed. For the palliation of specific symptoms in patients with incurable gastric cancer, operative interventions should be applied selectively if less invasive modalities are insufficient and only if a meaningful benefit can be expected from a resection or bypass procedure. Prophylactic total gastrectomy should be considered for individuals at risk for hereditary diffuse-type gastric cancer through germline E-cadherin gene mutations. Surgeons engaging in gastric cancer care are expected to provide specialty expertise in order to plan and deliver appropriate care, minimize postoperative morbidity, and optimize resulting survival.

Is nasogastric or nasojejunal decompression necessary following gastrectomy for gastric cancer? A systematic review and meta-analysis of randomised controlled trials

Whether nasogastric or nasojejunal decompression (ND) prevents anastomotic leakage, hastens the return of bowel function, and shortens hospital stay after gastrectomy for gastric cancer has long been controversial. We evaluated the necessity of routine ND after radical gastrectomy for gastric cancer with a systematic review and meta-analysis. We searched literature published prior to January 2014 in PubMed, Embase, Cochrane Library, Web of Science, and BIOSIS Previews for relevant randomized controlled trials (RCTs). Only prospective RCTs comparing individuals with and without ND after gastrectomy for gastric cancer were included. Outcome measures included time to first flatus, time to starting oral diet, anastomotic leakage, pulmonary complications, wound dehiscence, length of hospital stay, morbidity, and mortality. Cochrane Collaboration RevMan 5.2 software was used for the meta-analysis. Eight RCT studies fulfilled our inclusion criteria. Of the 1,141 patients in those RCTs, 570 received nasogastric or nasojejunal decompression and 571 did not. Anastomotic leakage, pulmonary complications, wound dehiscence, morbidity, and mortality were comparable between the groups. Stratified by the type of gastrectomy or gastrojejunostomy, no significant differences in above mentioned outcomes were observed in subgroup analyses. The no ND group displayed a significantly shorter time to oral diet (weighted mean difference [WMD] = 0.45, 95% confidence interval [CI] = 0.29 to 0.61, p < 0.001) and a marginally shorter end of hospital stay (WMD = 0.48, 95% CI = -0.01 to 0.98, p = 0.05). The ND group significantly shortened time to first flatus (WMD = -0.7, 95% CI = -1.13 to -0.27, p = 0.001), especially with Roux-en-Y reconstruction (WMD = -1.0, 95 % CI = -1.52 to -0.48, p = 0.0002) and prolonged time to starting oral diet (WMD = 0.52, 95% CI = 0.13 to 0.90, p = 0.009) in the patients with subtotal gastrectomy. Routine ND appears to be unnecessary after gastrectomy for gastric cancer, irrespective of the extent of resection, and the type of digestive reconstruction.