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

Risk factors for pneumonia after radical gastrectomy for gastric cancer: a systematic review and meta-analysis

OBJECTIVE

The objective is to systematically gather relevant research to determine and quantify the risk factors and pooled prevalence for pneumonia after a radical gastrectomy for gastric cancer.

METHODS

The reporting procedures of this meta-analysis conformed to the PRISMA 2020. Chinese Wan Fang data, Chinese National Knowledge Infrastructure (CNKI), Chinese Periodical Full-text Database (VIP), Embase, Scopus, CINAHL, Ovid MEDLINE, PubMed, Web of Science, and Cochrane Library from inception to January 20, 2024, were systematically searched for cohort or case-control studies that reported particular risk factors for pneumonia after radical gastrectomy for gastric cancer. The pooled prevalence of pneumonia was estimated alongside risk factor analysis. The quality was assessed using the Newcastle-Ottawa Scale after the chosen studies had been screened and the data retrieved. RevMan 5.4 and R 4.4.2 were the program used to perform the meta-analysis.

RESULTS

Our study included data from 20,840 individuals across 27 trials. The pooled prevalence of postoperative pneumonia was 11.0% (95% CI = 8.0% ~ 15.0%). Fifteen risk factors were statistically significant, according to pooled analyses. Several factors were identified to be strong risk factors, including smoking history (OR 2.71, 95% CI = 2.09 ~ 3.50, I2 = 26%), prolonged postoperative nasogastric tube retention (OR 2.25, 95% CI = 1.36-3.72, I2 = 63%), intraoperative bleeding ≥ 200 ml (OR 2.21, 95% CI = 1.15-4.24, I2 = 79%), diabetes mellitus (OR 4.58, 95% CI = 1.84-11.38, I2 = 96%), male gender (OR 3.56, 95% CI = 1.50-8.42, I2 = 0%), total gastrectomy (OR 2.59, 95% CI = 1.83-3.66, I2 = 0%), COPD (OR 4.72, 95% CI = 3.80-5.86, I2 = 0%), impaired respiratory function (OR 2.72, 95% CI = 1.58-4.69, I2 = 92%), D2 lymphadenectomy (OR 4.14, 95% CI = 2.29-7.49, I2 = 0%), perioperative blood transfusion (OR 4.21, 95% CI = 2.51-7.06, I2 = 90%), and hypertension (OR 2.21, 95% CI = 1.29-3.79, I2 = 0%). Moderate risk factors included excessive surgery duration (OR 1.51, 95% CI = 1.25-1.83, I2 = 90%), advanced age (OR 1.91, 95% CI = 1.42-2.58, I2 = 94%), nutritional status (OR 2.62, 95% CI = 1.55-4.44, I2 = 71%), and history of pulmonary disease (OR 1.61, 95% CI = 1.17-2.21, I2 = 79%).

CONCLUSIONS

This study identified 15 independent risk factors significantly associated with pneumonia after radical gastrectomy for gastric cancer, with a pooled prevalence of 11.0%. These findings emphasize the importance of targeted preventive strategies, including preoperative smoking cessation, nutritional interventions, blood glucose and blood pressure control, perioperative respiratory training, minimizing nasogastric tube retention time, and optimizing perioperative blood transfusion strategies. For high-risk patients, such as the elderly, those undergoing prolonged surgeries, experiencing excessive intraoperative blood loss, undergoing total gastrectomy, or receiving open surgery, close postoperative monitoring is essential. Early recognition of pneumonia signs and timely intervention can improve patient outcomes and reduce complications.

Improving Perioperative Care in Gastric Surgery: Insights from the EUropean PErioperative MEdical Networking (EUPEMEN) Project

Background/Objectives: Gastric cancer remains a leading cause of cancer-related deaths worldwide and surgical resection represents the mainstay of treatment procedures. However, despite the advancements noted in the field of surgical oncology, perioperative complications and variability in the perioperative care provided persist. To address the challenges caused by non-standardized perioperative care for gastric surgery across European healthcare systems, the EUropean PErioperative MEdical Networking (EUPEMEN) protocol has been developed. The present study concisely provides the EUPEMEN protocol's development, implementation, and impact on perioperative management in gastric resections. Methods: The EUPEMEN protocol was developed through a multidisciplinary collaboration involving five academic healthcare professionals from four European countries. The main activities of the collaborative group included a literature review, consensus development, the creation of multimodal rehabilitation manuals, and the development of an online learning platform. The EUPEMEN project aims for the uniform adoption of evidence-based practices across preoperative, intraoperative, and postoperative phases, leading in nutritional, psychological, and physiological optimization. Results: The implementation of the EUPEMEN protocol aims to optimize perioperative outcomes, including reduced postoperative complications, a shorter length of hospitalization, and improved recovery trajectories. The above have been achieved through structured guidelines that ensure consistent care delivery across diverse healthcare settings and tools such as rehabilitation manuals and a free-access online educational platform. Conclusions: The EUPEMEN protocol represents a new standard for perioperative care in the field of gastric surgery that is based on multidisciplinary collaboration and evidence-based practices. While challenges such as resource constraints and variability in adherence remain, the protocol demonstrates significant potential to improve patient outcomes and streamline perioperative management. Future research should focus on long-term effects and adaptation challenges in the setting of non-European healthcare systems.

Enhanced recovery after surgery: Progress in adapted pathways for implementation in standard and emerging surgical settings

The concept of enhanced recovery after surgery (ERAS) has been practiced for decades and has been implemented in numerous surgical specialties. ERAS is a global surgical quality improvement initiative, and it is an element in the field of perioperative care. ERAS had shown significant clinical outcomes, patient-reported satisfaction, and improvements in medical service cost. ERAS has been developed for specific surgical procedures, but with the fast progress of newly introduced surgical procedures, the original ERAS have been developed and modified. Recently appearing Topics and future research trends encompass ERAS protocols for other types of surgery and the enhancement of perioperative status, including but not limited to pediatric surgery, laparoscopic and robotic assisted surgery, bariatric surgery, thoracic surgery, and renal transplantation. The elements and pathways of ERAS have been developed with the introduction of up-to-date methodologies in the pre-operative, operative, and post-operative pathways. ERAS costs are higher than traditional care, but the patient's clinical outcome and satisfaction are higher. ERAS is in progress in the fields of anesthetic tasks, pediatric surgery, and organ transplantation. Although ERAS has shown significant clinical outcomes, there are needs to modify the protocol for specific cases, hospital facilities, resources, and nurses training on elements of ERAS. Several challenges and limitations exist in the implementation of ERAS that deserve consideration, it includes: Frailty, maximizing nutrition, prehabilitation, treating preoperative anemia, and enhancing ERAS adoption globally are all included.

Short-term outcomes of distal gastrectomy versus total gastrectomy for gastric cancer under enhanced recovery after surgery: a propensity score-matched analysis

Enhanced recovery after surgery (ERAS) has been used safely and effectively in patients with gastric cancer. Our aim was to evaluate the short-term outcomes of total gastrectomy (TG) versus distal gastrectomy (DG) for gastric cancer under ERAS. A prospectively collected database of 1349 patients with gastric cancer who underwent TG or DG between January 2016 and September 2022 was retrospectively analyzed. Propensity score matching analysis was used at a ratio of 1:1 to reduce confounding effects, and perioperative clinical outcomes were compared between the two groups. The primary outcome was overall postoperative complications (POCs). Secondary outcomes comprised time to bowel function recovery, postoperative hospital stay, mortality, and 30-day readmission rate. Of 1349 identified patients, 296 (21.9%) experienced overall POCs. Before matching, multivariable analysis revealed that age, body mass index, diabetes, operation time, and extent of gastrectomy were independent risk factors for overall POCs. After matching, each group comprised 495 patients, and no significant differences were observed between the groups for all parameters except tumor location. Compared with TG, DG was associated with significantly earlier days to first flatus and to eating a soft diet, and shorter postoperative hospital stay (P < 0.05). The incidence of overall- and severe POCs (Clavien-Dindo grade ≥ IIIa) in the TG group was significantly higher vs. the DG group (P < 0.05). There was no significant difference in the number of days to eating a liquid diet, or mortality and 30-day readmission rates between the groups (P > 0.05). In the subgroup analysis for middle-third gastric cancer, the TG group experienced higher rates of overall- and severe POCs, with a longer postoperative hospital stay. Compared with DG, patients who underwent TG had higher POC rates, slower recovery of bowel function, and longer duration of hospitalization under ERAS. Therefore, caution is needed when initiating early feeding for patients who undergo TG.

Outcomes before and after Implementation of the ERAS (Enhanced Recovery after Surgery) Protocol in Open and Laparoscopic Colorectal Surgery: A Comparative Real-World Study from Northern Italy

Enhanced Recovery After Surgery (ERAS) protocols have changed perioperative care, aiming to optimize patient outcomes. This study assesses ERAS implementation effects on postoperative complications, length of hospital stay (LOS), and mortality in colorectal cancer (CRC) patients. A retrospective real-world analysis was conducted on CRC patients undergoing surgery within a Northern Italian Cancer Registry. Outcomes including complications, re-surgeries, 30-day readmission, mortality, and LOS were assessed in 2023, the year of ERAS protocol adoption, and compared with data from 2022. A total of 158 surgeries were performed, 77 cases in 2022 and 81 in 2023. In 2023, a lower incidence of postoperative complications was observed compared to that in 2022 (17.3% vs. 22.1%), despite treating a higher proportion of patients with unfavorable prognoses. However, rates of reoperations and readmissions within 30 days post-surgery increased in 2023. Mortality within 30 days remained consistent between the two groups. Patients diagnosed in 2023 experienced a statistically significant reduction in LOS compared to those in 2022 (mean: 5 vs. 8.1 days). ERAS protocols in CRC surgery yield reduced postoperative complications and shorter hospital stays, even in complex cases. Our study emphasizes ERAS' role in enhancing surgical outcomes and recovery.

PERIOPERATIVE CARE IN DIGESTIVE SURGERY: THE ERAS AND ACERTO PROTOCOLS - BRAZILIAN COLLEGE OF DIGESTIVE SURGERY POSITION PAPER

BACKGROUND

The concept introduced by protocols of enhanced recovery after surgery modifies perioperative traditional care in digestive surgery. The integration of these modern recommendations components during the perioperative period is of great importance to ensure fewer postoperative complications, reduced length of hospital stay, and decreased surgical costs.

AIMS

To emphasize the most important points of a multimodal perioperative care protocol.

METHODS

Careful analysis of each recommendation of both ERAS and ACERTO protocols, justifying their inclusion in the multimodal care recommended for digestive surgery patients.

RESULTS

Enhanced recovery programs (ERPs) such as ERAS and ACERTO protocols are a cornerstone in modern perioperative care. Nutritional therapy is fundamental in digestive surgery, and thus, both preoperative and postoperative nutrition care are key to ensuring fewer postoperative complications and reducing the length of hospital stay. The concept of prehabilitation is another key element in ERPs. The handling of crystalloid fluids in a perfect balance is vital. Fluid overload can delay the recovery of patients and increase postoperative complications. Abbreviation of preoperative fasting for two hours before anesthesia is now accepted by various guidelines of both surgical and anesthesiology societies. Combined with early postoperative refeeding, these prescriptions are not only safe but can also enhance the recovery of patients undergoing digestive procedures.

CONCLUSIONS

This position paper from the Brazilian College of Digestive Surgery strongly emphasizes that the implementation of ERPs in digestive surgery represents a paradigm shift in perioperative care, transcending traditional practices and embracing an intelligent approach to patient well-being.

Clinical study of enhanced recovery after surgery in laparoscopic appendectomy for acute appendicitis

BACKGROUND

Enhanced recovery after surgery (ERAS) protocol is a comprehensive management modality that promotes patient recovery, especially in the patients undergoing digestive tumor surgeries. However, it is less commonly used in the appendectomy.

AIM

To study the application value of ERAS in laparoscopic surgery for acute appendicitis.

METHODS

A total of 120 patients who underwent laparoscopic appendectomy due to acute appendicitis were divided into experimental group and control group by random number table method, including 63 patients in the experimental group and 57 patients in the control group. Patients in the experimental group were managed with the ERAS protocol, and those in the control group were received the traditional treatment. The exhaust time, the hospitalization duration, the hospitalization expense and the pain score between the two groups were compared.

RESULTS

There was no significant difference in age, gender, body mass index and Sunshine Appendicitis Grading System score between the experimental group and the control group (P > 0.05). Compared to the control group, the patients in the experimental group had earlier exhaust time, shorter hospitalization time, less hospitalization cost and lower degree of pain sensation. The differences were statistically significant (P < 0.01).

CONCLUSION

ERAS could significantly accelerate the recovery of patients who underwent laparoscopic appendectomy for acute appendicitis, shorten the hospitalization time and reduce hospitalization costs. It is a safe and effective approach.

The Effect of Surgery on the Prognosis of Gastric Lymphoma: A Meta-analysis

OBJECTIVE

Surgery is an effective clinical approach that has been used for the treatment of gastric lymphoma. However, its specific effect on the prognosis of patients with gastric lymphoma remains largely unknown. The current meta-analysis aimed to identify the effect of surgery on the prognosis of gastric lymphoma.

METHODS

We searched the MEDLINE, Embase, and Cochrane Central databases to obtain relevant studies investigating the influence of surgery on overall survival (OS) and relapse-free survival (RFS). We extracted the hazard ratios (HRs) and associated 95% confidence intervals (CIs) of each included report for pooled analysis. We assessed heterogeneity (I2 statistic) and funnel plots to select the data models and evaluate publication bias.

RESULTS

Ultimately, we included 12 studies containing 26 comparisons in the current quantitative meta-analysis. The analysis revealed that surgery had no significant effect on OS (HR .83, P = .13) or RFS (HR .78, P = .08). However, subgroup analysis revealed that the effect of surgery on OS differed significantly between the surgery plus conservative therapy subgroup and the conservative therapy alone groups, with HR = .69 (P = .01). No significant publication bias was detected regarding the main outcomes.

CONCLUSION

Surgery had a limited effect on the prognosis of patients with gastric lymphoma. However, the use of surgery as an additional therapy may confer potential benefits. This was an interesting research direction, and additional high-quality, large-scale randomized controlled trials should be conducted.

Application effect of gastrointestinal bundle nursing on the protection of gastrointestinal function in patients with gastric cancer

Evidence-based nursing practice was used to formulate the enhanced recovery surgery bundle nursing strategy and apply it to patients with gastric cancer, to explore its safety, effectiveness and feasibility in perioperative gastrointestinal function protection in patients with gastric cancer. Selected the clinical medical records of 100 gastric cancer patients treated in our hospital from June 2019 to June 2021 as the research objects, and divided them into the control group and the observation group with 50 cases in each group according to the random number table. Among them, the control group was given routine nursing measures for nursing intervention, and the observation group was given gastrointestinal enhanced recovery surgery cluster nursing on the basis of the control group. The differences in stress response, gastrointestinal function protection, negative emotions and pain scores of gastric cancer patients before and after nursing were compared between the 2 groups. The postoperative bowel sounds recovery time, first anal exhaust, and first defecation time in the observation group were lower than those in the control group, and the differences were statistically significant (P < .05). Before nursing, there was no significant difference in the scores of stress response changes between the 2 groups (P > .05). After nursing, heart rate (HR), mean arterial pressure (MAP), norepinephrine (NE), and epinephrine (E2) in the observation group were lower than those in the control group, and the difference was statistically significant (P < .05). The pain scores of the 2 groups were significantly improved at different time points, and the observation group was significantly less than the control group, and the difference was statistically significant (P < .05). Gastrointestinal enhanced recovery surgery bundle nursing can effectively improve the gastrointestinal function of patients with gastric cancer, improve the emotional response and stress response of patients, and has certain reference value for the nursing of patients with gastric cancer.

Harnessing interventions during the immediate perioperative period to improve the long-term survival of patients following radical gastrectomy

Although the incidence and mortality of gastric cancer (GC) have been decreasing steadily worldwide, especially in East Asia, the disease burden of this malignancy is still very heavy. Except for tremendous progress in the management of GC by multidisciplinary treatment, surgical excision of the primary tumor is still the cornerstone intervention in the curative-intent treatment of GC. During the relatively short perioperative period, patients undergoing radical gastrectomy will suffer from at least part of the following perioperative events: Surgery, anesthesia, pain, intraoperative blood loss, allogeneic blood transfusion, postoperative complications, and their related anxiety, depression and stress response, which have been shown to affect long-term outcomes. Therefore, in recent years, studies have been carried out to find and test interventions during the perioperative period to improve the long-term survival of patients following radical gastrectomy, which will be the aim of this review.

Impact of postoperative NSAIDs administration on anastomotic leak after esophago-gastric surgery: systematic review and meta-analysis

Anastomotic leak (AL) is a feared complication of esophago-gastric surgery. Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used to treat postoperative pain. Previous analyses conveyed heterogeneous data for colorectal surgery with a tendency toward high risk for AL after NSAIDs administration. In the setting of upper gastrointestinal (GI) surgery data are even more puzzled. The purpose of the present study was to assess whether an association exists between postoperative NSAIDs administration and AL after esophago-gastric surgery. PubMed, MEDLINE, Scopus, and Web of Science were searched up to November 2022. The included studies evaluated outcomes for NSAIDs vs. no NSAIDs administration after esophago-gastric surgery. The primary outcome was anastomotic leak (AL). Risk ratio (RR) and 95% confidence intervals (95% CI) were used to assess pooled effect size and relative inference. Six studies (43,784 patients) were included. The patient age ranged from 31 to 84 years, 82.4% were males and preoperative BMI ranged from 15 to 31 kg/m². Esophagectomy was performed in 95% of patients. NSAIDs were administered in 18,075 (41.3%) patients. The cumulative incidence of AL was similar for NSAIDs vs. no NSAIDs (13.6% vs. 13.4%). The risk for postoperative AL was similar for NSAIDs vs. no NSAIDs administration (RR 1.49; 95% CI 0.81-2.75; p = 0.19). The cumulative incidence of postoperative gastrointestinal bleeding (0.36% vs. 0.39%), acute kidney injury (0.62% vs. 0.71%), and in-hospital mortality (2.39% vs. 2.66%) were comparable. NSAIDs administration for postoperative analgesia seems not associated with an increased risk for AL after esophago-gastric surgery.

Feasibility of Enhanced Recovery After Surgery Protocols Implemented Perioperatively in Endoscopic Submucosal Dissection for Early Gastric Cancer: A Single-Center Retrospective Study

Background: Endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) has advantages over traditional radical gastrectomy. We investigated whether enhanced recovery after surgery (ERAS) protocols are appropriate in the ESD perioperative period. Materials and Methods: We screened 129 consecutive patients, and 12 were excluded. All study patients underwent ESD for EGC. Of the 117 included patients, 57 received traditional perioperative care between January 2017 and December 2018, and 60 patients received perioperative care according to ERAS protocols between January 2019 and September 2020. The primary study endpoint was ESD-related complications. Secondary endpoints included the following postoperative parameters: anal exhaust time, incidence of nausea or vomiting, length of hospitalization, fever rate, abdominal pain on the visual analog scale (VAS), and reported perioperative satisfaction. Results: Complications were comparable between the 2 groups. In the ERAS group, no patients experienced delayed bleeding or perforation. One traditional group patient bled, and one perforated. Postoperative anal exhaust time, nausea or vomiting incidence, hospitalization, fever rate, and VAS pain scores were significantly lower, and perioperative satisfaction rate was significantly higher in the ERAS group. Conclusions: ERAS protocols are both feasible and safe for patients undergoing ESD. ERAS protocols enhance the advantages of ESD for EGC without increasing complications.

Where Enhanced Recovery after Surgery (ERAS) Protocols Meet the Three Major Current Pandemics: COVID-19, Obesity and Malignancy

Simple Summary

The SARS-CoV-2 (COVID-19) pandemic has significantly modified the medical services provided for patients that receive care either for COVID-19 or for those that need care for benign diseases, including obesity, or for malignant ones, such as gynecological cancer. We sought to investigate the association among three major worldwide health issues (COVID-19, obesity, and malignancy) and how ERAS protocols can potentially provide optimal management of patients with obesity and malignancy during the COVID-19 pandemic, with special attention to patients who required surgery for gynecologic oncology. We strongly believe that the application of ERAS protocols could play a key role during these unprecedented COVID-19 times.

Abstract

The outbreak of the SARS-CoV-2 (COVID-19) pandemic has transformed the provision of medical services for both patients that receive care for COVID-19 and for those that need care either for benign diseases, including obesity, or for malignancies, such as gynecological cancer. In this perspective article, we focus on the association among three major worldwide health issues and how ERAS protocols can potentially provide optimal management of patients with obesity and malignancy during the COVID-19 pandemic, with special attention to patients who required surgery for gynecologic oncology. A thorough search of the literature on the respective topics was performed. Patients with malignancy and obesity presented with increased vulnerability to COVID-19 infection. However, the management of their disease should not be withheld. Protective measures should be established to reduce exposure of patients with oncological diseases to SARS-CoV-2 while simultaneously enabling their access to vaccination. Since ERAS protocols have proved to be efficient in many surgical fields, including gynecologic oncology, general surgery, and orthopedics, we strongly believe that ERAS protocols may play a significant role in this effort. The end of the COVID-19 pandemic cannot be accurately predicted. Nevertheless, we have to ensure the appropriate and efficient management of certain groups of patients.