Fast-track program vs traditional care in surgery for gastric cancer

Clinical nursing pathway improves disease cognition and quality of life of elderly patients with hypertension and cerebral infarction

OBJECTIVE

This study aimed to explore the application effect of clinical nursing pathway model in elderly patients with hypertension and cerebral infarction.

METHODS

A total of 106 elderly patients with hypertension and cerebral infarction were recruited and divided into a control group (n=51) and a test group (n=55). Both groups of patients received conventional care, and the test group was given additional care if clinical nursing pathway. The blood pressure indexes, knowledge of stroke, nursing satisfaction, neurological deficit, and activity of daily living (ADL) of the two groups of patients were observed.

RESULTS

After nursing care, the scores of Stroke Knowledge Questionnaire (SKQ) and Barthel index (BI) increased in both groups, and they were significantly higher in the test group than in the control group. The scores of systolic blood pressure (SBP), diastolic blood pressure (DBP) and National Institutes of Health Stroke Scale (NIHSS) decreased significantly in both groups after nursing, and they were lower in the test group than the control group. In addition, patients in the test group exhibited higher nursing satisfaction than the control group, as well as higher rates of blood pressure control at discharge, two months, four months and six months after discharge.

CONCLUSION

The application of clinical nursing pathway can improve the disease cognition and quality of life of elderly patients with hypertension and cerebral infarction, and promote their recovery.

Causes of prolonged hospitalization after open incisional hernia repair: an observational single-center retrospective study of a prospective database

PURPOSE

Enhanced recovery after surgery (ERAS) is a well-known approach to optimize the recovery after surgery. Little is known about specific causes of prolonged hospitalization despite enhanced recovery after open incisional hernia repair (OIHR). The purpose of this study was to identify the causes of continued hospitalization on each of the first 5 postoperative days (PODs) after OIHR.

METHODS

This was a retrospective study of consecutive patients undergoing open AWR at a regional academic hernia center from 2008 to 2018. Patient charts were evaluated using predefined potential causes of continued hospitalization on each of the first five PODs.

RESULTS

A total of 388 patients (mean age 60.9 years, 54.6% male, mean BMI 27.9 kg/m²) were included in the study. Mesh placement was either preperitoneal/intraperitoneal (20%) or retromuscular (80%) and 61% of the patients had an epidural catheter. The median length of stay (LOS) in the cohort was four [IQR 2-6] days. On PODs 4 and 5, causes of continued hospital stay were absent bowel function (2% on POD 4, 1% on POD 5), pain (7% on POD 3, 2% on POD 4), lack of mobilization (1% on POD 4, 1% on POD 5), and other causes (urinary retention, high drain output, and complications to the surgery).

CONCLUSION

Causes for prolonged hospitalization after OIHR were possibly reducible. Future efforts to improve the ERAS regime and reduce LOS after OIHR should focus on pain treatment- and prevention, alternatives to epidural treatment, and well-defined, evidence-based discharge criteria.

Taiwan nutritional consensus on the nutrition management for gastric cancer patients receiving gastrectomy

Currently, consensus reports on the nutritional management for gastric cancer patients receiving gastric resection are lacking. The Gastroenterological Society of Taiwan therefore organized the Taiwan Gastric Cancer Nutritional Consensus Team to provide an overview of evidence and recommendations on nutritional support for gastric cancer patients undergoing gastrectomy. This consensus statement on the nutritional support for gastric cancer patients has two major sections:(1)perioperative nutritional support; and (2)long-term postoperative nutritional care. Thirty Taiwan medical experts conducted a consensus conference, by a modified Delphi process, to modify the draft statements. The key statements included that preoperative nutritional status affects the incidence of operative complications and disease-specific survival in gastric cancer patients undergoing gastrectomy. Following gastrectomy, both early oral and enteral tube feeding can result in a shorter stay than total parenteral nutrition. Compared to late oral feeding, early oral feeding can reduce hospital stay in gastric cancer patients receiving gastrectomy without an increase in complication rate. Routine supplementation with vitamin B12 is indicated for gastric cancer patients undergoing a total gastrectomy. Both high-dose oral vitamin B12 supplementation and intramuscular administration of vitamin B12 are equally effective in the treatment of vitamin B12 deficiency.

Laparoscopic versus open distal gastrectomy for advanced gastric cancer: A meta-analysis of randomized controlled trials and high-quality nonrandomized comparative studies

BACKGROUND

Controversy persists about the effects of laparoscopic distal gastrectomy (LDG) versus open distal gastrectomy (ODG) on short-term surgical outcomes and long-term survival within the field of advanced gastric cancer (AGC).

METHODS

Studies published from January 1994 to February 2020 that compare LDG and ODG for AGC were identified. All randomized controlled trials (RCTs) were included. The selection of high-quality nonrandomized comparative studies (NRCTs) was based on a validated tool (Methodological Index for Nonrandomized Studies, MINORS). The short- and long-term outcomes of both procedures were compared.

RESULTS

Overall, 30 studies were included in this meta-analysis, which comprised of 8 RCTs and 22 NRCTs involving 16,029 patients (7864 LDGs, 8165 ODGs). The recurrence, 3-year disease-free survival (DFS), 3-year overall survival (OS), and 5-year OS rates for LDG and ODG were comparable. LDG was associated with a lower postoperative complication rate (OR 0.79; P < 0.00001), lower estimated volume of blood loss (WMD -102.21 mL; P < 0.00001), shorter postoperative hospital stay (WMD -1.96 days; P < 0.0001), shorter time to first flatus (WMD -0.54 day; P = 0.0007) and shorter time to first liquid diet (WMD -0.66 day; P = 0.001). The number of lymph nodes retrieved, mortality, intraoperative complications, intraoperative blood transfusion, and time to ambulation were similar. However, LDG was associated with a longer surgical time (WMD 33.57 min; P < 0.00001).

CONCLUSIONS

LDG with D2 lymphadenectomy is a safe and effective technique for patients with AGC when performed by experienced surgeons at high-volume specialized centers.

Laparoscopic versus open subtotal gastrectomy for gastric adenocarcinoma: cost-effectiveness analysis

Background

Laparoscopic subtotal gastrectomy (LSG) for cancer is associated with good perioperative outcomes and superior quality of life compared with the open approach, albeit at higher cost. An economic evaluation was conducted to compare the two approaches.

Methods

A cost–effectiveness analysis between LSG and open subtotal gastrectomy (OSG) for gastric cancer was performed using a decision‐tree cohort model with a healthcare system perspective and a 12‐month time horizon. Model inputs were informed by a meta‐analysis of relevant literature, with costs represented in 2016 Canadian dollars (CAD) and outcomes measured in quality‐adjusted life‐years (QALYs). A secondary analysis was conducted using inputs extracted solely from European and North American studies. Deterministic (DSA) and probabilistic (PSA) sensitivity analyses were performed.

Results

In the base‐case model, costs of LSG were $935 (€565) greater than those of OSG, with an incremental gain of 0·050 QALYs, resulting in an incremental cost–effectiveness ratio of $18 846 (€11 398) per additional QALY gained from LSG. In the DSA, results were most sensitive to changes in postoperative utility, operating theatre and equipment costs, as well as duration of surgery and hospital stay. PSA showed that the likelihood of LSG being cost‐effective at willingness‐to‐pay thresholds of $50 000 (€30 240) per QALY and $100 000 (€60 480) per QALY was 64 and 68 per cent respectively. Secondary analysis using European and North American clinical inputs resulted in LSG being dominant (cheaper and more effective) over OSG, largely due to reduced length of stay after LSG.

Conclusion

In this decision analysis model, LSG was cost‐effective compared with OSG for gastric cancer.

Enhanced recovery after surgery on multiple clinical outcomes: Umbrella review of systematic reviews and meta-analyses

BACKGROUND

Previously, many meta-analyses have reported the impact of enhanced recovery after surgery (ERAS) programs on many surgical specialties.

OBJECTIVES

To systematically assess the effects of ERAS pathways on multiple clinical outcomes in surgery.

DESIGN

An umbrella review of meta-analyses.

DATE SOURCES

PubMed, Embase, Web of Science and the Cochrane Library.

RESULTS

The umbrella review identified 23 meta-analyses of interventional study and observational study. Consistent and robust evidence shown that the ERAS programs can significantly reduce the length of hospital stay (MD: -2.349 days; 95%CI: -2.740 to -1.958) and costs (MD: -$639.064; 95%CI:: -933.850 to -344.278) in all the surgery patients included in the review compared with traditional perioperative care. The ERAS programs would not increase mortality in all surgeries and can even reduce 30-days mortality rate (OR: 0.40; 95%CI: 0.23 to 0.67) in orthopedic surgery. Meanwhile, it also would not increase morbidity except laparoscopic gastric cancer surgery (RR: 1.49; 95%CI: 1.04 to 2.13). Moreover, readmission rate was increased in open gastric cancer surgery (RR: 1.92; 95%CI: 1.00 to 3.67).

CONCLUSION

The ERAS programs are considered to be safe and efficient in surgery patients. However, precaution is necessary for gastric cancer surgery.

The application of enhanced recovery after surgery for upper gastrointestinal surgery: Meta-analysis

BACKGROUND

Although enhanced recovery after surgery (ERAS) has made great progress in the field of surgery, the guidelines point to the lack of high-quality evidence in upper gastrointestinal surgery.

METHODS

Randomized controlled trials in four electronic databases that involved ERAS protocols for upper gastrointestinal surgery were searched through December 12, 2018. The primary endpoints were lung infection, urinary tract infection, surgical site infection, postoperative anastomotic leakage and ileus. The secondary endpoints were postoperative length of stay, the time from end of surgery to first flatus and defecation, and readmission rates. Subgroup analysis was performed based on the type of surgery.

RESULTS

A total of 17 studies were included. The results of the meta-analysis indicate that there was a decrease in rates of lung infection (RR = 0.50, 95%CI: 0.33 to 0.75), postoperative length of stay (MD = -2.53, 95%CI: - 3.42 to - 1.65), time until first postoperative flatus (MD = -0.64, 95%CI: - 0.84 to - 0.45) and time until first postoperative defecation (MD = -1.10, 95%CI: - 1.74 to - 0.47) in patients who received ERAS, compared to conventional care. However, other outcomes were not significant difference. There was no significant difference between ERAS and conventional care in rates of urinary tract infection (P = 0.10), surgical site infection (P = 0.42), postoperative anastomotic leakage (P = 0.45), readmissions (P = 0.31) and ileus (P = 0.25).

CONCLUSIONS

ERAS protocols can reduce the risk of postoperative lung infection and accelerating patient recovery time. Nevertheless, we should also consider further research ERAS should be performed undergoing gastrectomy and esophagectomy.

Safety and Efficacy of Early Oral Feeding after Liver Transplantation with Roux-en-Y Choledochojejunostomy: A Single-Center Experience

BACKGROUND

Early oral feeding, as one of the most important components of multimodal strategies referred to as Enhanced Recovery After Surgery (ERAS), is now widely adopted for optimization of post-operative recovery of surgical patients.

OBJECTIVE

To assess ERAS outcome in patients who underwent liver transplantation in our center.

METHODS

In a prospective study, patients who underwent liver transplantation from April 2015 to June 2018 at Imam Khomeini Hospital Complex, affiliated to Tehran University of Medical Sciences, Tehran, Iran, were enrolled in this study. Serum albumin, total iron-binding capacity (TIBC), and course of hospital stay were assessed.

RESULTS

39 (23 male) patients who underwent choledochojejunostomy with Roux-en-Y anastomosis for liver transplantation were enrolled. The mean±SD pre-operative serum albumin and TIBC levels of patients were 3.0±0.6 (range: 1.9-4.1) g/dL and 304±75 (range: 154.0-437.0) µg/dL, respectively. The mean±SD time between the end of operation and starting oral feeding was 11.6±1.8 (range: 9.0-15.0) hours. All patients tolerated early oral feeding with liquids followed by solid foods; no vomiting reported in patients. Overall, patient survival rates at one month and three months were 89.7% and 89.7%, respectively. In our study, no leak of anastomosis was reported.

CONCLUSION

There was no major harm for ERAS after liver transplantation and it might be even helpful as in colorectal surgeries. As seen in our study, oral feeding was started as soon as possible after the end of operation in almost all patients and all of them tolerated early oral feeding. No one had vomiting or nausea.

Effects of the Enhanced Recovery Program on the Recovery and Stress Response in Patients With Cancer Undergoing Pancreatoduodenectomy

Aim the study was the comparison of enhanced recovery after surgery (ERAS) versus conventional care (CON) protocols in patients undergoing pancreatoduodenectomy with regard to pain intensity, emotional response (optimism/sadness/stress), and stress biomarker levels (adrenocorticotropopic hormone, cortisol). We conducted a prospective two-group randomized controlled study with repeated measures in 85 patients with cancer pancreatoduodenectomy. In the ERAS group (N = 44), the ERAS protocol was followed, compared with the CON group (N = 41). We assessed pain with the numeric rating scale and a behavioral scale (Critical Care Pain Observation Tool), emotional responses (numeric rating scale), and serum adrenocorticotropopic hormone and cortisol levels at three time points: T1, admission day; T2, day of surgery; and T3, discharge day (ERAS) or the fifth day of stay (CON). Data were analyzed by linear mixed modeling to account for repeated measurements. We observed decreased postoperative pain in ERAS patients after adjusting for confounders (p = .002) and a trend for less complications. No significant associations with stress/emotional responses were noted. Only age, but not protocol, appeared to have a significant effect on adrenocorticotropopic hormone levels despite a significant interaction with time toward increased adrenocorticotropopic hormone levels in the ERAS group. In conclusion, despite its fast track nature, ERAS is not associated with increased stress in patients undergoing pancreatoduodenectomy and is associated with decreased pain.

Postoperative stress and pain response applying fast-track protocol in patients undergoing hepatectomy

Aim

To assess the clinical parameters and compare the stress and pain response between fast-track recovery protocol and conventional treatment in patients undergoing major liver resection.

Methods

Eighty-eight patients suffering from malignant liver tumours were surgically treated from May 2012 to March 2015. After randomisation, they were prospectively divided into two groups: group fast-track patients (n = 46) and group conventional treatment patients (n = 42). Demographic and clinical data were collected and patients were assessed with pain scale (behavioural observation scale and visual analog scale), while depression levels were evaluated with Zung self-rating depression scale and three Numeric Analog Scale self-reported questions. Peripheral blood samples were collected at time points: T1 on the admission day, T2 on the day of surgery and T3 on the day of discharge examining serum levels of adrenocorticotropic hormone and cortisol.

Conclusion

Fast-track recovery protocols seem to be associated with improvement in several clinical parameters, without compromising, biologic or emotional stress in patients undergoing major liver resection.

Effects of Early Initiation of Solid Versus Liquid Diet after Endoscopic Submucosal Dissection on Quality of Life and Postoperative Outcomes: A Prospective Pilot Randomized Controlled Trial

BACKGROUND/AIMS

Feeding recommendations after endoscopic submucosal dissection (ESD) for gastric neoplasms are not established and based on clinical experience.

METHODS

This was a prospective pilot randomized controlled trial. Patients undergoing ESD for gastric neoplasms were randomly assigned to solid (n = 50) or liquid diet (n = 50) groups. Beginning the day after hemostasis confirmation until discharge, the solid diet group started on a diet of rice porridge, whereas the liquid diet group started on a liquid diet, with gradual transition to solid food. The primary endpoint was delayed bleeding rate. The secondary endpoints were quality of life (QOL), ulcer-stage, hospital fees, and post-ESD symptoms.

RESULTS

Delayed bleeding occurred in the solid diet group (2%) but not in the liquid diet group. The QOL evaluation using European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-STO22 showed better score in the solid diet group. The patients who felt dietary restriction at discharge was of a larger number in the liquid diet group (p = 0.019). More patients experienced appetite loss (p = 0.038), constipation (p = 0.022), and dietary restriction (p = 0.037) in the liquid diet group during hospitalization. The other endpoints were equivalent between the groups.

CONCLUSION

Early initiation of solid foods after ESD is feasible and associated with higher QOL, potentially rendering conventional liquid diets unnecessary, although additional studies are needed (Trial registration number: UMIN000013297).

Application of fast-track surgery in the perioperative period of laparoscopic partial nephrectomy for renal tumors

OBJECTIVES

This study aimed to examine application of fast-track surgery (FTS) in the perioperative period of laparoscopic partial nephrectomy for renal tumors, and to discuss its effects and safety.

METHODS

Eighty patients who received laparoscopic partial nephrectomy in urinary surgery from January 2016 to December 2017 were selected and randomly classified as the observation group (n = 40) and control group (n = 40). Traditional treatments were performed in the control group, while FTS was applied in the observation group. The complication rate after the operation was recorded.

RESULTS

The duration of the operation and intraoperative blood loss were not different between the groups. The duration of anesthesia and fluid transfusion volume on the day of the operation were significantly less in the observation group than in the control group. The rates of infection of the incisional wound, nausea and vomiting, and anastomotic stomal bleeding were not significantly different between the groups. However, the rates of postoperative urinary tract infection, abdominal distension, thirst, hypothermia, and pulmonary infection were significantly lower in the observation group than in the control group.

CONCLUSION

Application of FTS in laparoscopic partial nephrectomy contributes to postoperative recovery and reduction of postoperative complications.

Enhanced recovery versus conventional care in gastric cancer surgery: a meta-analysis of randomized and non-randomized controlled trials

INTRODUCTION

Enhanced recovery after surgery (ERAS) protocols have been successfully integrated into peri-operative management of different cancer surgeries such as colorectal cancer. Their value for gastric cancer surgery, however, remains uncertain.

METHODS

A search for randomized and observational studies comparing ERAS versus conventional care in gastric cancer surgery was performed according to PRISMA guidelines. Random-effects meta-analyses with inverse variance weighting were conducted, and quality of included studies was assessed using the Cochrane risk-of-bias tool and Newcastle-Ottawa scale (PROSPERO: CRD42017080888).

RESULTS

Twenty-three studies involving 2686 patients were included. ERAS was associated with reduced length of hospital stay (WMD-2.47 days, 95% CI - 3.06 to - 1.89, P < 0.00001), time to flatus (WMD-0.70 days, 95% CI - 1.02 to - 0.37, P < 0.0001), and hospitalization costs (WMD-USD$ 4400, 95% CI - USD$ 5580 to - USD$ 3210, P < 0.00001), with consistent results across open and laparoscopic surgery. Postoperative morbidity and 30-day mortality were similar, although a higher rate of readmission was observed in the ERAS group (RR = 1.95, 95% CI 1.03-3.67, P = 0.04). Patients in the ERAS arm had significantly attenuated C-reactive protein levels on days 3/4 and 7, interleukin-6 levels on days 1, and 3/4, and tumor necrosis factor-α levels on days 3/4 postoperatively.

CONCLUSION

Compared to conventional care, ERAS reduces hospital stay, costs, surgical stress response and time to return of gut function, without increasing post-operative morbidity in gastric cancer surgery. However, precaution is necessary to reduce the increased risk of hospital readmission when adopting ERAS.

Beyond surgery: clinical and economic impact of Enhanced Recovery After Surgery programs

Background

Enhanced Recovery After Surgery (ERAS) is a perioperative management based on multimodality and multidisciplinary work. ERAS has been shown to have important clinical and economic benefits, but its spread remains slow worldwide.

Discussion

This manuscript reviews the overall program benefits and focuses on important aspects for implementation well beyond surgery.

Summary

Implementation of ERAS pathways improves clinical outcomes and induces substantial economic gains. ERAS is the current surgical revolution.

Direct visualization transversus abdominis plane blocks offer superior pain control compared to ultrasound guided blocks following open posterior component separation hernia repairs

PURPOSE

Transversus abdominis plane (TAP) blockade with long-acting anesthetic can be used during open ventral hernia repair (VHR) with posterior component separation (PCS). TAP block can be performed under ultrasound guidance (US-TAP) or under direct visualization (DV-TAP). We hypothesized that US-TAP and DV-TAP provide equivalent postoperative analgesia following open VHR.

METHODS

A retrospective review of patients undergoing open VHR with PCS who received TAP blocks with 266 mg of liposomal bupivacaine was performed. Data included demographics, comorbidities, length of stay (LOS), average postoperative day (POD) pain scores, and narcotic requirements (normalized to mg oral morphine). Statistical analysis utilized Student's t test and Fisher's exact test.

RESULTS

Thirty-nine patients were identified (22 DV-TAP). There were no differences between the groups with respect to demographics, comorbidities, pre-operative pain medication usage (narcotic and non-narcotic) or herniorrhaphy-related data. The average POD0 pain score was lower for the DV-TAP group (2.35 vs 4.18; p = 0.019). Narcotic requirements on POD0 (48.0 vs 103.76 mg; p = 0.02), POD1 (128.45 vs 273.82 mg; p = 0.03), POD4 (54.29 vs 160.75 mg; p = 0.042), and during the complete hospitalization (408.52 vs 860.92 mg; p = 0.013) were lower in the DV-TAP group. There were no differences between initiation of diet or LOS. During the study, no changes were made to the VHR enhanced recovery pathway.

CONCLUSIONS

DV-TAP blocks appear to provide superior analgesia in the immediate postoperative period. To achieve similar post-operative pain scores, patients in the US-TAP group required significantly more narcotic administration during their hospitalization. The study highlights DV-TAP as a valuable addition to VHR recovery pathways.

Application of enhanced recovery after gastric cancer surgery: An updated meta-analysis

AIM

To provide an updated assessment of the safety and efficacy of enhanced recovery after surgery (ERAS) protocols in elective gastric cancer (GC) surgery.

METHODS

PubMed, Medline, EMBASE, World Health Organization International Trial Register, and Cochrane Library were searched up to June 2017 for all available randomized controlled trials (RCTs) comparing ERAS protocols and standard care (SC) in GC surgery. Thirteen RCTs, with a total of 1092 participants, were analyzed in this study, of whom 545 underwent ERAS protocols and 547 received SC treatment.

RESULTS

No significant difference was observed between ERAS and control groups regarding total complications (P = 0.88), mortality (P = 0.50) and reoperation (P = 0.49). The incidence of pulmonary infection was significantly reduced (P = 0.03) following gastrectomy. However, the readmission rate after GC surgery nearly tripled under ERAS (P = 0.009). ERAS protocols significantly decreased the length of postoperative hospital stay (P < 0.00001) and medical costs (P < 0.00001), and accelerated bowel function recovery, as measured by earlier time to the first flatus (P = 0.0004) and the first defecation (P < 0.0001). Moreover, ERAS protocols were associated with a lower level of serum inflammatory response, higher serum albumin, and superior short-term quality of life (QOL).

CONCLUSION

Collectively, ERAS results in accelerated convalescence, reduction of surgical stress and medical costs, improved nutritional status, and better QOL for GC patients. However, high-quality multicenter RCTs with large samples and long-term follow-up are needed to more precisely evaluate ERAS in radical gastrectomy.

Enhanced Recovery Pathway in Microvascular Autologous Tissue-Based Breast Reconstruction: Should It Become the Standard of Care?

BACKGROUND

Enhanced recovery pathway programs have demonstrated improved perioperative care and shorter length of hospital stay in several surgical disciplines. The purpose of this study was to compare outcomes of patients undergoing autologous tissue-based breast reconstruction before and after the implementation of an enhanced recovery pathway program.

METHODS

The authors retrospectively reviewed consecutive patients who underwent autologous tissue-based breast reconstruction performed by two surgeons before and after the implementation of the enhanced recovery pathway at a university center over a 3-year period. Patient demographics, perioperative data, and 45-day postoperative outcomes were compared between the traditional standard of care (pre-enhanced recovery pathway) and enhanced recovery pathway patients. Multivariate logistic regression was performed to identify risk factors for length of hospital stay. Cost analysis was performed.

RESULTS

Between April of 2014 and January of 2017, 100 consecutive women were identified, with 50 women in each group. Both groups had similar demographics, comorbidities, and reconstruction types. Postoperatively, the enhanced recovery pathway cohort used significantly less opiate and more acetaminophen compared with the traditional standard of care cohort. Median length of stay was shorter in the enhanced recovery pathway cohort, which resulted in an extrapolated $279,258 savings from freeing up inpatient beds and increase in overall contribution margins of $189,342. Participation in an enhanced recovery pathway program and lower total morphine-equivalent use were independent predictors for decreased length of hospital stay. Overall 45-day major complication rates, partial flap loss rates, emergency room visits, hospital readmissions, and unplanned reoperations were similar between the two groups.

CONCLUSION

Enhanced recovery pathway program implementation should be considered as the standard approach for perioperative care in autologous tissue-based breast reconstruction because it does not affect morbidity and is associated with accelerated recovery with reduced postoperative opiate use and decreased length of hospital stay, leading to downstream health care cost savings.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Benefits of multimodal enhanced recovery pathway in patients undergoing kidney transplantation

BACKGROUND

Use of enhanced recovery after surgery (ERAS) pathways to accelerate functional recovery and reduce length of stay (LOS) has rarely been investigated in kidney transplantation (KTX).

MATERIALS AND METHODS

Consecutive adult isolated KTXs between July 2015 and July 2016 (ERAS, n = 139) were compared with a historical cohort between January 2014 and July 2015 (HISTORIC, n = 95).

RESULTS

Enhanced recovery after surgery recipients were significantly more likely to receive kidneys that were non-local (56.1% vs 4.2%), higher Kidney Donor Profile Index (36-85, 58.4% vs 45.2%; >85, 15.2% vs 10.7%), cold ischemia time ≥30 h (62.4% vs 4.7%), induced with antithymocyte globulin (97.1% vs 87.4%), and to develop delayed graft function (46.4% vs 25.0%). LOS was shorter by 1 day among ERAS (mean 4.59) compared to HISTORIC patients (mean 5.65) predominantly due to a shift in discharges within 3 days (32.4% vs 4.2%); 30-day readmission to the hospital (27.3% vs 27.4%) or emergency room visit (9.4% vs 7.4%) was similar. There was one 30-day death in the ERAS group and none in the HISTORIC group. Return to bowel function and early meal consumption were significantly associated with ERAS, however, with somewhat higher diarrhea and emesis rates.

CONCLUSION

ERAS following KTX correlated with lower LOS without change in readmissions or ER visits despite higher delayed graft function rates.

The application of enhanced recovery after surgery (ERAS)/fast-track surgery in gastrectomy for gastric cancer: a systematic review and meta-analysis

BACKGROUND

The study aimed to compare the safety and effectiveness of Enhanced recovery after surgery (ERAS) with conventional care in gastrectomy for gastric cancer.

METHODS

Search strategy from Pubmed, Embase, Web of science, Cochrane library and reference lists was performed. The collected studies were randomized controlled trials and published only in English, and undergoing ERAS in gastrectomy for gastric cancer from January 1994 to August 2016.

RESULTS

A total of eight studies including 801 patients were included. There were 399 cases in the ERAS and 402 cases in the conventional care groups. Meta-analysis showed that time to first passage of flatus (weighted mean difference (WMD) -14.57; 95% confidence interval (CI) -20.31 to -8.83, p<0.00001), level of C-reaction protein (WMD -19.46; 95 % CI -21.74 to -17.18, p<0.00001) and interleukin-6 (WMD-32.16; 95 % CI -33.86 to -30.46,p<0.00001) on postoperative days, postoperative hospital stay (WMD -1.85; 95 % CI -2.35 to -1.35, p<0.00001), hospital charge (WMD -0.94, 95 % CI, -1.40 to 0.49, p<0.0001) were significantly decreased for ERAS, but increased readmission rates (odds ratio (OR), 3.42, 95 % CI, 1.43 to 8.21, P=0.006). There were no statistically significant differences in intraoperative blood loss, operation time, number of retrieved lymph nodes, duration of foley catheter and postoperative complications (p>0.05).

CONCLUSIONS

ERAS is considered to be safe and effective in gastrectomy for gastric cancer. Further larger, multicenter and randomized trials were needed to beresearched.

Introduction of laparoscopic gastrectomy for gastric cancer in a Western tertiary referral centre: A prospective cost analysis during the learning curve

AIM

To evaluate the costs of the introduction of a laparoscopic surgery program for gastric cancer in a Western community training hospital and tertiary referral centre for gastric cancer surgery.

METHODS

All patients who underwent surgery for gastric cancer with curative intent in 2013 and 2014 were prospectively included. Primary outcomes were costs regarding surgery and hospital stay.

RESULTS

Laparoscopic gastrectomy was used in 52 patients [mean age 68 years (± 9, range 50 to 87)] and open gastrectomy was used in 25 patients [mean age 70 years (± 10, range 46 to 85)]. Mean costs (in euro’s) of surgical instrumentation were significantly higher for laparoscopic surgery: 2270 ± 670 vs 1181 ± 680 in the open approach (P < 0.001). Costs of theatre use were higher in the laparoscopic group: mean 3819 ± 865 vs 2545 ± 1268 in the open surgery (P < 0.001). Total costs of hospitalization (i.e., costs of surgery and admission) were not different between laparoscopic and open surgery, 8187 ± 4864 and 7673 ± 8064 respectively (P = 0.729). Mean length of hospital stay was 9 ± 12 d in the laparoscopic group vs 14 ± 14 d in the open group (P = 0.044).

CONCLUSION

The introduction of laparoscopic gastrectomy for gastric cancer coincided with higher costs for theatre use and surgical instrumentation compared to the open technique. Total costs were not significantly different due to shorter length of stay and less intensive care unit (ICU) admissions and shorter ICU stay in the laparoscopic group.

Outcomes From an Enhanced Recovery Program for Laparoscopic Gastric Surgery

PURPOSE

To examine the outcomes from an enhanced recovery after surgery (ERAS) program for laparoscopic gastric surgery.

MATERIALS AND METHODS

This was a prospective study of patients undergoing elective laparoscopic gastric resection in an ERAS protocol at a single institution between 2008 and 2012. Outcomes included the length of hospital stay, intraoperative and postoperative complications, the readmission rate, the reoperation rate, and the 30-day mortality.

RESULTS

Of the 86 patients, 60 underwent partial gastrectomy and 26 underwent total gastrectomy. Median lymph nodes sampled was 15 (range, 9 to 47). The median length of hospital stay was 4 (range, 1 to 44) days. The conversion rate to open surgery was 11.6%. Four patients (4.7%) had an anastomotic leak. Three patients had postoperative bleeding (4.7%). About 4.7% (n=4) of the patients required readmission and 8.1% required reoperation (n=7). The 30-day mortality rate was 2.3% (n=2) due to complications from anastomotic leak.

CONCLUSIONS

Laparoscopic gastrectomy within an ERAS protocol results in a short hospital stay with an acceptable morbidity and mortality rate.

Propensity Score Analysis of an Enhanced Recovery Programme in Upper Gastrointestinal Cancer Surgery

INTRODUCTION

The aim of this study was to examine the influence of an enhanced recovery programme (ERP) on outcomes of upper gastrointestinal (UGI) cancer surgery by means of propensity score-matched analysis.

METHODS

Three hundred consecutive patients diagnosed with UGI cancer were studied prospectively before and after the introduction of an ERP. Multiple regression models, including propensity scores, were developed to assess confounding variables associated with undergoing surgery, and the risk adjusted association between treatment and length of hospital stay (LOHS).

RESULTS

After regression for confounding factors, a cohort of 252 patients was available of whom 160 received ERP [median age 66 years (IQR 58-73), 119 male, 81 oesophageal, 79 gastric cancer] and 92 control [66 years (IQR 58-74), 74 male, 58 oesophageal, 34 gastric cancer]. ERP operative morbidity (Clavien-Dindo ≥3) and mortality were 13.8 and 3.1 % compared with 17.4 (p = 0.449) and 2.2 % (p = 0.658) in controls. Median ERP critical care and total LOS were 1 (IQR 0-1) and 13 (IQR 10-17) days, compared with 1 (IQR 1-2, p = 0.009) and 16 (IQR 13-26, p < 0.001) days. Multivariable analysis revealed ERP (HR 1.477, 95 % CI 1.084-2.013, p = 0.013), tumour location (HR 2.420, 95 % CI 1.624-3.606, p < 0.001), operative procedure (HR 1.143, 95 % CI 1.032-1.265, p = 0.010), and operative morbidity (HR 0.277, 95 % CI 0.179-0.429, p < 0.001) to be associated with LOHS.

CONCLUSION

An ERP in UGI cancer surgery was feasible, safe, and effective.

Enhanced Recovery after Surgery in a Single High-Volume Surgical Oncology Unit: Details Matter

Benefits of ERAS protocol have been well documented; however, it is unclear whether the improvement stems from the protocol or shifts in expectations. Interdisciplinary educational seminars were conducted for all health professionals. However, one test surgeon adopted the protocol. 394 patients undergoing elective abdominal surgery from June 2013 to April 2015 with a median age of 63 years were included. The implementation of ERAS protocol resulted in a decrease in the length of stay (LOS) and mortality, whereas the difference in cost was found to be insignificant. For the test surgeon, ERAS was associated with decreased LOS, cost, and mortality. For the control providers, the LOS, cost, mortality, readmission rates, and complications remained similar both before and after the implementation of ERAS. An ERAS protocol on the single high-volume surgical unit decreased the cost, LOS, and mortality.

Comparison of laparoscopic versus open gastrectomy for advanced gastric cancer: an updated meta-analysis

BACKGROUND

Laparoscopic gastrectomy (LG) has been used as an alternative to open gastrectomy (OG) to treat early gastric cancer. However, the use of LG for advanced gastric cancer (AGC) has been in debate.

METHODS

Literature retrieval was performed by searching PubMed, EMBASE, and the Cochrane library up to July 2014. Potential studies comparing the surgical effects between LG with OG were evaluated and data were extracted accordingly. Meta-analysis was carried out using RevMan. The pooled risk ratio and weighted mean difference (WMD) with 95 % confidence interval (95 % CI) were calculated.

RESULTS

Overall, 26 studies were included in this meta-analysis. LG had some advantages over OG, including shorter hospitalization (WMD, -3.63, 95 % CI, -4.66 to -2.60; P < 0.01), less blood loss (WMD, -161.37, 95 % CI, -192.55 to -130.18; P < 0.01), faster bowel recovery (WMD, -0.78, 95 % CI, -1.05 to -0.50; P < 0.01), and earlier ambulation (WMD, -0.95, 95 % CI, -1.47 to -0.44; P < 0.01). In terms of surgical and oncological safety, LG could achieve similar lymph nodes (WMD, -0.49, 95 % CI, -1.78 to 0.81; P = 0.46), a lower complication rate [odds ratio (OR), 0.71, 95 % CI, 0.59 to 0.87; P < 0.01], and overall survival (OS) and disease-free survival (DFS) comparable to OG.

CONCLUSIONS

For AGCs, LG appeared comparable with OG in short- and long-term results. Although more time was needed to perform LG, it had some advantages over OG in achieving faster postoperative recovery. Ongoing trials and future studies could help to clarify this controversial issue.

Fast-track surgery protocol in elderly patients undergoing laparoscopic radical gastrectomy for gastric cancer: a randomized controlled trial

Aim

To study the efficacy of the fast-track surgery (FTS) program combined with laparoscopic radical gastrectomy for elderly gastric cancer (GC) patients.

Methods

Eighty-four elderly patients diagnosed with GC between September 2014 and August 2015 were recruited to participate in this study and were divided into four groups randomly based on the random number table as follows: FTS + laparoscopic group (Group A, n=21), FTS + laparotomy group (Group B, n=21), conventional perioperative care (CC) + laparoscopic group (Group C, n=21), and CC + laparotomy group (Group D, n=21). Observation indicators include intrasurgery indicators, postoperative recovery indicators, nutritional status indicators, and systemic stress response indicators.

Results

Preoperative and intraoperative baseline characteristics showed no significant differences between patients in each group (P>0.05). There were no significant differences between each group in nausea and vomiting, intestinal obstruction, urinary retention, incision infection, pulmonary infection, and urinary tract infection after operation (P>0.05). Time of first flatus and postoperative hospital stay time of FTS Group A were the shortest, and total medical cost of this group was the lowest. For all groups, serum albumin, prealbumin, and transferrin significantly decreased, while CRP and interleukin 6 were significantly increased postoperative day 1. From postoperative day 4–7, all indicators of the four groups gradually recovered, but compared with other three groups, those of Group A recovered fastest.

Conclusion

FTS combined with laparoscopic surgery can promote faster postoperative recovery, improve early postoperative nutritional status, and more effectively reduce postoperative stress reaction, and hence is safe and effective for elderly GC patients.

Benefits of Multimodal Enhanced Recovery Pathway in Patients Undergoing Open Ventral Hernia Repair

BACKGROUND

Use of Enhanced Recovery After Surgery (ERAS) pathways have evidenced improved outcomes in several surgical specialties. The effectiveness of ERAS pathways specific to hernia surgery, however, has not yet been investigated. We hypothesized that our ERAS pathway would accelerate functional recovery and shorten hospitalization in patients undergoing open ventral hernia repair (VHR).

STUDY DESIGN

Consecutive patients undergoing open major VHR using transversus abdominis release and sublay synthetic mesh placement, with use of our ERAS pathway, were compared with a historical cohort before ERAS implementation. Main outcomes measures were time to diet advancement, time to return of bowel function, time to oral narcotics, length of stay (LOS), and 90-day readmissions.

RESULTS

Between January 2014 and January 2015, 100 patients undergoing VHR with ERAS implementation were compared with a historical cohort. The ERAS group demonstrated significantly shorter times to liquid and regular diet: 1.1 vs 2.7 and 3.0 vs 4.8 days, respectively (p < 0.001). Furthermore, ERAS patients demonstrated significantly shorter times to flatus and bowel movement: 3.1 vs 3.9 and 3.6 vs 5.2 days, respectively (p < 0.001). Average LOS was reduced from 6.1 to 4.0 days (p < 0.001), and ERAS patients had significantly fewer 90-day readmissions, 4% vs 16% (p < 0.001).

CONCLUSIONS

A comprehensive ERAS pathway for major open VHR was implemented safely. Multimodal perioperative pain management, oral opioid-receptor blockade, and early feeding strategies resulted in accelerated intestinal recovery, shorter hospitalizations, and fewer readmissions. Use of our ERAS pathway appears to result in improved outcomes in patients undergoing open VHR.

Feasibility of Fast-Track Surgery in Elderly Patients with Gastric Cancer

BACKGROUND

The aim of this study was to investigate the role of the fast-track surgery (FTS) program in elderly patients (aged ≥75 years) who underwent open surgery for gastric cancer (GC) in China.

METHODS

A total of 256 patients with GC were randomly assigned to four groups, each of which consisted of 64 cases: the 45-74-year-old age group was subdivided into the FTS-1 group and the conventional care (CC)-1 group, and the 75-89-year-old age group was subdivided into the FTS-2 group and the CC-2 group. All patients underwent open gastrectomy by the same experienced surgical team. We compared the differences between the pairs of groups in different age ranges with respect to the postoperative recovery index, complications, and medical costs.

RESULTS

Compared with the CC-1 group, the FTS-1 group exhibited earlier postoperative flatus, a shorter postoperative hospital stay, lower medical costs, and a decreased incidence of sore throat (P = 0.010, P = 0.000, P = 0.000, and P = 0.019, respectively). Compared with the CC-2 group, the FTS-2 group had more nausea and vomiting, stomach retention, and intestinal obstruction, as well as a higher readmission rate (P = 0.015, P = 0.011, P = 0.041, and P = 0.013, respectively).

CONCLUSION

The application of FTS can significantly speed up postoperative rehabilitation, shorten the hospitalization time, and lower the medical costs for 45-74-year-old GC patients, but this procedure does not show the same benefits for elderly patients. These findings suggest that we should carefully consider whether the FTS program should be applied to elderly patients with GC.

Evidence or eminence in abdominal surgery: Recent improvements in perioperative care

Repeated surveys from Europe, the United States, Australia, and New Zealand have shown that adherence to an evidence-based perioperative care protocol, such as Enhanced Recovery After Surgery (ERAS), has been generally low. It is of great importance to support the implementation of the ERAS protocol as it has been shown to improve outcomes after a number of surgical procedures, including major abdominal surgery. However, despite an increasing awareness of the importance of structured perioperative management, the implementation of this complex protocol has been slow. Barriers to implementation involve both patient- and staff-related factors as well as practice-related issues and resources. To support efficient and successful implementation, further educational and structural measures have to be made on a national or regional level to improve the standard of general health care. Besides postoperative morbidity, biological and physiological variables have been quite commonly reported in previous ERAS studies. Little information, however, has been obtained on cost-effectiveness, long-term outcomes, quality of life and patient-related outcomes, and these issues remain important areas of research for future studies.

Is early oral feeding after gastric cancer surgery feasible? A systematic review and meta-analysis of randomized controlled trials

AIM

To assess the feasibility and safety of early oral feeding (EOF) after gastrectomy for gastric cancer through a systematic review and meta-analysis based on randomized controlled trials.

METHODS

A literature search in PubMed, Embase, Web of Science and Cochrane library databases was performed for eligible studies published between January 1995 and March 2014. Systematic review was carried out to identify randomized controlled trials comparing EOF and traditional postoperative oral feeding after gastric cancer surgery. Meta-analyses were performed by either a fixed effects model or a random effects model according to the heterogeneity using RevMan 5.2 software.

RESULTS

Six studies remained for final analysis. Included studies were published between 2005 and 2013 reporting on a total of 454 patients. No significant differences were observed for postoperative complication (RR = 0.95; 95%CI, 0.70 to 1.29; P = 0.75), the tolerability of oral feeding (RR = 0.98; 95%CI, 0.91 to 1.06; P = 0.61), readmission rate (RR = 1; 95%CI, 0.30 to 3.31; P = 1.00) and incidence of anastomotic leakage (RR = 0.31; 95%CI, 0.01 to 7.30; P = 0.47) between two groups. EOF after gastrectomy for gastric cancer was associated with significant shorter duration of the hospital stay (WMD = -2.36; 95%CI, -3.37 to -1.34; P<0.0001) and time to first flatus (WMD = -19.94; 95%CI, -32.03 to -7.84; P = 0.001). There were no significant differences in postoperative complication, tolerability of oral feeding, readmission rates, duration of hospital stay and time to first flatus among subgroups stratified by the time to start EOF or by partial and total gastrectomy or by laparoscopic and open surgery.

CONCLUSIONS

The result of this meta-analysis showed that EOF after gastric cancer surgery seems feasible and safe, even started at the day of surgery irrespective of the extent of the gastric resection and the type of surgery. However, more prospective, well-designed multicenter RCTs with more clinical outcomes are needed for further validation.

Health economics in Enhanced Recovery After Surgery programs

PURPOSE

The Enhanced Recovery After Surgery (ERAS) program aims to combine and coordinate evidence-based perioperative care interventions that support standardizing and optimizing surgical care. In conjunction with its clinical benefits, it has been suggested that ERAS reduces costs through shorter convalescence and reduced morbidity. Nevertheless, few studies have evaluated the cost-effectiveness of ERAS programs. The aim of this systematic review, therefore, is to evaluate the claims that ERAS is cost-effective and to characterize how these costs were reported and evaluated.

SOURCE

The electronic databases, MEDLINE(®) and EMBASE™, were searched from inception to April 2014.

PRINCIPAL FINDINGS

Seventeen studies met the inclusion criteria and were included for review. Enhanced Recovery After Surgery protocols in various abdominal surgeries have been investigated, including colorectal, bariatric, gynecological, gastric, pancreatic, esophageal, and vascular surgery. All studies reported cost savings associated with hastening recovery and reducing morbidity and complications. All studies included in this review focused primarily on in-hospital costs, with some attempting to account for readmission costs and follow-up services. In all but two studies, the breakdown of cost data for the individual studies was poorly detailed.

CONCLUSIONS

In conclusion, ERAS protocols appear to be both clinically efficacious and cost effective across a variety of surgical specialties in the short term. Nevertheless, studies reporting out-of-hospital cost data are lacking. Further research is required to determine how best to evaluate both medium- and long-term costs relating to ERAS pathways while taking quality of life data into account.

Subtotal gastrectomy for gastric cancer

Although a steady decline in the incidence and mortality rates of gastric carcinoma has been observed in the last century worldwide, the absolute number of new cases/year is increasing because of the aging of the population. So far, surgical resection with curative intent has been the only treatment providing hope for cure; therefore, gastric cancer surgery has become a specialized field in digestive surgery. Gastrectomy with lymph node (LN) dissection for cancer patients remains a challenging procedure which requires skilled, well-trained surgeons who are very familiar with the fast-evolving oncological principles of gastric cancer surgery. As a matter of fact, the extent of gastric resection and LN dissection depends on the size of the disease and gastric cancer surgery has become a patient and “disease-tailored” surgery, ranging from endoscopic resection to laparoscopic assisted gastrectomy and conventional extended multivisceral resections. LN metastases are the most important prognostic factor in patients that undergo curative resection. LN dissection remains the most challenging part of the operation due to the location of LN stations around major retroperitoneal vessels and adjacent organs, which are not routinely included in the resected specimen and need to be preserved in order to avoid dangerous intra- and postoperative complications. Hence, the surgeon is the most important non-TMN prognostic factor in gastric cancer. Subtotal gastrectomy is the treatment of choice for middle and distal-third gastric cancer as it provides similar survival rates and better functional outcome compared to total gastrectomy, especially in early-stage disease with favorable prognosis. Nonetheless, the resection range for middle-third gastric cancer cases and the extent of LN dissection at early stages remains controversial. Due to the necessity of a more extended procedure at advanced stages and the trend for more conservative treatments in early gastric cancer, the indication for conventional subtotal gastrectomy depends on multiple variables. This review aims to clarify and define the actual landmarks of this procedure and the role it plays compared to the whole range of new and old treatment methods.