1
|
Abstract
Surgery is an essential component of curative-intent treatment strategies for gastric cancer. However, the care of each patient with gastric cancer must be individualized based on patient and tumor characteristics. It is important that all physicians who will be caring for patient with gastric cancer understand the current best practices of surgical management to provide patients with the highest quality of care. This article aims to provide this information while acknowledging areas of surgical management that are still controversial.
Collapse
Affiliation(s)
- Ian Solsky
- Department of Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, 1300 Morris Park Avenue Block Building #112, New York, NY 10461, USA
| | - Haejin In
- Department of Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, 1300 Morris Park Avenue Block Building #112, New York, NY 10461, USA; Department of Surgery, Albert Einstein College of Medicine, New York, NY, USA; Department of Epidemiology and Population Health, Albert Einstein College of Medicine, New York, NY, USA.
| |
Collapse
|
2
|
Willis MA, Schwenk W, Post S, Nothacker M, Follmann M, Vilz TO. [Background, Necessity and Methodology of the S3 Guideline "Perioperative Management of Gastrointestinal Tumours (POMGAT)"]. Zentralbl Chir 2021; 146:241-248. [PMID: 34154005 DOI: 10.1055/a-1481-9394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Malignancies are among the most common diseases, especially in old age, and are responsible for 25% of all deaths in Germany. Especially carcinomas of the gastrointestinal tract can be cured in most cases only through extensive surgery with significant morbidity. About 25 years ago, the multimodal, perioperative Fast Track (FT) concept for reducing postoperative complications was introduced and additional elements were added in the following years. Meanwhile, there is growing evidence that adherence to the key elements of more than 70% leads to reduction in postoperative adverse events as well as a shorter hospital stay and could be associated with an improved oncological outcome. Despite the high level of awareness and the proven advantages of the FT concept, the implementation and maintenance of the measures is difficult and results in an adherence of only 20 - 40%. There are many reasons for this: In addition to a lack of interdisciplinary and interprofessional cooperation and the time consuming and extended logistical efforts, limited human resources are often listed as one of the main causes. We took these aspects as an opportunity and started to develop a S3 guideline for perioperative treatment to accelerate the recovery of patients with gastrointestinal malignancies. By creating a consensus- and evidence-based, multidisciplinary guideline, many of the problems listed above could probably be solved by optimising and standardising interdisciplinary care, which is particularly important in a setting with many different disciplines and their competing interests. Furthermore, the standardisation of the perioperative procedures will reduce the time and logistical effort. The presentation of the evidence allows increased transparency and justifies the additional personnel expenditure on hospital medicine and health insurance companies. In addition, the evidence-based quality indicators generated during the development of the guideline make it possible to include perioperative standards in certification systems and thus to measure and check the quality of perioperative care.
Collapse
Affiliation(s)
- Maria A Willis
- Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Deutschland
| | | | - Stefan Post
- ehemals Chirurgische Klinik, Universitätsklinikum Mannheim, Mannheim, Deutschland
| | - Monika Nothacker
- Philipps-Universität Marburg, Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V., Marburg, Deutschland
| | - Markus Follmann
- Office des Leitlinienprogrammes Onkologie, Deutsche Krebsgesellschaft e. V., Berlin, Deutschland
| | - Tim O Vilz
- Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Deutschland
| |
Collapse
|
3
|
Abstract
INTRODUCTION Perioperative enhanced recovery after surgery (ERAS) concepts or fast-track are supposed to accelerate recovery after surgery, reduce postoperative complications and shorten the hospital stay when compared to traditional perioperative treatment. METHODS Electronic search of the PubMed database to identify systematic reviews with meta-analysis (SR) comparing ERAS and traditional treatment. RESULTS The presented SR investigated 70 randomized controlled studies (RCT) with 12,986 patients and 93 non-RCT (24,335 patients) concerning abdominal, thoracic and vascular as well as orthopedic surgery. The complication rates were decreased under ERAS following colorectal esophageal, liver and pulmonary resections as well as after implantation of hip endoprostheses. Pulmonary complications were reduced after ERAS esophageal, gastric and pulmonary resections. The first bowel movements occurred earlier after ERAS colorectal resections and delayed gastric emptying was less often observed after ERAS pancreatic resection. Following ERAS fast-track esophageal resection, anastomotic leakage was diagnosed less often as well as surgical complications after ERAS pulmonary resection. The ERAS in all studies concerning orthopedic surgery and trials investigating implantation of a hip endoprosthesis or knee endoprosthesis reduced the risk for postoperative blood transfusions. Regardless of the type of surgery, ERAS shortened hospital stay without increasing readmissions. CONCLUSION Numerous clinical trials have confirmed that ERAS reduces postoperative morbidity, shortens hospital stay and accelerates recovery without increasing readmission rates following most surgical operations.
Collapse
|
4
|
Parise P, Cinelli L, Ferrari C, Cossu A, Puccetti F, Garutti L, Elmore U, Rosati R. Early Red Flags Associated with Delayed Discharge in Patients Undergoing Gastrectomy: Analysis of Perioperative Variables and ERAS Protocol Items. World J Surg 2020; 44:223-231. [PMID: 31620813 DOI: 10.1007/s00268-019-05223-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) perioperative pathways are safe and effective for patients undergoing gastrectomy. However, adherence to these protocols varies and is generally underreported. This retrospective study aimed to assess whether perioperative variables or deviation from ERAS items is associated with delayed discharge after gastrectomy. METHODS All patients undergoing gastrectomy at our institution were managed with a standardised perioperative pathway according to ERAS principles. The target length of stay was set as the ninth post-operative day (POD). All significant variables were derived from a bivariate analysis and were entered into a logistic regression to confirm their statistical value. RESULTS The study included 180 patients. Multivariate regression analysis revealed that incomplete immunonutrition, failure to extubate the patient at the end of surgery, intraoperative crystalloids >2150 ml and blood transfusion >268 ml, surgery duration >195 min, and failure to mobilise patients within 24 h from surgery were associated with delayed discharge. The logistic regression model was statistically significant (p < 0.001) and correctly classified 73.6% of cases. Sensitivity and specificity were 74.1% and 73.2%, respectively. CONCLUSIONS These results seem clinically significant and consistent with those of previous studies. The reported perioperative variables showed a strong relationship with the length of hospital stay.
Collapse
Affiliation(s)
- Paolo Parise
- Department of Gastrointestinal Surgery, San Raffaele Hospital, via Olgettina 60, 20132, Milan, Italy
| | - Lorenzo Cinelli
- Department of Gastrointestinal Surgery, San Raffaele Hospital, via Olgettina 60, 20132, Milan, Italy.
| | - Carlo Ferrari
- Department of Gastrointestinal Surgery, San Raffaele Hospital, via Olgettina 60, 20132, Milan, Italy
| | - Andrea Cossu
- Department of Gastrointestinal Surgery, San Raffaele Hospital, via Olgettina 60, 20132, Milan, Italy
| | - Francesco Puccetti
- Department of Gastrointestinal Surgery, San Raffaele Hospital, via Olgettina 60, 20132, Milan, Italy
| | - Leonardo Garutti
- Department of Gastrointestinal Surgery, San Raffaele Hospital, via Olgettina 60, 20132, Milan, Italy
| | - Ugo Elmore
- Department of Gastrointestinal Surgery, San Raffaele Hospital, via Olgettina 60, 20132, Milan, Italy
| | - Riccardo Rosati
- Department of Gastrointestinal Surgery, San Raffaele Hospital, via Olgettina 60, 20132, Milan, Italy
| |
Collapse
|
5
|
Neary C, McAnena P, McAnena O, Kerin M, Collins C. C-Reactive Protein-Lymphocyte Ratio Identifies Patients at Low Risk for Major Morbidity after Oesophagogastric Resection for Cancer. Dig Surg 2020; 37:515-523. [PMID: 33105139 DOI: 10.1159/000510963] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 08/17/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Complications following oesophagogastric surgery have significant implications for patient recovery. OBJECTIVE identify cost-effective biomarkers which can predict morbidity. METHODS Analysis of all upper gastrointestinal resections in Galway University Hospital from 2014 to 2018 was performed. The ability of C-reactive protein (CRP), neutrophil-lymphocyte ratio (NLR), and CRP-lymphocyte ratio (CLR) to predict morbidity, including anastomotic leak (AL), was assessed and compared. RESULTS Seventy-one oesophagectomies and 77 gastrectomies were performed. There were 2 (1%) 30-day mortalities and 83 (56%) morbidities of which 30 (20%) were of Clavien-Dindo grade 3 or higher. The rate of major morbidity within the oesophagectomy cohort was 27% and was 14% in the gastrectomy cohort. There were 11 (7%) ALs, 7 in the oesophagectomy cohort, and 4 in the gastrectomy cohort. From post-operative day (POD) 2 onwards, CRP could predict AL (POD2 AUC = 0.705, p = 0.025; POD3 AUC = 0.757, p = 0.005, POD4 AUC = 0.811, p = 0.001; and POD5 AUC = 0.824, p = 0.001). CLR predicted AL on POD2 onwards (POD2 AUC = 0.722, p = 0.005; POD3 AUC = 0.736, p = 0.01; POD4 AUC = 0.775, p = 0.003; and POD5 AUC = 0.817, p = 0.001). CRP level of 218 mg/dL and CLR level of 301 at POD 2 generated negative predictive values of 97 and 98%, respectively, for AL. Post-operative NLR did not display sufficient discriminatory ability for the outcomes. CONCLUSION CRP and CLR are reliable negative predictors of major morbidity, including AL, after oesophagogastric resection. Their use can inform patient intervention and recovery.
Collapse
Affiliation(s)
- Colm Neary
- Discipline of Surgery, Lambe Institute for Translational Research, National University of Ireland Galway, Galway, Ireland,
| | - Peter McAnena
- Discipline of Surgery, Lambe Institute for Translational Research, National University of Ireland Galway, Galway, Ireland
| | - Oliver McAnena
- Discipline of Surgery, Lambe Institute for Translational Research, National University of Ireland Galway, Galway, Ireland.,Department of Upper Gastrointestinal Surgery, Galway University Hospital, Galway, Ireland
| | - Michael Kerin
- Discipline of Surgery, Lambe Institute for Translational Research, National University of Ireland Galway, Galway, Ireland
| | - Chris Collins
- Discipline of Surgery, Lambe Institute for Translational Research, National University of Ireland Galway, Galway, Ireland.,Department of Upper Gastrointestinal Surgery, Galway University Hospital, Galway, Ireland
| |
Collapse
|
6
|
Sivakumar J, Alnimri F, Johnson MA, Ward S, Chong L, Hii MW. Health economic analysis of curative-intent gastrectomy for gastric carcinoma and the costs related to post-operative complications. ANZ J Surg 2020; 91:E1-E6. [PMID: 32483869 DOI: 10.1111/ans.16014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 05/09/2020] [Accepted: 05/11/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND The management of post-gastrectomy complications requires considerable resources and is likely associated with a substantial economic burden. The objectives of this study were to perform a cost analysis of admissions following gastrectomy for gastric carcinoma and then to quantify the financial impact of post-operative complications. METHODS A retrospective analysis was conducted in patients that underwent a gastrectomy from 2008 to 2019. Demographic data, operative information, post-operative complications and facility costs were compared. RESULTS A total of 74 patients underwent a curative-intent gastrectomy during the study period. The 36 (48.6%) patients that had no complications had a median total admission cost of AU$29 228. A total of 21 (28.4%) patients had a minor complication and 17 (23.0%) patients had a major complication, with a median total admission cost of AU$36 592 and AU$71 808, respectively. The difference across all three groups was statistically significant. In patients who had major complications compared to those without complications, there was a significant increase in the cost of intensive care services, theatre resources and nursing care. Across the whole cohort, the principal cost centres accounting for the largest proportion of total cost were theatre equipment and resources (33.9%), nursing care on the ward (23.0%) and staffing time of the surgical team (16.7%). CONCLUSION The surgical management of gastric cancer carries a substantial cost burden. The presence and severity of post-operative complications is strongly associated with increasing cost. Minimizing complications, in addition to obvious clinical benefits, enables a large reduction in costs of care.
Collapse
Affiliation(s)
- Jonathan Sivakumar
- Department of Hepatobiliary and Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - Feras Alnimri
- Department of Hepatobiliary and Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Mary A Johnson
- Department of Hepatobiliary and Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Salena Ward
- Department of Hepatobiliary and Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Lynn Chong
- Department of Hepatobiliary and Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Michael W Hii
- Department of Hepatobiliary and Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
7
|
Effects of a fast track surgery nursing program in perioperative care of older patients with a hip fracture. Eur Geriatr Med 2020; 11:519-525. [DOI: 10.1007/s41999-020-00298-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 02/07/2020] [Indexed: 12/14/2022]
|
8
|
Miao YM, Wang J, Liu JE, Li L. Nutritional management of patients undergoing laparoscopic surgery for gastric cancer based on the concept of rapid rehabilitation. Shijie Huaren Xiaohua Zazhi 2019; 27:1349-1355. [DOI: 10.11569/wcjd.v27.i22.1349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
As a common malignant tumor, patients with gastric cancer (GC) are prone to malnutrition during the development and treatment of the disease. Fast track surgery (FTS), as a perioperative medical concept based on evidence-based medicine, plays an important role in nutrition management, including preoperative malnutrition screening and treatment, preoperative nutritional management, postoperative early oral feeding, accelerated promotion of gastrointestinal function recovery, and nutritional support. Based on a series of small sample studies, the safety and importance of FTS in laparoscopic nutrition management of GC are gradually emerging, but clinical implementation is difficult. This article will review the research progress of FTS in the field of laparoscopic nutrition management of GC in the past decade.
Collapse
Affiliation(s)
- Ying-Ming Miao
- Department of Nursing, Second Affiliated Hospital of Hainan Medical College, Haikou 570100, Hainan Province, China
| | - Jie Wang
- Department of Nursing, Second Affiliated Hospital of Hainan Medical College, Haikou 570100, Hainan Province, China
| | - Jun-Er Liu
- Department of Nursing, Second Affiliated Hospital of Hainan Medical College, Haikou 570100, Hainan Province, China
| | - Long Li
- Department of Nursing, Second Affiliated Hospital of Hainan Medical College, Haikou 570100, Hainan Province, China
| |
Collapse
|
9
|
Kang C, Qiao X, Sun M. Application of fast-track surgery in the perioperative period of laparoscopic partial nephrectomy for renal tumors. J Int Med Res 2019; 47:2580-2590. [PMID: 31109232 PMCID: PMC6567727 DOI: 10.1177/0300060519847853] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 04/11/2019] [Indexed: 01/11/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Chunmei Kang
- Department of Gynaecology and Obstetrics, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Xueliang Qiao
- PIVAS of The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Meiling Sun
- Department of Cardiac Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| |
Collapse
|
10
|
Outcomes of the Learning Curve in Our First 100 Consecutive Laparoscopic Gastrectomies. Surg Laparosc Endosc Percutan Tech 2019; 29:309-310. [PMID: 31107853 DOI: 10.1097/sle.0000000000000675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
11
|
Enhanced recovery versus conventional care in gastric cancer surgery: a meta-analysis of randomized and non-randomized controlled trials. Gastric Cancer 2019; 22:423-434. [PMID: 30805742 DOI: 10.1007/s10120-019-00937-9] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 02/04/2019] [Indexed: 02/07/2023]
Abstract
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.
Collapse
|
12
|
Comparison of short-term and long-term efficacy of laparoscopic and open gastrectomy in high-risk patients with gastric cancer: a propensity score-matching analysis. Surg Endosc 2019; 33:58-70. [PMID: 29931452 DOI: 10.1007/s00464-018-6268-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Accepted: 06/07/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND To determine whether laparoscopic surgery can be used in high-risk patients with gastric cancer. METHODS The clinicopathological data of 3743 patients with primary gastric adenocarcinoma, collected from January 2007 to December 2014, were retrospectively analyzed. Patients who had ≥ 1 of the following conditions were defined as high-risk patients: (1) age ≥ 80 years; (2) BMI ≥ 30 kg/m2; (3) ASA (American Society of Anesthesiologists) grade ≥ 3; or (4) clinical T stage 4 (cT4). Propensity score matching (PSM) was used to reduce confounding bias; then, we compared the short-term and long-term efficacy of laparoscopic gastrectomy (LG) with open gastrectomy (OG) in high-risk patients with gastric cancer. RESULTS A total of 1296 patients were included in PSM. After PSM, no significant difference in clinicopathological data was observed between the LG group (n = 341) and the OG group (n = 341). The operative time (181.70 vs. 266.71 min, p < 0.001) and blood loss during the operation (68.11 vs. 225.54 ml, p < 0.001) in the LG group were significantly lower than those in the OG group. In the LG and OG groups, postoperative complications occurred in 39 (11.4%) and 63 (18.5%) patients, respectively, p = 0.010. Multivariate analysis showed that laparoscopic surgery was an independent protective factor against postoperative complications (p = 0.019). The number of risk factors was an independent risk factor for postoperative complications (p = 0.021). The 5-year overall survival rate in the LG group was comparable to that in the OG group (55.0 vs. 52.0%, p = 0.086). Hierarchical analysis further confirmed that the LG and OG groups exhibited comparable survival rates among patients with stages cI, pI, cII, pII, cIII, and pIII (all p > 0.05). CONCLUSIONS For high-risk patients with gastric cancer, LG not only exhibits better short-term efficacy than OG but also has a comparable 5-year survival rate to OG.
Collapse
|
13
|
Tweed T, van Eijden Y, Tegels J, Brenkman H, Ruurda J, van Hillegersberg R, Sosef M, Stoot J. Safety and efficacy of early oral feeding for enhanced recovery following gastrectomy for gastric cancer: A systematic review. Surg Oncol 2018; 28:88-95. [PMID: 30851919 DOI: 10.1016/j.suronc.2018.11.017] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 10/22/2018] [Accepted: 11/17/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Early oral feeding (EOF) is believed to be a crucial item of Enhanced Recovery After Surgery (ERAS) programs. Though this is widely accepted for colorectal surgery, evidence for early oral feeding after gastrectomy is scarce. The aim of this review is to assess the evidence of safety and benefits of early oral feeding after gastrectomy in patients with gastric cancer. METHODS A systematic literature search of Pubmed, Embase and Cochrane was performed for eligible studies published till September 2018. Studies were analyzed and selected by predetermined criteria. RESULTS After having assessed 23 eligible articles, a total of four randomized controlled trials (RCT) remained who fully met all requirements to be included in this review. All four RCTs compared early oral feeding (n = 320) with conventional care (n = 334) after gastrectomy. In all four studies, EOF was associated with a decreased length of hospital stay ranging from -1.3 to -2.5 days when compared to conventional care. A faster time to first flatus was recorded in all four studies in the EOF group, ranging from -6.5 hours to -1.5 days. Furthermore, EOF does not increase postoperative complication risk when compared to conventional care. CONCLUSION Current evidence for early oral feeding after gastrectomy is promising, proving its safety, feasibility and benefits. However, most studies have been conducted amongst an Asian population. Well powered and larger randomized controlled trials performed amongst a Western population is needed.
Collapse
Affiliation(s)
- Thaís Tweed
- Department of Surgery, Zuyderland Medical Center, Dr. H. van der Hoffplein 1, 6162 BG, Sittard-Geleen, the Netherlands.
| | - Yara van Eijden
- Department of Surgery, Zuyderland Medical Center, Dr. H. van der Hoffplein 1, 6162 BG, Sittard-Geleen, the Netherlands
| | - Juul Tegels
- Department of Surgery, Zuyderland Medical Center, Dr. H. van der Hoffplein 1, 6162 BG, Sittard-Geleen, the Netherlands
| | - Hylke Brenkman
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
| | - Jelle Ruurda
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
| | - Richard van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
| | - Meindert Sosef
- Department of Surgery, Zuyderland Medical Center, Dr. H. van der Hoffplein 1, 6162 BG, Sittard-Geleen, the Netherlands
| | - Jan Stoot
- Department of Surgery, Zuyderland Medical Center, Dr. H. van der Hoffplein 1, 6162 BG, Sittard-Geleen, the Netherlands
| |
Collapse
|
14
|
Jang A, Jeong O. Early Postoperative Oral Feeding After Total Gastrectomy in Gastric Carcinoma Patients: A Retrospective Before-After Study Using Propensity Score Matching. JPEN J Parenter Enteral Nutr 2018; 43:649-657. [PMID: 30144113 DOI: 10.1002/jpen.1438] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Accepted: 07/25/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Despite its clinical benefits, early oral nutrition after total gastrectomy is not widely implemented because of concerns about tolerability and safety. We investigated the feasibility and safety of early oral nutrition after total gastrectomy in gastric carcinoma patients. METHODS This is a retrospective before-after study. From 2008-2016, 301 patients received conventional oral feeding (COF) before May 2012, and 454 patients, early oral feeding (EOF) after May 2012. The EOF group received oral diet on postoperative day 1, and the COF group was maintained nil-by-mouth until patients demonstrated gas passage. After balancing potential confounders using propensity score matching, 203 patients were selected in each group. RESULTS Both matched groups demonstrated well-balanced baseline characteristics. The EOF group demonstrated significantly earlier first flatus time (2.9 vs 3.1 days, P = .013) and hospital discharge (8.9 vs 12.6 days, P < .001) than the COF group. No significant differences were observed for overall morbidity and mortality, but the EOF group demonstrated lower incidence of abdominal infection (3.0% vs 7.4%, P = .044) and anastomosis leakage (1.5% vs 4.9%, P = .048). Subgroup analyses by age, sex, operative approach, lymph node dissection, and tumor stage demonstrated no increased risk of morbidity, anastomosis leakage, and short hospital stay in the EOF group. CONCLUSION Early oral nutrition may be feasible and safe after total gastrectomy, with no increase in postoperative complications. Large, randomized, controlled trials are warranted to further investigate the clinical benefits of early oral nutrition after total gastrectomy.
Collapse
Affiliation(s)
- Aelee Jang
- Biomedical Research Institute, Pusan National University Hospital, Busan, South Korea
| | - Oh Jeong
- Department of Surgery, Chonnam National University School of Medicine, Jeollanam-do, South Korea
| |
Collapse
|
15
|
Li MZ, Wu WH, Li L, Zhou XF, Zhu HL, Li JF, He YL. Is ERAS effective and safe in laparoscopic gastrectomy for gastric carcinoma? A meta-analysis. World J Surg Oncol 2018; 16:17. [PMID: 29373978 PMCID: PMC5787292 DOI: 10.1186/s12957-018-1309-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 01/08/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND It is still unclear whether enhanced recovery after surgery is effective and safe in laparoscopic gastrectomy for gastric carcinoma. METHODS Cochrane library databases, Medline, Embase, and Pubmed were searched from January 1, 1986, to December 31, 2016. Randomized controlled trials (RCTs) comparing fast-track recovery with conventional recovery strategies in laparoscopic radical gastrectomy for gastric carcinoma were included. The main outcomes measured were postoperative hospital stay, time to first flatus, hospital charge, and overall complication rate. RESULTS Six RCTs with 400 patients were included in this study. Fast-track surgery has shorter postoperative hospital stays (weighted mean difference (WMD) - 2.65; 95% CI, - 4.01 to - 1.29, z = 3.82, P < 0.01) and less hospitalization expenditure (WMD - 523.43; 95% CI, - 799.79 to - 247.06, z = 3.71, P < 0.01) than conventional recovery strategies. There was no significant difference with respect to duration to first flatus (WMD - 17.72; 95% CI, - 39.46-4.02, z = 1.60, P = 0.11) and complication rate (OR 1.57; 95% CI, 0.82-2.98, z = 1.37, P = 0.17). CONCLUSIONS Enhanced recovery after surgery is effective and safe and is thus recommended in laparoscopic radical gastrectomy for gastric carcinoma.
Collapse
Affiliation(s)
- Ming-Zhe Li
- Department of Gastrointestinal Surgery, The Seventh Affiliated Hospital, Sun Yat-sen University, No.628 Zhenyuan Road, Guangming new district, Shenzhen, 518017, China
| | - Wen-Hui Wu
- Department of Gastrointestinal Surgery, The Seventh Affiliated Hospital, Sun Yat-sen University, No.628 Zhenyuan Road, Guangming new district, Shenzhen, 518017, China
| | - Liang Li
- Department of Gastrointestinal Surgery, The Seventh Affiliated Hospital, Sun Yat-sen University, No.628 Zhenyuan Road, Guangming new district, Shenzhen, 518017, China
| | - Xue-Fu Zhou
- Department of Gastrointestinal Surgery, The Seventh Affiliated Hospital, Sun Yat-sen University, No.628 Zhenyuan Road, Guangming new district, Shenzhen, 518017, China
| | - Heng-Liang Zhu
- Department of Gastrointestinal Surgery, The Seventh Affiliated Hospital, Sun Yat-sen University, No.628 Zhenyuan Road, Guangming new district, Shenzhen, 518017, China
| | - Jian-Feng Li
- Department of Gastrointestinal Surgery, The Seventh Affiliated Hospital, Sun Yat-sen University, No.628 Zhenyuan Road, Guangming new district, Shenzhen, 518017, China
| | - Yu-Long He
- Department of Gastrointestinal Surgery, The Seventh Affiliated Hospital, Sun Yat-sen University, No.628 Zhenyuan Road, Guangming new district, Shenzhen, 518017, China.
| |
Collapse
|
16
|
Siotos C, Stergios K, Naska A, Frountzas M, Pergialiotis V, Perrea DN, Nikiteas N. The impact of fast track protocols in upper gastrointestinal surgery: A meta-analysis of observational studies. Surgeon 2018; 16:183-192. [PMID: 29337046 DOI: 10.1016/j.surge.2017.12.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 10/01/2017] [Accepted: 12/01/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Fast track surgery has been implemented in colorectal procedures during the last decade and is accompanied by significant improvement in patient outcomes during the early postoperative period. However, to date, its adoption in upper gastrointestinal surgery remains a matter of debate. In this context, we aimed to summarize the existing evidence in the international literature. MATERIALS AND METHODS We searched Medline, Scopus, ClinicalTrials.gov and Cochrane Central Register databases for published randomized controlled trials. The meta-analysis was performed with the RevMan 5.3.5 software. MAIN FINDINGS Thirty studies were finally included in the present meta-analysis. The post-operative morbidity was not influenced by the implementation of fast track surgery (FTS) (OR 0.84, 95% CI 0.64-1.09). However, in cases treated with laparoscopic surgery fast track surgery seemed to reduce morbidity by 50% (p = .006). The overall mortality of patients was low in the majority of included studies and was not influenced by fast track surgery (OR 1.12, 95% CI 0.50-2.52). The duration of postoperative hospitalization was significantly reduced with the adoption of FTS (MD -2.24, 95% CI -2.63 to -1.85 days). Concurrently, the overall cost was significantly reduced in cases treated with FTS (MD -982.30, 95% CI -1367.68 to -596.91 U.S dollars). CONCLUSION According to the findings of our meta-analysis suggest that FTS seems to be safe in patients undergoing upper gastrointestinal surgery and reduce both the days of postoperative hospitalization and the overall cost. This observation should be taken into account in future recommendations to enhance the implementation of FTS protocols in current clinical practice.
Collapse
Affiliation(s)
- Charalampos Siotos
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Stergios
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Medical School, National and Kapodistrian University of Athens, Athens, Greece; Department of General Surgery, Watford General Hospital - West Hertfordshire Hospitals NHS Trust, UK.
| | - Androniki Naska
- Department of Hygiene, Epidemiology and Medical Statistics, WHO Collaborating Center for Food and Nutrition Policies, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Maximos Frountzas
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Vasilios Pergialiotis
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Despina N Perrea
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Nikiteas
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| |
Collapse
|
17
|
Efficacy of fast track surgery in laparoscopic radical gastrectomy for gastric cancer:a meta-analysis of randomized controlled trials. Int J Surg 2017; 50:28-34. [PMID: 29288114 DOI: 10.1016/j.ijsu.2017.12.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 11/02/2017] [Accepted: 12/20/2017] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To conduct a systematic review of efficacy and security of fast track surgery (FTS) in laparoscopic radical gastrectomy for gastric cancer. METHODS We searched PubMed, Embase, and Cochrane Library Databases and supplemented by other searches to collect randomized controlled trials (RCTs) on the comparison of fast track surgery combined with laparoscopy versus laparoscopy separately used in radical gastrectomy for gastric cancer before December 2016. After screening for inclusion, data extraction, and quality assessment, meta-analysis was conducted by the Review Manager 5.3 software. RESULTS A total of 6 RCTs, involving 464 patients, were included. There were 232 patients in the FTS group and conventional care group separately. Compared with the conventional care group, patients of FTS group had shorter postoperative hospital stay [WMD = -1.85, 95%CI: (-2.60, -1.11), P < .00001], earlier first flatus [WMD = -9.33, 95%CI: (-13.74, -4.91), P < .0001], lower level of C-reactive protein (CRP) at postoperative day 4 [WMD = -13.94, 95%CI: (-22.74, -5.15), P = .002], and less hospitalization fees [SMD = -1.12, 95%CI: (-2.07, -0.18), P = .02]. There were no significant differences in operation time, intraoperative blood loss, and postoperative complications between the two groups. CONCLUSION Based on current evidence, the FTS protocol is safe and effective in laparoscopic radical gastrectomy for gastric cancer. Due to the limitations of our study, further larger and multicenter studies are needed to validate our findings.
Collapse
|
18
|
Li Z, Wang Q, Li B, Bai B, Zhao Q. Influence of enhanced recovery after surgery programs on laparoscopy-assisted gastrectomy for gastric cancer: a systematic review and meta-analysis of randomized control trials. World J Surg Oncol 2017; 15:207. [PMID: 29169362 PMCID: PMC5701340 DOI: 10.1186/s12957-017-1271-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 11/15/2017] [Indexed: 12/11/2022] Open
Abstract
Background This meta-analysis is aimed to evaluate the feasibility and safety of enhanced recovery after surgery (ERAS) programs in gastric cancer patients undergoing laparoscopy-assisted gastrectomy (LAG). Methods We performed a meta-analysis of randomized control trials involving either enhanced recovery after surgery (ERAS)/fast track surgery (FTS) for patients underwent LAG. EMBASE, Pubmed, Web of science, and Cochrane Library were searched. Primary outcomes included the length of postoperative hospital stay, cost of hospitalization, postoperative complications, and readmission rate. Results Five randomized control trials were eligible for analysis. There were 159 cases in FTS group and 156 cases in conventional care group. Compared with conventional care group, FTS group relates to shorter postoperative hospital stay (WMD − 2.16; 95% CI − 3.05 to − 1.26, P < 0.00001), less cost of hospitalization (WMD − 4.72; 95% CI − 6.88 to − 2.55, P < 0.00001), shorter time to first flatus (WMD − 9.72; 95% CI − 13.75 to − 5.81, P < 0.00001), lower level of C-reaction protein on postoperative days 3 or 4 (WMD − 19.66; 95% CI − 28.98 to − 10.34, P < 0.00001), higher level of albumin on postoperative day 4 (WMD 3.45; 95% CI 2.01 to 4.89, P < 0.00001), and postoperative day 7 (WMD 5.63; 95% CI 1.01 to 10.24, P = 0.02). Regarding postoperative complications, no significant differences were observed between FTS group and conventional care group (OR 0.63, 95% CI 0.37 to 1.09, P = 0.10). The readmission rate of FTS group was comparable to conventional care group (WMD 3.14; 95% CI 0.12 to 81.35, P = 0.49). Conclusions Among patients undergoing LAG, FTS is associated with shorter postoperative hospital stay, rapid postoperative recovery, and decreased cost without increasing complications or readmission rate. The combined effects of the two methods could further accelerate clinical recovery of gastric cancer patients.
Collapse
Affiliation(s)
- Zhengyan Li
- Department of Surgery, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, No. 127 Changle West Road, Xian, 710032, China
| | - Qian Wang
- Department of Surgery, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, No. 127 Changle West Road, Xian, 710032, China
| | - Bofei Li
- Department of Surgery, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, No. 127 Changle West Road, Xian, 710032, China
| | - Bin Bai
- Department of Surgery, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, No. 127 Changle West Road, Xian, 710032, China
| | - Qingchuan Zhao
- Department of Surgery, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, No. 127 Changle West Road, Xian, 710032, China.
| |
Collapse
|
19
|
Ding J, Sun B, Song P, Liu S, Chen H, Feng M, Guan W. The application of enhanced recovery after surgery (ERAS)/fast-track surgery in gastrectomy for gastric cancer: a systematic review and meta-analysis. Oncotarget 2017; 8:75699-75711. [PMID: 29088903 PMCID: PMC5650458 DOI: 10.18632/oncotarget.18581] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 03/10/2017] [Indexed: 12/14/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Jie Ding
- Department of General Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008 China
| | - Benlong Sun
- Department of General Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008 China
| | - Peng Song
- Department of General Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008 China
| | - Song Liu
- Department of General Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008 China
| | - Hong Chen
- Department of General Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008 China
| | - Min Feng
- Department of General Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008 China
| | - Wenxian Guan
- Department of General Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008 China
| |
Collapse
|
20
|
Zhang HW, Sun L, Yang XW, Feng F, Li GC. Safety of total gastrectomy without nasogastric and nutritional intubation. Mol Clin Oncol 2017; 7:421-426. [PMID: 28894580 DOI: 10.3892/mco.2017.1331] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 04/03/2017] [Indexed: 02/04/2023] Open
Abstract
The aim of the present study was to evaluate the safety of gastrectomy without nasogastric and nutritional intubations. Between January 2010 and August 2015, 74 patients with gastric cancer received total gastric resection and esophagogastric anastomosis without nasogastric and nutritional intubations at the First Department of Digestive Surgery of the XiJing Hospital of Digestive Diseases (Xi'an, China), of whom 42 were also received earlier oral feeding within 48 h. The data were retrospectively analyzed. An additional 301 cases who underwent traditional postoperative intubation were used for comparison. In patients without intubation compared with those managed traditionally with intubation, the mean operative time was decreased (190.97±38.18 vs. 216.12±59.52 min, respectively; P=0.026). In addition, the postoperative activity was resumed earlier (1.16±0.47 vs. 1.36±0.84 days, respectively; P=0.009), oral food intake was started earlier (4.28±1.79 vs. 5.71±2.66 days, respectively; P=0.009), the incidence of fever was lower (12.16 vs. 29.23%, respectively; P=0.003), and the incidence of total complications was not statistically significantly different between the two groups (9.41 vs. 6.31%, respectively; P=0.317). There were no significant differences regarding complications of the anastomotic port (1.37 vs. 1.69%, respectively; P=0.849). Compared with traditional postoperative management, earlier oral feeding did not increase the incidence of complications (7.21 vs. 4.76%, respectively; P=0.557). Our results suggest that total gastric resection without nasogastric and nutritional intubation is a safe and feasible option for patients undergoing total gastrectomy.
Collapse
Affiliation(s)
- Hong-Wei Zhang
- First Department of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Li Sun
- First Department of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Xue-Wen Yang
- First Department of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Fan Feng
- First Department of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Guo-Cai Li
- First Department of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| |
Collapse
|
21
|
Current status of perioperative management for elderly patients. Nihon Ronen Igakkai Zasshi 2017; 54:299-313. [PMID: 28855453 DOI: 10.3143/geriatrics.54.299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
22
|
Karavokyros I, Angelou A, Pikoulis E. The devil hides in the details. Int J Surg 2016; 30:175. [PMID: 27060718 DOI: 10.1016/j.ijsu.2016.03.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 03/22/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Ioannis Karavokyros
- First Department of Surgery, "Laikon" General Hospital, University of Athens, Medical School, Athens, Greece
| | - Anastasios Angelou
- First Department of Surgery, "Laikon" General Hospital, University of Athens, Medical School, Athens, Greece.
| | - Emmanouil Pikoulis
- First Department of Surgery, "Laikon" General Hospital, University of Athens, Medical School, Athens, Greece
| |
Collapse
|
23
|
Bond‐Smith G, Belgaumkar AP, Davidson BR, Gurusamy KS. Enhanced recovery protocols for major upper gastrointestinal, liver and pancreatic surgery. Cochrane Database Syst Rev 2016; 2:CD011382. [PMID: 26829903 PMCID: PMC8765738 DOI: 10.1002/14651858.cd011382.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND 'Fast-track surgery' or 'enhanced recovery protocol' or 'fast-track rehabilitation', incorporating one or more elements of preoperative education, pain relief, early mobilisation, enteral nutrition and growth factors, may improve health-related quality of life and reduce length of hospital stay and costs. The role of enhanced recovery protocols in major upper gastrointestinal, liver and pancreatic surgery is unclear. OBJECTIVES To assess the benefits and harms of enhanced recovery protocols compared with standard care (or usual practice) in major upper gastrointestinal, liver and pancreatic surgery. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; Cochrane Library; 2015, Issue 3), MEDLINE, EMBASE and Science Citation Index Expanded until March 2015 to identify randomised trials. We also searched the references of included trials to identify further trials. SELECTION CRITERIA We considered only randomised controlled trials (RCTs) performed in people undergoing major upper gastrointestinal, liver and pancreatic surgery, irrespective of language, blinding or publication status for inclusion in the review. DATA COLLECTION AND ANALYSIS Two review authors independently identified trials and independently extracted data. We calculated the risk ratio (RR), mean difference (MD), or standardised mean difference (SMD) with 95% confidence intervals (CIs) using both fixed-effect and random-effects models using Review Manager 5, based on available case analysis. MAIN RESULTS Ten studies met the inclusion criteria for the review, and nine studies provided information on one or more outcomes for the review. A total of 1014 participants were randomly assigned to the enhanced recovery protocol (499 participants) or standard care (515 participants) in the nine RCTs. Most of the trials included low anaesthetic risk participants with high performance status undergoing different upper gastrointestinal, liver and pancreatic surgeries. Eight trials incorporated more than one element of the enhanced recovery protocol. All of the trials were at high risk of bias. The overall quality of evidence was low or very low.None of the trials reported long-term mortality, medium-term health-related quality of life(three months to one year), time to return to normal activity, or time to return to work. The difference between the enhanced recovery protocol and standard care were imprecise for short-term mortality (enhanced recovery protocol: 4/425 (adjusted proportion = 0.6%); standard care: 1/443 (0.2%); seven trials; 868 participants; RR 2.79; 95% CI 0.44 to 17.73; very low quality evidence), proportion of people with serious adverse events (enhanced recovery protocol: 4/157 (adjusted proportion = 0.6%); standard care: 0/184 (0.0%); two trials; 341 participants; RR 5.57; 95% CI 0.68 to 45.89; very low quality evidence), number of serious adverse events (enhanced recovery protocol: 34/421 (8 per 100 participants); standard care: 46/438 (11 per 100 participants); seven trials; 859 participants; rate ratio 0.72; 95% CI 0.45 to 1.13; very low quality evidence), health-related quality of life (four trials; 373 participants; SMD 0.29; 95% CI -0.04 to 0.62; very low quality evidence) and hospital readmissions (enhanced recovery protocol: 14/355 (adjusted proportion = 3.3%); standard care: 9/378 (2.4%); seven trials; 733 participants; RR 1.4; 95% CI 0.69 to 2.87; very low quality evidence). The enhanced recovery protocol group had a lower proportion of people with mild adverse events (enhanced recovery protocol: 31/254 (adjusted proportion = 10.9%); standard care: 51/271 (18.8%); four trials; 525 participants; RR 0.58; 95% CI 0.39 to 0.85; low quality evidence), fewer number of mild adverse events (enhanced recovery protocol: 69/499 (13 per 100 participants); standard care: 128/515 (25 per 100 participants); nine trials; 1014 participants; rate ratio 0.52; 95% CI 0.39 to 0.70; low quality evidence), shorter length of hospital stay (nine trials; 1014 participants; MD -2.19 days; 95% CI -2.53 to -1.85; low quality evidence) and lower costs (four trials; 282 participants; MD USD -6300; 95% CI -8400 to -4200; low quality evidence) than standard care group. AUTHORS' CONCLUSIONS Based on low quality evidence, enhanced recovery protocols may reduce length of hospital stay and costs (primarily because of reduction in hospital stay) in people undergoing major upper gastrointestinal, liver and pancreatic surgeries. However, the validity of the results is uncertain because of the risk of bias in the trials and the way the outcomes were measured. Future RCTs should be conducted with low risk of bias, and measure clinically important outcomes for including the three months to one year period.
Collapse
Affiliation(s)
- Giles Bond‐Smith
- Churchill HospitalDepartment of Hepatobiliary SurgeryOxfordUKOx3 7L3
| | - Ajay P Belgaumkar
- Royal Free London NHS Foundation TrustHPB and Liver Transplant Surgery, 8 SouthPond StreetLondonUKNW3 2QG
| | - Brian R Davidson
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryPond StreetLondonUKNW3 2QG
| | | | | |
Collapse
|