Early Red Flags Associated with Delayed Discharge in Patients Undergoing Gastrectomy: Analysis of Perioperative Variables and ERAS Protocol Items

Short- and Long-Term Advantages of Laparoscopic Gastrectomy for Elderly Patients with Locally Advanced Cancer

Minimally invasive surgery has provided several clinical advantages in locally advanced gastric cancer (LAGC) care, although a consensus on its application criteria remains unclear. Surgery remains a careful choice in elderly patients, who frequently present with frailty, comorbidities, and other disabling diseases. This study aims to assess the possible advantages of laparoscopic gastric resections in elderly patients presenting with LAGC. This retrospective study analyzed a single-center series of elderly patients (≥75 years) undergoing curative resections for LAGC between 2015 and 2020. A comparative analysis of open versus laparoscopic approaches was conducted, focusing on postoperative complications, length of hospital stay (LOS), and long-term survival. A total of 62 patients underwent gastrectomy through an open or a laparoscopic approach (31 pts each). The study population did not show statistically significant differences in demographics, operative risk, and neoadjuvant chemotherapy. The laparoscopic group reported significantly minimized overall complications (45.2 vs. 71%, p = 0.039) and pulmonary complications (0 vs. 9.7%, p = 0.038) as well as a shorter LOS (8 vs. 12 days, p = 0.007). Lymph node harvest was equal between the groups, although long-term overall survival presented significantly better after laparoscopic gastrectomy (p = 0.048), without a relevant difference in terms of disease-free and disease-specific survivals. Laparoscopic gastrectomy proves effective in elderly LAGC patients, offering substantial short- and long-term postoperative benefits.

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

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

Preoperative Nutritional Status and Risk Factors Associated with Delayed Discharge in Geriatric Patients Undergoing Gastrectomy: A Single-Center Retrospective Study

Objective

Preoperative malnutrition is an independent risk factor for postoperative complications and survival for gastric cancer patients. The study is aimed at investigating the prevalence of malnutrition, perioperative nutritional support, and the risk factors associated with delayed discharge of geriatric patients undergoing gastrectomy.

Methods

A retrospective study of gastric cancer patients (age ≥ 65) who underwent gastrectomy at Zhongshan Hospital from January 2018 to May 2020 was conducted. Clinical data, including demographic information, medical history, surgery-related factors, and perioperative nutritional management, were collected and analyzed. Postoperative complications were assessed according to the Clavien-Dindo grading system, and the prognostic nutritional index (PNI) was calculated. The risk factors affecting the prolongation of postoperative hospital stay were analyzed.

Results

A total of 783 patients were reviewed. The overall frequency of malnutrition was 31.3% (249/783). The albumin, prealbumin, and hemoglobin levels were lower in the malnutrition group than in the well-nourished group. The proportion of patients who received preoperative total parenteral nutritional support in the malnutrition group was significantly higher than in the well-nourished group (12.4% vs. 3.7%, P < 0.001). All patients received postoperative parenteral nutrition (PN); the proportion of patients who received total nutrient admixture (TNA) in the malnutrition group was lower than in the well-nourished group (22.1% vs. 33.5%, P = 0.001). No significant difference was found in the duration of postoperative nutrition between groups (P > 0.05). The malnutrition group was associated with a higher rate of postoperative complications (P < 0.001). Univariate and multivariate regressions revealed that age > 70 years (OR = 1.216, 95% CI 1.048-1.411, P = 0.010), operation time > 180 min (OR = 1.431, 95% CI 1.237-1.656, P < 0.001), PNI < 44.5 (OR = 1.792, 95% CI 1.058-3.032, P = 0.030), and postoperative complications (OR = 2.191, 95% CI 1.604-2.991, P < 0.001) were significant risk factors associated with delayed discharge.

Conclusion

Malnutrition is relatively common in elderly patients undergoing gastrectomy. Advanced age, duration of surgery, lower levels of PNI, and postoperative complications were risk factors associated with delay discharge. Elderly gastric cancer patients with risk factors urgently require specific attention for reducing hospital stay.

Enhanced recovery after surgery (ERAS) program for elderly patients with short-level lumbar fusion

Background

Degenerative disorders of the lumbar spine decrease the mobility and quality of life of elderly patients. Lumbar fusion surgery is the primary method of treating degenerative lumbar spine disorders; however, the surgical stress response associated with major surgery has been linked to pathophysiological changes in the elderly, resulting in undesirable postoperative morbidity, complications, pain, fatigue, and extended convalescence. In the present study, we aimed to determine whether enhanced recovery after surgery significantly improved satisfaction and outcomes in elderly patients (> 65 years old) with short-level lumbar fusion.

Methods

The study enrolled lumbar disc herniation or lumbar spinal stenosis patients if they were over the age of 65 years old underwent lumbar fusion at one or two levels. Data including demographic, comorbidity, and surgical information were collected from electronic medical records. Enhanced recovery after surgery interventions was categorized as preoperative, intraoperative, and postoperative. We also evaluated primary outcome, surgical complication, length of stay, postoperative pain scores, and 30-day readmission rates.

Results

A total of 192 patients were included, 96 in the enhanced recovery after surgery group and 96 case-matched patients in the non- enhanced recovery after surgery group. There were no statistically significant intergroup differences in regards to demographics, comorbidities, American Society of Anaesthesiologists grade, or the number of fusion levels. There were also no differences between mean surgery time of intraoperative blood loss between the enhanced recovery after surgery and non- enhanced recovery after surgery groups. In addition, the mean preoperative Japanese Orthopaedic Association score, visual analog score for the back and legs, and Oswestry Disability Index score were not significantly different between the two groups. Overall, enhanced recovery after surgery pathway compliance was 92.1%. There were no significant differences in the number of complications or the mortality rates between the enhanced recovery after surgery and non-enhanced recovery after surgery groups. Furthermore, the mean postoperative Japanese Orthopaedic Association score, Visual analog score for the back and legs, Oswestry Disability Index score, and readmission rates score revealed no significant differences between the groups at 30-day follow-up point. However, we observed a statistically significant decrease in length of stay in the enhanced recovery after surgery group (12.30 ± 3.03 of enhanced recovery after surgery group versus 15.50 ± 1.88 in non- enhanced recovery after surgery group, p = 0). Multivariable linear regression showed that comorbidities (p = 0.023) and implementation of enhanced recovery after surgery program (p = 0.002) were correlated with prolonged length of stay. Multivariable logistic regression showed that no characteristics were associated with complications.

Conclusions

This report describes the first enhanced recovery after surgery protocol used in elderly patients after short-level lumbar fusion surgery. Our enhanced recovery after surgery program is safe and could help decrease length of stay in elderly patients with short-level lumbar fusion.

Enhanced recovery after surgery in colon and rectal surgery: identification of predictive variables of failure in a monocentric series including 733 patients

To identify factors associated with early deviation and delayed discharge within an Enhanced Recovery after Surgery (ERAS) pathway. This is a retrospective review of prospectively collected data of consecutive patients who underwent laparoscopic or open colorectal surgery and managed with a standardized ERAS pathway between April 2015 and October 2018. ERAS items were assessed within 48 h after surgery. Patients with early complications were excluded. The influence of factors on length of stay was calculated by univariate and multivariate analysis. A binary logistic regression was used to model a predicting score. Seven hundred and thirty-three patients met the inclusion criteria. Multivariate analysis showed that age ≥ 75 years (P = 0.02), ASA score ≥ 3 (P = 0.03), open surgery or conversion to open (P = 0.001), non-compliance with the intra-operative balanced fluid therapy (P = 0.049), failure to early removal of the urinary catheter (P = 0.001), to discontinue IV fluid (P = 0.02) and to early mobilization (P = 0.001) were independently associated with ERAS failure. The generated score had a specificity of 84% and a positive predictive value of 72%. Patients who would have a length of stay longer than the median for each surgical procedure were properly identified (Area under ROC Curve = 0.753, P < 0.001). The delayed discharge could be predicted at 48 h from the intervention. The ability of the model to weight the specific role of each statistically significant variable might be a useful tool to identify the most frail patients.