Fast-track surgery improves postoperative clinical recovery and reduces postoperative insulin resistance after esophagectomy for esophageal cancer

Advances in diagnosis and management of cancer of the esophagus

Esophageal cancer is the seventh most common malignancy worldwide, with over 470 000 new cases diagnosed each year. Two distinct histological subtypes predominate, and should be considered biologically separate disease entities.1 These subtypes are esophageal adenocarcinoma (EAC) and esophageal squamous cell carcinoma (ESCC). Outcomes remain poor regardless of subtype, with most patients presenting with late stage disease.2 Novel strategies to improve early detection of the respective precursor lesions, squamous dysplasia, and Barrett's esophagus offer the potential to improve outcomes. The introduction of a limited number of biologic agents, as well as immune checkpoint inhibitors, is resulting in improvements in the systemic treatment of locally advanced and metastatic esophageal cancer. These developments, coupled with improvements in minimally invasive surgical and endoscopic treatment approaches, as well as adaptive and precision radiotherapy technologies, offer the potential to improve outcomes still further. This review summarizes the latest advances in the diagnosis and management of esophageal cancer, and the developments in understanding of the biology of this disease.

Enhanced Recovery After Surgery Guidelines and Hospital Length of Stay, Readmission, Complications, and Mortality: A Meta-Analysis of Randomized Clinical Trials

Importance

A comprehensive review of the evidence exploring the outcomes of enhanced recovery after surgery (ERAS) guidelines has not been completed.

Objective

To evaluate if ERAS guidelines are associated with improved hospital length of stay, hospital readmission, complications, and mortality compared with usual surgical care, and to understand differences in estimates based on study and patient factors.

Data Sources

MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central were searched from inception until June 2021.

Study Selection

Titles, abstracts, and full-text articles were screened by 2 independent reviewers. Eligible studies were randomized clinical trials that examined ERAS-guided surgery compared with a control group and reported on at least 1 of the outcomes.

Data Extraction and Synthesis

Data were abstracted in duplicate using a standardized data abstraction form. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Risk of bias was assessed in duplicate using the Cochrane Risk of Bias tool. Random-effects meta-analysis was used to pool estimates for each outcome, and meta-regression identified sources of heterogeneity within each outcome.

Main Outcome and Measures

The primary outcomes were hospital length of stay, hospital readmission within 30 days of index discharge, 30-day postoperative complications, and 30-day postoperative mortality.

Results

Of the 12 047 references identified, 1493 full texts were screened for eligibility, 495 were included in the systematic review, and 74 RCTs with 9076 participants were included in the meta-analysis. Included studies presented data from 21 countries and 9 ERAS-guided surgical procedures with 15 (20.3%) having a low risk of bias. The mean (SD) Reporting on ERAS Compliance, Outcomes, and Elements Research checklist score was 13.5 (2.3). Hospital length of stay decreased by 1.88 days (95% CI, 0.95-2.81 days; I2 = 86.5%; P < .001) and the risk of complications decreased (risk ratio, 0.71; 95% CI, 0.59-0.87; I2 = 78.6%; P < .001) in the ERAS group. Risk of readmission and mortality were not significant.

Conclusions and Relevance

In this meta-analysis, ERAS guidelines were associated with decreased hospital length of stay and complications. Future studies should aim to improve implementation of ERAS and increase the reach of the guidelines.

Is recovery enhancement after gastric cancer surgery really a safe approach for elderly patients?

BACKGROUND

This study aimed to evaluate the safety of enhanced recovery after surgery (ERAS) in elderly patients with gastric cancer (GC).

AIM

To evaluate the safety of ERAS in elderly patients with GC.

METHODS

The PubMed, EMBASE, and Cochrane Library databases were used to search for eligible studies from inception to April 1, 2023. The mean difference (MD), odds ratio (OR) and 95% confidence interval (95%CI) were pooled for analysis. The quality of the included studies was evaluated using the Newcastle-Ottawa Scale scores. We used Stata (V.16.0) software for data analysis.

RESULTS

This study consists of six studies involving 878 elderly patients. By analyzing the clinical outcomes, we found that the ERAS group had shorter postoperative hospital stays (MD = -0.51, I2 = 0.00%, 95%CI = -0.72 to -0.30, P = 0.00); earlier times to first flatus (defecation; MD = -0.30, I² = 0.00%, 95%CI = -0.55 to -0.06, P = 0.02); less intestinal obstruction (OR = 3.24, I2 = 0.00%, 95%CI = 1.07 to 9.78, P = 0.04); less nausea and vomiting (OR = 4.07, I2 = 0.00%, 95%CI = 1.29 to 12.84, P = 0.02); and less gastric retention (OR = 5.69, I2 = 2.46%, 95%CI = 2.00 to 16.20, P = 0.00). Our results showed that the conventional group had a greater mortality rate than the ERAS group (OR = 0.24, I2 = 0.00%, 95%CI = 0.07 to 0.84, P = 0.03). However, there was no statistically significant difference in major complications between the ERAS group and the conventional group (OR = 0.67, I2 = 0.00%, 95%CI = 0.38 to 1.18, P = 0.16).

CONCLUSION

Compared to those with conventional recovery, elderly GC patients who received the ERAS protocol after surgery had a lower risk of mortality.

Impact of nasogastric tube exclusion after minimally invasive esophagectomy for esophageal cancer: a single-center retrospective study in India

Purpose

This study examines the impacts of omitting nasogastric tube (NGT) placement following cervical esophagogastric anastomosis (CEGA) in Enhanced Recovery After Surgery (ERAS) protocols, comparing outcomes to those from early NGT removal.

Methods

In a retrospective cohort of esophagectomy patients treated for esophageal cancer, participants were divided into two groups: group 1 had the NGT inserted post-CEGA and removed by postoperative day 3, while group 2 underwent the procedure without NGT placement. We primarily investigated anastomotic leak rates, also analyzing hospital stay duration, pulmonary complications, and NGT reinsertion.

Results

Among 50 esophageal squamous cell carcinoma patients, 30 in group I were compared with 20 in group II. The baseline demographic and tumor characteristics were similar between both groups. The overall incidence of anastomotic leak was 14.0%, comparable in both groups (16.7% vs. 10.0%, p = 0.63). The postoperative hospital stay was significantly shorter in the no NGT group (median of 7 days vs. 6 days, p = 0.03) with similar major morbidity (Clavien-Dindo grade ≥IIIa; 13.3% vs. 5.0%, p = 0.63). There was no 30-day mortality, and one patient in each group had reinsertion of NGT for conduit dilatation.

Conclusion

The exclusion of an NGT across CEGA after esophagectomy did not influence the anastomotic leak rate with comparable complications and a shorter hospital stay.

Exploring perioperative risk factors for poor recovery of postoperative gastrointestinal function following gynecological surgery: A retrospective cohort study

Purpose

To investigate perioperative risk factors that affect the recovery of postoperative gastrointestinal function in patients undergoing gynecological surgery and to establish a preoperative risk prediction scoring system.

Methods

In this retrospective cohort study, characteristics and perioperative factors of patients who underwent elective gynecological surgery at Union Hospital from January 2021 to March 2022 were extracted from electronic medical records. Patients were grouped according to the Intake, Feeling nauseated, Emesis, physical Exam, and Duration of symptoms (I-FEED) scoring system to compare collected data.

Results

In total, clinical data from 208 gynecological patients were extracted. The incidence of poor postoperative gastrointestinal recovery was 7.21 %. The number of previous abdominal surgeries (0.73 ± 0.06 vs 1.20 ± 0.24, p = 0.044), the incidence of malignant disease (20.2 % vs 53.3 %, p = 0.003), postoperative maximum WBC count (9.15 vs 12.44, p = 0.005) and postoperative minimum potassium (3.97 ± 0.36 vs 3.76 ± 0.37, p = 0.036) were not only associated with poor postoperative gastrointestinal recovery, but also malignant disease (p = 0.000), postoperative maximum WBC count (p = 0.027) and postoperative minimum potassium (p = 0.024) were significantly associated with the severity of postoperative gastrointestinal function. An increased number of previous abdominal surgeries and malignant primary disease could increase the risk of an I-FEED score >2 as independent risk factors.

Conclusion

Patients with poor postoperative GI function had poorer postoperative recovery outcomes. A preoperative score prediction system was established, in which patients with ≥2 points had a 19.4 % risk of poor postoperative gastrointestinal recovery. Higher-quality prospective studies should be performed to achieve more precise risk stratification and to construct a more accurate prediction system.

Safety and efficacy of laparoscopic transperitoneal versus retroperitoneal resection for benign retroperitoneal tumors: a retrospective cohort study

BACKGROUND AND OBJECTIVE

Benign retroperitoneal tumors (BRTs) are clinically rare solid tumors. This study aimed to compare the safety and efficacy of laparoscopic transperitoneal versus retroperitoneal resection for BRTs.

METHODS

The clinical data of 43 patients who had pathologically confirmed BRTs and underwent laparoscopic resection in a single center from January 2019 to May 2022 were retrospectively analyzed. Patients were divided into two groups according to the surgical methods: the Transperitoneal approach group (n = 24) and the Retroperitoneal approach group (n = 19). The clinical characteristics and perioperative data between the two groups were compared. The baseline data and surgical variables were analyzed to determine the impact of different surgical approaches on the treatment outcomes of BRTs.

RESULTS

No significant difference was observed between the two groups in gender, age, body mass index, the American Society of Anesthesiologists score, presence of underlying diseases, tumor size, tumor position, operation duration, intraoperative hemorrhage, postoperative hospital stay, intestinal function recovery time, and postoperative complication rate. The conversion rate from laparoscopic to open surgery was significantly lower in the Transperitoneal approach group than in the Retroperitoneal approach group (1/24 vs. 5/19, χ2 = 4.333, P = 0.037). Tumor size was an independent influencing factor for the effect of surgery (odds ratio = 1.869, 95% confidence interval = 1.135-3.078, P = 0.014) and had a larger efficacy on the retroperitoneal group (odds ratio = 3.740, 95% confidence interval = 1.044-13.394, P = 0.043).

CONCLUSION

The laparoscopic transperitoneal approach has the inherent advantages of anatomical hierarchies and surgical space, providing a better optical perspective of the targeted mass and improved bleeding control. This approach may have better efficacy than the retroperitoneal approach, especially in cases of a large tumor or when the tumor is located near important blood vessels.

Differential Gains in Surgical Outcomes for High-Risk vs Low-Risk Pancreaticoduodenectomy with Successive Refinements of Risk-Stratified Care Pathways

BACKGROUND

The use of risk-stratified pancreatectomy care pathways (RSPCPs) is associated with reduced length of stay (LOS). This study sought to evaluate the impact of successive pathway revisions with the hypothesis that high-risk patients require iterative pathway revisions to optimize outcomes.

STUDY DESIGN

A prospectively maintained database (October 2016 to December 2021) was evaluated for pancreaticoduodenectomy patients managed with RSPCPs preoperatively assigned based on postoperative pancreatic fistula (POPF) risk. Launched in October 2016 (version [V] 1), RSPCPs were optimized in February 2019 (V2) and November 2020 (V3). Targeted pathway components included earlier nasogastric tube removal, diet advancement, reduced intravenous fluids and opioids, institution-specific drain fluid amylase cutoffs for early day 3 removal, and patient education. Primary outcome was LOS. Secondary outcomes included major complication (Accordion grade 3+), POPF (International Study Group for Pancreatic Surgery Grade B/C), and delayed gastric emptying (DGE).

RESULTS

Of 481 patients, 234 were managed by V1 (83 high-risk), 141 by V2 (43 high-risk), and 106 by V3 (43 high-risk). Median LOS reduction was greatest in high-risk patients with a 7-day reduction (pre-RSPCP, 12 days; V1, 9 days; V2, 7 days; V3, 5 days), compared with low-risk patients (pre-pathway, 10 days; V1, 6 days; V2, 5 days; V3, 4 days). Complications decreased significantly among high-risk patients (V1, 45%; V2, 33%; V3, 19%; p < 0.001), approaching rates in low-risk patients (V1, 21%; V2, 20%; V3, 14%). POPF (V1, 33%; V2, 23%; V3, 16%; p < 0.001) and DGE (V1, 23%; V2, 22%; V3, 14%; p < 0.001) improved among high-risk patients.

CONCLUSIONS

Risk-stratified pancreatectomy care pathways are associated with reduced LOS, major complication, Grade B/C fistula, and DGE. The easiest gains in surgical outcomes are generated from the immediate improvement in the patients most likely to be fast-tracked, but high-risk patients benefit from successive application of the learning health system model.

Perioperative nutrition for gastrointestinal surgery: On the cutting edge

Evidence on perioperative nutrition interventions in gastrointestinal surgery is rapidly evolving. We conducted a narrative review of various aspects of nutrition support, including formula choice and route of administration, as well as duration and timing of nutrition support therapy. Studies have demonstrated that nutrition support is associated with improved clinical outcomes in malnourished patients and those at nutrition risk, emphasizing the importance of nutrition assessment, for which several validated nutrition risk assessment tools exist. The assessment of serum albumin levels has fallen out of favor, as it is an unreliable marker of nutrition status, whereas imaging evidence of sarcopenia has prognostic value and may emerge as a standard component of nutrition assessment. Preoperatively, evidence supports limiting fasting to reduce insulin resistance and improve oral tolerance. Benefits to preoperative carbohydrate loading remain unclear, whereas literature suggests preoperative parenteral nutrition (PN) may reduce postoperative complications in high-risk patients with malnutrition or sarcopenia. Postoperatively, early oral feeding is safe with benefits in time to return of bowel function and reduced hospital stay. There is a signal for potential benefit to early postoperative PN in critically ill patients, though evidence is sparse. There has also been a recent emergence in randomized studies evaluating the use of ω-3 fatty acids, amino acids, and immunonutrition. Meta-analyses have reported favorable outcomes for these supplements, though individual studies are small and with significant methodological limitations and risk of bias, emphasizing the need for high-quality randomized studies to guide clinical practice.

Association of Upper Gastrointestinal Surgery of Great Britain and Ireland (AUGIS)/Perioperative Quality Initiative (POQI) consensus statement on intraoperative and postoperative interventions to reduce pulmonary complications after oesophagectomy

BACKGROUND

Pulmonary complications are the most common morbidity after oesophagectomy, contributing to mortality and prolonged postoperative recovery, and have a negative impact on health-related quality of life. A variety of single or bundled interventions in the perioperative setting have been developed to reduce the incidence of pulmonary complications. Significant variation in practice exists across the UK. The aim of this modified Delphi consensus was to deliver clear evidence-based consensus recommendations regarding intraoperative and postoperative care that may reduce pulmonary complications after oesophagectomy.

METHODS

With input from a multidisciplinary group of 23 experts in the perioperative management of patients undergoing surgery for oesophageal cancer, a modified Delphi method was employed. Following an initial systematic review of relevant literature, a range of anaesthetic, surgical, and postoperative care interventions were identified. These were then discussed during a two-part virtual conference. Recommendation statements were drafted, refined, and agreed by all attendees. The level of evidence supporting each statement was considered.

RESULTS

Consensus was reached on 12 statements on topics including operative approach, pyloric drainage strategies, intraoperative fluid and ventilation strategies, perioperative analgesia, postoperative feeding plans, and physiotherapy interventions. Seven additional questions concerning the perioperative management of patients undergoing oesophagectomy were highlighted to guide future research.

CONCLUSION

Clear consensus recommendations regarding intraoperative and postoperative interventions that may reduce pulmonary complications after oesophagectomy are presented.

Iterative Changes in Risk-Stratified Pancreatectomy Clinical Pathways and Accelerated Discharge After Pancreaticoduodenectomy

BACKGROUND

Previous implementation of risk-stratified pancreatectomy clinical pathways (RSPCPs) decreased length of stay (LOS) following pancreaticoduodenectomy (PD). This study's primary aim was to measure the association of iterative RSPCP revisions with accelerated discharge and early postoperative outcomes.

METHODS

This is a retrospective cohort study of a prospectively maintained surgical database (10/2016-9/2020). In February 2019, revised RSPCPs were implemented with earlier nasogastric tube (NGT) removal (postoperative day [POD] 1 for low risk; POD 2 for high risk) and updated drain fluid amylase cutoffs for POD 1/POD 3 removal. Perioperative outcomes between original and revised pathways were compared. Predictors of accelerated discharge (defined as ≤ POD 5 for low risk; ≤ POD 6 for high risk) were identified.

RESULTS

There were 233 (36% high risk) patients in original and 131 (32% high risk) in revised RSPCPs. After revision, the rate of POD 1 NGT removal was higher while POD ≤ 3 drain removal was similar. Median LOS decreased for low risk (5 vs. 6 days, p = 0.011) and high risk (6 vs. 9 days, p = 0.005) with no increase in delayed gastric emptying, postoperative pancreatic fistula, or readmissions. With POD 1 NGT removal, diet tolerance was earlier without increased NGT reinsertions. In low-risk patients, younger age, POD 1 NGT removal, and POD ≤ 3 drain removal were independent predictors of accelerated discharge. In high-risk patients, POD 1 NGT removal and POD ≤ 3 drain removal were independent predictors of accelerated discharge.

CONCLUSIONS

Following iterative revisions in RSPCPs, LOS after PD decreased further without increasing readmissions, and NGTs were removed earlier without increased reinsertions. Early NGT and drain removal are modifiable practices within RSPCPs that are associated with accelerated discharge.

Impact of standardized clinical pathways on esophagectomy: a systematic review and meta-analysis

Esophageal surgery is historically associated with adverse postoperative outcomes. Selected high-volume centers have previously reported the effect on clinical outcomes following the adoption of a standardized clinical pathway (SCP). This meta-analysis aims to evaluate the current literature to document the effect of SCP and enhanced recovery after surgery (ERAS) on esophagectomy outcomes. A literature search was conducted through the main search engines (PubMed, Embase, Medline, and Cochrane database) in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. All eligible comparative studies (randomized control trial, prospective, retrospective, and combined) were identified and assessed based on Methodological Index for Non-Randomized Studies and Jadad quality criteria. Data concerning overall morbidity, early mortality, and length of stay (LOS) were primarily collected and compared. Secondary outcomes included anastomotic leaks, pulmonary complications, and readmission rate. Twenty-six articles (including five randomized controlled trials and six prospective trials) were included in the analysis. Overall study quality was moderate and the included studies utilized a variable approach to SCP. No statistically significant differences were found between groups in terms of overall morbidity, postoperative mortality, anastomotic leak, and readmission rates. Significant improvements included pulmonary complications (odds ratios [OR] 0.66, 95% confidence interval [CI] 0.49-0.94) and hospital LOS (OR -3.68, 95% CI -4.49 to -2.87). Previous reports of SCP within esophagectomy programs have demonstrated clinical improvements in postoperative pulmonary complications and LOS. Given the high heterogeneity historically demonstrated within SCPs, further improvement in outcomes should be expected following the adoption of standardized ERAS guidelines.

Early versus the traditional start of oral intake following esophagectomy for esophageal cancer: a systematic review and meta-analysis

BACKGROUND

Nil by mouth is considered the standard of care during the first days following esophagectomy. However, with the routine implementation of enhanced recovery after surgery, early oral intake is more likely to be the preferred mode of nutrition following esophagectomy. The present study aims to evaluate the safety and effectiveness of early oral intake following esophagectomy for esophageal cancer.

METHODS

Comprehensive literature searches were conducted using PubMed, Web of Science, Embase, and Cochrane Library. Weighted mean differences (WMD) and odds ratios (OR) with 95% confidence intervals (CI) were calculated as the effect sizes for continuous and dichotomous variables, respectively.

RESULTS

Fourteen studies with a total of 1947 patients were included. Length of hospital stay (WMD =  - 3.94, CI: - 4.98 to - 2.90; P < 0.001), the time to first flatus (WMD =  - 1.13, CI: - 1.25 to - 1.01; P < 0.001) and defecation (WMD =  - 1.26, CI: - 1.82 to - 0.71; P < 0.001) favored the early oral intake group. There was no statistically significant difference in mortality (OR = 1.23, CI: 0.45 to 3.36; P = 0.69). Early oral intake also did not increase the risk of pneumonia and overall postoperative complications.

CONCLUSIONS

Current evidence indicates early oral intake following esophagectomy seems to be safe and effective. It may be the preferred mode of nutrition following esophagectomy. However, more high-quality studies are still needed to further validate this conclusion.

[Fast-track Rehabilitation after Oesophagectomy]

The multimodal and interprofessional concept of fast-track rehabilitation ("enhanced recovery after surgery", ERAS) is generally applicable to transthoracic oesophagectomy, but is associated with two special features as compared to other oncological procedures. Due to the high comorbidity of oesophageal cancer patients, fast-track pathways have to be considered as one component of perioperative management and cannot be separated from prehabilitation with preoperative conditioning of single organ dysfunctions. Since gastric reconstruction causes a high prevalence of delayed gastric conduit emptying (DGCE), early and sufficient postoperative oral feeding is not easily feasible. There is currently no generally accepted algorithm for the postoperative nutritional management as well as for the prophylaxis/treatment of DGCE. Fast-track prehabilitation does not influence the mortality rate in specialised centres. At present, it is not clear whether a fast-track pathway helps to reduce postoperative morbidity. After modified fast-track rehabilitation, hospital discharge is possible from the 8th postoperative day.

Comparison of perioperative outcomes of single-port laparoscopy, three-port laparoscopy and conventional laparotomy in removing giant ovarian cysts larger than 15 cm

Background

Although conventional laparoscopy has gradually accepted as a surgical treatment for ovarian cancer, reducing the port numbers of laparoscopy still has great challenge for larger ovarian tumors. Thus, this study aims to explore the surgical outcomes of single-port laparoscopy for removing giant ovarian cysts (≥ 15 cm) and compare with laparotomy and three-port laparoscopy.

Methods

This study enrolled 95 patients with giant ovarian cysts (> 15 cm) who underwent single-port laparoscopy, three-port laparoscopy or laparotomy. Their medical records, perioperative surgical outcomes, and postoperative pain score and complications were analyzed and compared retrospectively.

Results

Single-port laparoscopy showed better perioperative outcomes and less postoperative pain than three-port laparoscopy and laparotomy. The time between post-surgery and getting out of bed in single-port laparoscopy was significant shorter than that in the laparotomy and three-port laparoscopy (17.53 ± 7.26 vs 29.40 ± 9.57 vs 24.56 ± 7.76, P < 0.01). The length of hospital stay in single-port laparoscopy was significantly shorter than that in other two groups (4.06 ± 0.5 vs 5.46 ± 1.63 vs 4.81 ± 0.83, P < 0.001). In addition, single-port laparoscopy had the lowest postoperative pain scores than in the laparotomy and three-port laparoscopy. There were no significant differences of total hospital cost, postoperative complications and time until gas passing among the three surgical groups. Importantly, in the removal of giant ovarian cysts, the proportion of cyst rupture in single-port laparoscopy was far lower than that in three-port laparoscopy (3.0 vs 22.2%).

Conclusions

For giant ovarian cysts, single-port laparoscopy is still a safe and efficient technique with the advantages of short operation time, less estimated blood loss, short hospital stay, lower spillage rate, and less postoperative pain.

The Japan Society for Surgical Infection: guidelines for the prevention, detection, and management of gastroenterological surgical site infection, 2018

BACKGROUND

The guidelines for the prevention, detection, and management of gastroenterological surgical site infections (SSIs) were published in Japanese by the Japan Society for Surgical Infection in 2018. This is a summary of these guidelines for medical professionals worldwide.

METHODS

We conducted a systematic review and comprehensive evaluation of the evidence for diagnosis and treatment of gastroenterological SSIs, based on the concepts of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The strength of recommendations was graded and voted using the Delphi method and the nominal group technique. Modifications were made to the guidelines in response to feedback from the general public and relevant medical societies.

RESULTS

There were 44 questions prepared in seven subject areas, for which 51 recommendations were made. The seven subject areas were: definition and etiology, diagnosis, preoperative management, prophylactic antibiotics, intraoperative management, perioperative management, and wound management. According to the GRADE system, we evaluated the body of evidence for each clinical question. Based on the results of the meta-analysis, recommendations were graded using the Delphi method to generate useful information. The final version of the recommendations was published in 2018, in Japanese.

CONCLUSIONS

The Japanese Guidelines for the prevention, detection, and management of gastroenterological SSI were published in 2018 to provide useful information for clinicians and improve the clinical outcome of patients.

Modified model for predicting early C-reactive protein levels after gastrointestinal surgery: A prospective cohort study

Background

Postoperative serum concentration of C-reactive protein (CRP) is one of the objective quantitative indices integrating the effects of preoperative and intraoperative variables. Higher levels of CRP after gastrointestinal surgery are associated with major postoperative complications. To develop a model for predicting CRP levels on postoperative day (POD) 1 in surgical patients both with and without serious conditions and comorbidities, we modified the previous formula for prediction of CRP levels on POD1, and assessed the accuracy of our modified predictive formula for CRP levels.

Material and methods

Consecutive patients of all ages undergoing gastrointestinal surgery under general anesthesia were enrolled in this single-institution prospective cohort study. We developed a modified predictive formula in a calculation cohort. Next, associations between measured CRP levels on POD1, predicted CRP levels on POD1 using the previous and modified models, and major complications after surgery were examined in a validation cohort.

Results

We obtained the following model in the calculation cohort (n = 222): Modified model for predicting CRP levels on POD1 (mg•dL^-1) = -10.13 + 0.0025 Duration of surgery (min) + 15.9 Mean Nociceptive Response (NR) + 0.66 Preoperative CRP level (mg•dL^-1). In the validation cohort (n = 440), there was a significant association between measured and predicted CRP levels on POD1 (P < 0.001) No significant difference between the measured and predicted CRP levels using the modified model was observed (P = 0.847). There were also significant associations between the predicted CRP levels and major complications after surgery.

Conclusion

CRP levels predicted using duration of surgery, mean NR, and preoperative CRP levels are likely identical to measured CRP levels on POD1, being associated with major complications after gastrointestinal surgery.

Glycemic variability in patients with gastrointestinal cancer: An integrative review

PURPOSE

Glycemic variability is associated with risks for adverse events in patients with cancer. Several studies have evaluated the presence and impact of hyperglycemia and/or hypoglycemia in patients with cancer; however, few studies have evaluated glycemic variability. The purpose of this integrative review of studies in patients with gastrointestinal cancers was to investigate the presence and methods of reporting glycemic variability during and following treatments.

METHODS

A comprehensive review of the literature was conducted. PubMed, CINAHL, EMBASE, and Cochrane databases were searched for publications between 1/1/1969 and 7/24/2019. Studies of patients with gastrointestinal cancer following surgery, during treatment, and <5 years following treatment were included and evaluated by cancer type and method of glucose and glycemic variability measurement.

RESULTS

Among 1526 patients with gastrointestinal cancer across 19 studies, gastric and pancreatic cancers were most prevalent. Timing of glucose testing and methods of analyzing glycemic variability varied. Most analyses used the standard deviation or interquartile range. Glycemic variability was more prevalent among patients with Type 2 Diabetes and among those with pancreatic cancer. In some patients glycemic variability remained notable > one year following surgery despite improvements in glycemic control.

CONCLUSION

Patients with gastrointestinal cancer experience glycemic variability during and up to one year following treatment. There was heterogeneity in methods related to timing of testing and reporting glycemic variability among the 19 studies in this review. Future investigations need to identify the presence and define the methods of measuring glycemic variability in patients with gastrointestinal cancer.

Preoperative Oral Carbohydrate Reduces Postoperative Insulin Resistance by Activating AMP-Activated Protein Kinase after Colorectal Surgery

BACKGROUND

Postoperative insulin resistance (PIR) is a common response after colorectal surgery and an independent risk factor for recovery. Preoperative oral carbohydrate (POC) has been known to reduce PIR. Herein, we investigated whether its mechanism of action involves AMP-activated protein kinase (AMPK) and mTOR/S6K1/insulin receptor substrate-1 (IRS-1) pathways.

METHODS

Patients undergoing colorectal cancer resection were randomly assigned to a POC, fasting, or placebo group. The exclusion criteria were association with diseases or intake of medication affecting insulin sensitivity. Pre- and postoperative insulin resistance, and protein phosphorylation of AMPK, mTOR, and IRS-1 in the rectus abdominis muscle were evaluated.

RESULTS

From January 2017 to December 2017, 70 patients were randomized and 63 were evaluated. No difference was found in the clinical and operative characteristics among the 3 groups. In the POC group, the levels of blood glucose, blood insulin, and homeostasis model assessment of insulin resistance were significantly lower in the POC group than the fasting and placebo groups, and the insulin sensitivity index was significantly higher. The phosphorylation of AMPK in the POC group was significantly higher than that in the other 2 groups, whereas the phosphorylation of mTOR and IRS-1 was significantly lower.

CONCLUSION

PIR involves AMPK and mTOR/S6K1/IRS-1 pathways. POC reduces PIR by the stimulation of AMPK, which suppresses the phosphorylation of mTOR/IRS-1 and attenuates PIR after colorectal resection.

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.

Current status of esophageal cancer treatment

Esophageal cancer (EC) remains one of the most common and aggressive diseases worldwide. This review discusses some debates in the modern management of the disease. Endoscopic procedures for early cancer (T1a−b) are now embedded in routine care and the challenge will be to more accurately select patients for endoscopic resection with or without adjuvant therapy. Perioperative multimodal therapies are associated with improved survival compared to surgery alone for locally advanced esophageal cancer. However, there is no global consensus on the optimal regimen. Furthermore, histological subtype (adenocarcinomavs. squamous cell cancer) plays a role in the choice for treatment. New studies are underway to resolve some issues. The extent of the lymphadenectomy during esophagectomy remains controversial especially after neoadjuvant chemoradiation. The ideal operation balances between limiting surgical trauma and optimizing survival. Minimally invasive esophagectomy and enhanced recovery pathways are associated with decreased morbidity and faster recovery albeit there is no consensus yet what approach should be used. Finally, immune checkpoint inhibitors present promising preliminary results in the novel treatment of advanced or metastatic EC but their widespread application in clinical practice is still awaited.

Enhanced recovery protocol in esophagectomy, is it really worth it? A cost analysis related to team experience and protocol compliance

Application of enhanced recovery protocols (ERP) in esophageal surgery seems to lead an advantage in terms of length of hospital staying and outcomes, but only few data exist on its cost effectiveness. Previous literature analyzed pre- and post-ERP groups, finding a cost reduction with the introduction of the pathway. We aimed to study the influence on costs of accumulating experience and compliance in an ERP group. Seventy-one patients have been treated at our institution from January 2014 to June 2017 with our ERP for Ivor-Lewis esophagectomy. Direct costs were divided into subcategories and were analyzed as a function of calendar year and compliance. Factor affecting costs were searched. Univariable analysis highlighted a significant reduction in costs over time. Increase in compliance led to a progressive cost reduction for each ERP item completed (€14 852-€11 045). While age was not found to significantly influence the cost (p = 0.341), complications seemed to nullify the effect of experience: the median was €11 507 in uncomplicated patients, and increased to €13 791 in Clavien-Dindo 3-4 (CD3-4) patients. Compliance and CD3-4 remained significant also in multivariable analysis, accomplished by quantile regression, while year of surgery lost its significance. Our results evidence how accumulating experience in ERP led to a cost reduction over time, which was mainly mediated by an increase in compliance. Indeed, compliance was the main factor in reducing ERP cost while CD3-4 complications were the most important factor in cost increasing, nullifying the benefit of compliance.

Regionalization of esophagectomy: where are we now?

The morbidity and mortality benefits of performing high-risk operations in high-volume centers by high-volume surgeons are evident. Regionalization is a proposed strategy to leverage high-volume centers for esophagectomy to improve quality outcomes. Internationally, regionalization occurs under national mandates. Those mandates do not exist in the United States and spontaneous regionalization of esophagectomy has only modestly occurred in the U.S. Regionalization must strike a careful balance and not limit access to optimal oncologic care to our most vulnerable cancer patient populations in rural and disadvantaged socioeconomic areas. We reviewed the recent literature highlighting: the justification of hospital and surgeon annual esophagectomy volumes for regionalization; how safety performance metrics could influence regionalization; whether regionalization is occurring in the US; what impact regionalization may have on esophagectomy costs; and barriers to patients traveling to receive oncologic treatment at regionalized centers of excellence.

Quality of life in patients with upper GI malignancies managed by a strategy of chemoradiotherapy alone versus surgery

BACKGROUND AND OBJECTIVES

Neoadjuvant chemoradiotherapy (nCRT) induces a pathological complete response (pCR) in 25-85% of oesophago-gastric cancer. As surgery entails morbidity and mortality risks and quality of life (QL) impairment, its avoidance in patients without residual disease is desirable. This study aimed to compare quality of life of patients with a cCR who chose surveillance with those who chose surgery.

METHODS

Four groups of patients were studied. Group 1(n = 31) were controls; Group 2 (n = 26) had chemoradiotherapy only; Group 3 (n = 31) had oesophagectomy after nCRT; Group 4 (n = 26) had gastrectomy alone. A 33-point novel questionnaire was administered at two 3 month time points. Participants were also interviewed with a validated questionnaire.

RESULTS

Mean(±sd) quality of life scores in cCR patients offered surveillance (28.9 ± 4.5) were superior to patients undergoing oesophagectomy (32.3 ± 58. p=0.042) or gastrectomy (33.19 ± 5.9, p=0.004). This result was replicated in the validated questionnaire (p=0.017). There was a trend towards increased reflux-related respiratory symptoms in the oesophagectomy group (7.3 ± 2.2 vs 6.5 ± 1.9; p=0.396) and towards early dumping (8.2 ± 1.4 vs 7.1 ± 1.; p=0.239) and vagotomy-related symptoms (1.82 ± 0.9 vs 1.4 ± 0.6; p=0.438) in the gastrectomy group.

CONCLUSIONS

Avoidance of surgery in cCR patients is rewarded with a superior quality of life to those undergoing surgery.

Integrating perioperative medicine with anaesthesia in India: Can the best be achieved? A review

Integrating perioperative medicine with anaesthesia is the need of the hour. Evolution of a new superspeciality called perioperative anaesthesia can improve surgical outcomes by quality perioperative care and guarantee imminent escalation of influence and power for anaesthesiologists. All original peer-reviewed manuscripts pertaining to surgery-specific perioperative surgical home models involving preoperative, intraoperative and postoperative initiatives spanning the past 5 years have been reviewed using PubMed and Google Scholar. Whether the perioperative surgical home model is feasible or still a distant dream in the Indian perspective has been analysed.

The evolution of fast track protocols after oesophagectomy

Fast track is a standardised goal directed patient's care pathway that aims to facilitate recovery following surgery. Currently, there are large variations in the fast track protocols used in oesophagectomy due to the complexity of the procedure. The objective of this systematic review is to assess the evolution of fast track protocols following oesophagectomy since its implementation and the resulting effect on postoperative outcomes. Relevant electronic databases were searched for studies assessing the clinical outcome from fast track in oesophagectomy and also those assessing the effects of the individual key components in fast track protocols. The search yielded twenty-three publications regarding fast track implementation in oesophagectomy. A pattern of consistent evolution in fast-track protocols was clearly demonstrated and these have shown variations in the core-identified components across the studies. However, evolution in fast track protocols over time showed, an overall improvement in length of stay, anastomotic leak, pulmonary complications and mortality over time. Thirty publications were included that evaluated specific components of fast track protocols, with an increasing trend towards addressing the nutritional aspect in oesophagectomy care in more recent years. The variations in the key components of fast track protocol of care identify the need for continued assessment and identification for areas of improvement. In the future incremental gains through focused improvements in key components will lend itself to even better postoperative outcomes and patient experience during oesophageal cancer treatment.

Identification of serological markers for pre- and postoperative fasting periods

BACKGROUND & AIMS

Prolonged preoperative fasting periods lead to catabolic states and decelerate recovery after surgery. Valid plasma markers reflecting the patients' metabolic state may improve tailored nutrition support before surgery. Within this study, we sought to advance the knowledge on fasting time-sensitive plasma markers that allow the metabolic characterisation of surgical patients for an optimised preoperative metabolic preparation.

METHODS

Patients scheduled for elective surgery of the upper (n = 23) or lower (n = 27) gastrointestinal tract participated in a prospective observational study. Patients' charateristics and nutritional status were recorded and blood samples were drawn on the day of admission. Further blood samples were collected before skin incision of the surgical procedure, on postoperative day 3 and on the day of discharge. Values of clinical chemistry, electrolytes, hemograms and plasma amino acids were determined and correlated with fasting times.

RESULTS

Preoperative fasting times were positively correlated with plasma levels of valine, leucine, serine, α-amino butyric acid, free fatty acids, 3-hydroxy butyric acid and significantly negative correlated with chloride and glutamic acid. Postoperative fasting times were correlated with erythrocytes, leukocytes and plasma levels of albumin, CRP, HDL, asparagine and 3-methylhistidine. The multivariate regression analysis revealed glutamic acid and valine as significant independent predictors of preoperative fasting periods. The regression model showed best performance (sensitivity of 90.91% and specificity of 92.31%) to detect patients fasted for ≥20 h.

CONCLUSION

Valine and glutamic acid appear as independent metabolic markers for accurate prediction of prolonged fasting periods, independent of the overall nutritional status, age or BMI of patients.

Postoperative Level of C-Reactive Protein Is a Prognosticator After Esophageal Cancer Surgery With Perioperative Steroid Therapy and Enhanced Recovery After Surgery Care

BACKGROUND

This study investigated the impact of postoperative C-reactive protein (CRP) level on survival in patients with esophageal cancer who received perioperative steroid therapy and enhanced recovery after surgery (ERAS) care.

PATIENTS AND METHODS

Overall, 115 patients were retrospectively reviewed. The patients were classified into those with a high CRP level (≥4.0 mg/dl) on postoperative day 4 and those with low CRP level (<4.0 mg/dl). The risk factors for overall survival (OS) and recurrence-free survival (RFS) were identified.

RESULTS

The OS and RFS rates at 5 years after surgery were significantly low in patients with high CRP level on postoperative day 4. The multivariate analysis demonstrated that high CRP level on postoperative day 4 was a significant independent risk factor for OS and RFS.

CONCLUSION

The present results suggest that the postoperative CRP level can be a prognosticator in patients with esophageal cancer who have received perioperative steroid therapy and ERAS care.

THE INFLUENCE OF THE PREOPERATIVE PRELOAD WITH CARBOHYDRATES UPON METABOLIC, IMMUNE AND CYTOKINE STATUSES AFTER RECONSTRUCTIVE ESOPHAGEAL SURGICAL INTERVENTIONS

The aimof this prospective randomized clinical study was to investigate the role of preoperative carbohydrate admnistration in surgery-induced metabolic, immune and inflammatory reactions after thoracoabdominal operations. At the Surgical department I (B.V. Petrovsky National Research Center of Surgery), we investigated a modulatory role of carbohydrate preload upon surgical stress observed after major thoracoabdominal operations (thoracoscopic and open esophagectomy, retrosternal colonic esophagoplasty) followed by the enhanced recovery protocol. The study was performed in 2014-2017, it included 30 patients, divided into 2 groups. Group A patients (n = 16) received carbohydrates preload (12.5% maltodextrin solution per os or enterally). In patients with dysphagia, the 12.5% dextrose solution was used intravenously in equal volumes. Group B patients didn’t receive any additional preload with carbohydrates. The groups were age- and gendermatched, similar for disease and surgery types. Glucose and insulin levels (with HOMA insulin resistance index, HOMA-IR) were measured before surgery and on day +1, interleukin levels (IL-6, IL-10, IL-8) and index IL-8/IL-10 were assessed before surgery, and on days +1 and +5 after surgery. Cell-mediated immunity was investigated before surgery and on day +5.The stress-induced hyperglycemia (> 7.8 mmol/L) was detected more frequently in group B (50%), than in group A (6%), p = 0.012. Insulin resistance measured by HOMA-IR in group B was detected in 71% of patients and in 25% patients of group A only, p = 0.027. Individual analysis of immune response demonstrated that a trend for immune recovery was detected by the day +5 post-op in the group A. Postoperative levels of IL-6 and IL-10 were lower on day +1 and +5 in group A. Morbidity rates and the terms of hospitalization were similar in both groups. Local postsurgical infections in group A were developed in 6% of the patients vs 35.6% in group B (p = 0.072).In conclusion, a complex study of surgical stress, i.e., metabolic, immune and inflammatory reactions after esophageal surgery has shown that the carbohydrate preload decreased the incidence of postoperative insulin resistance and stress-induced hyperglycemia, being accompanied by lower release of proinflammatory cytokines and provides positive effects upon the patient’s immune system.

Risk-stratified clinical pathways decrease the duration of hospitalization and costs of perioperative care after pancreatectomy

BACKGROUND

Postoperative pancreatic fistula is associated with adverse events, increased duration of stay and hospital costs. We developed perioperative care pathways stratified by postoperative pancreatic fistula risk with the aims of minimizing variations in care, improving quality, and decreasing costs.

STUDY DESIGN

Three unique risk-stratified pancreatectomy clinical pathways-low-risk pancreatoduodenectomy, high-risk pancreatoduodenectomy, and distal pancreatectomy were developed and implemented. Consecutive patients treated after implementation of the risk-stratified pancreatectomy clinical pathways were compared with patients treated immediately prior. Duration of stay, rates of perioperative adverse effects, discharge disposition, and hospital readmission, as well as the associated costs of care, were evaluated.

RESULTS

The median hospital stay after pancreatectomy decreased from 10 to 6 days after implementation of the risk-stratified pancreatectomy clinical pathways (P < .001), and the median cost of index hospitalization decreased by 22%. Decreased changes in median hospital stay and costs of hospitalization were observed in association with low-risk pancreatoduodenectomy (P < .05) and distal pancreatectomy (P < .05), but not high-risk pancreatoduodenectomy. The rates of 90-day adverse events, grade B/C postoperative pancreatic fistula, discharge to a facility other than home, or readmission did not change after implementation.

CONCLUSION

Implementation of risk-stratified pancreatectomy clinical pathways decreased median stay and cost of index hospitalization after pancreatectomy without unfavorably affecting rates of perioperative adverse events or readmission, or discharge disposition. Outcomes were most favorably improved for low-risk pancreatoduodenectomy and distal pancreatectomy. Additional work is necessary to decrease the rate of postoperative pancreatic fistula, minimize variability, and improve outcomes after high-risk pancreatoduodenectomy.

Is closed thoracic drainage tube necessary for minimally invasive thoracoscopic-esophagectomy?

Background

Closed thoracic drainage tube (CTDT) is a conventional treatment after esophagectomy, even after minimally invasive esophagectomy. Here, we report a single-center, retrospective study to explore the safety and necessity of CTDT after thoracoscopic-esophagectomy.

Methods

From October 2015 and August 2016, 50 patients were enrolled and underwent thoracoscopic-esophagectomy in semi-prone position by same surgical team. Perioperative demographic and surgical parameters, and patients' satisfaction with or without CTDT after thoracoscopic-esophagectomy were collected and analyzed.

Results

All eligible patients (18 patients without CTDT and 32 patients with CTDT) were successfully underwent thoracoscopic procedures without conversion to open approach or major intraoperative complications and perioperative death. The two groups, with similar demographic parameters, had no statistically difference in thoracic operation time, blood loss, ICU stay, postoperative mobilization and oral feeding, and hospital stay. Also, the incidence of postoperative complications was similar with or without CTDT after esophagectomy. But, no-CTDT group had better post-operative satisfaction, including less pain scale scoring and better Norton scoring.

Conclusions

This study demonstrated that the treatment of no-CTDT after the minimally invasive thoracoscopic-esophagectomy is safe and feasible, might reduce the work intensity of medical stuff and lead to a better patients' experience.

Effect of fast track surgery concept based nursing intervention on rehabilitation and nursing satisfaction in patients with advanced gastric cancer after laparoscopic assisted D2 radical operation

AIM

To evaluate the effect of fast track surgery (FTS) concept based nursing intervention on the rehabilitation and nursing satisfaction in patients with advanced gastric cancer after laparoscopic assisted D2 radical operation.

METHODS

Seventy patients with advanced gastric cancer undergoing laparoscopic assisted D2 radical surgery from January 2013 to September 2017 at the Zhuji Municipal Hospital of Traditional Chinese Medicine were divided into an observation group (n = 35) and a control group (n = 35) according to admission sequence. The control group was given routine perioperative nursing intervention, and the observation group underwent FTS concept based perioperative nursing intervention. Operative and postoperative recovery parameters (operative time, intraoperative blood loss, number of lymph nodes dissected, time to first postoperative exhaust, time to food intake, and hospitalization time), perioperative stress response [levels of serum C reactive protein (CRP) and interleukin-6 (IL-6) before and 1 d after operation], immune function [peripheral blood T lymphocyte subsets (CD3⁺, CD4⁺, and CD4⁺/CD8⁺ ratio) before and 1 d after operation], and postoperative complications and nursing satisfaction were compared between the two groups.

RESULTS

There was no significant difference in operative time or the number of lymph nodes dissected between the two groups (P > 0.05). Compared with the control group, intraoperative blood loss was significantly less and the time to first exhaust, time to food intake, and hospitalization time were significantly shorter in the observation group (P < 0.05). There was no significant difference in serum CRP or IL-6 level between the two groups before operation (P > 0.05); one day after operation, the levels of serum CRP and IL-6 in both groups were significantly higher than those before operation (P < 0.05), but the levels of serum CRP and IL-6 in the observation group were significantly lower than those in the control group (P < 0.05). There was no significant difference in CD3⁺, CD4⁺, or CD4⁺/CD8⁺ ratio between the two groups before operation (P > 0.05); one day after operation, CD3⁺, CD4⁺, and CD4⁺/CD8⁺ ratio were significantly lower in both groups than those before operation (P < 0.05), but these indexes in the observation group were significantly higher than those in the control group (P < 0.05). There was no significant difference in the incidence of complications between the observation group and the control group (11.43% vs 22.86%, P > 0.05). The nursing satisfaction was significantly higher in the observation group than in the control group (91.43% vs 71.43%, P < 0.05).

CONCLUSION

FTS concept based nursing intervention in patients with advanced gastric cancer after laparoscopic assisted D2 radical operation can reduce the stress reaction and immune function damage, decrease the incidence of complications, promote early rehabilitation of patients, and improve the degree of patients' satisfaction with nursing.

Enhanced recovery after surgery (ERAS) programs for esophagectomy protocol for a systematic review and meta-analysis

BACKGROUND

Esophageal cancer is one of the worst malignant digestive neoplasms with poor treatment outcomes. Esophagectomy plays an important role and offers a potential curable chance to these patients. However, esophagectomy with radical lymphadenectomy is known as one of the most invasive digestive surgeries which are associated with high morbidity and mortality. The enhanced recovery after surgery (ERAS) protocol is a patient-centered, surgeon-led system combining anesthesia, nursing, nutrition, and psychology, which is designed for reducing complications, promoting recovery, and improving treatment outcomes. This systematic review and meta-analysis is aiming at how beneficial, and to what extent ERAS really will be.

METHODS

A systematic literature search will be performed through January 2018 using MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and Google Scholar for relevant articles published in any language. Randomized controlled trials, prospective cohort studies, and propensity-matched comparative studies will be included. All meta-analyses will be performed using Review Manager software. The quality of the studies will be evaluated using the guidelines listed in the Cochrane Handbook. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statements will be followed until the findings of the systematic review and meta-analysis are reported.

RESULTS

The results of this systematic review and meta-analysis will be published in a peer-reviewed journal.

CONCLUSION

Our study will draw an objective conclusion of the comparisons between ERAS and conventional care in aspects of perioperative outcomes and provide level I evidences for clinical decision makings.

Enhanced Recovery After Surgery for Noncolorectal Surgery?: A Systematic Review and Meta-analysis of Major Abdominal Surgery

OBJECTIVE

To evaluate the impact of enhanced recovery after surgery (ERAS) protocols across noncolorectal abdominal surgical procedures.

BACKGROUND

ERAS programs have been studied extensively in colorectal surgery and adopted at many centers. Several studies testing such protocols have shown promising results in improving postoperative outcomes across various surgical procedures. However, surgeons performing major abdominal procedures have been slower to adopt these ERAS protocols.

METHODS

A systematic review was performed using "enhanced recovery after surgery" or "fast track" as search terms and excluded studies of colorectal procedures. Primary endpoints for the meta-analysis include length of stay (LOS) and complication rate. Secondary endpoints were time to first flatus, readmission rate, and costs.

RESULTS

A total of 39 studies (6511 patients) met inclusion and exclusion criteria. Among them 14 studies were randomized trials, and the remaining 25 studies were cohort studies. Meta-analysis showed a decrease in LOS of 2.5 days (95% confidence interval, CI: 1.8-3.2, P < 0.001) and a complication rate of 0.70 (95% CI: 0.56-0.86, P = 0.001) for patient treated in ERAS programs. There was also a significant reduction in time to first flatus of 0.8 days (95% CI: 0.4-1.1, P < 0.001) and cost reduction of $5109.10 (95% CI: $4365.80-$5852.40, P < 0.001). There was no significant increase in readmission rate (OR 1.03, 95% CI: 0.84-1.26, P = 0.80) in our analysis.

CONCLUSIONS

ERAS protocols decreased length of stay and cost by not increasing complications or readmission rates. This study adds to the evidence that ERAS protocols are safe to implement and are beneficial to surgical patients and the healthcare system across multiple abdominal procedures.

Prediction of postoperative inflammatory complications after esophageal cancer surgery based on early changes in the C-reactive protein level in patients who received perioperative steroid therapy and enhanced recovery after surgery care: a retrospective analysis

BACKGROUND

Serum C-reactive protein (CRP) level can be an indicator of the early stage of infectious complications. However, its utility in advanced esophageal cancer patients who receive radical esophagectomy with two- or three-field lymph node dissection with perioperative steroid therapy and enhanced recovery after surgery (ERAS) care is unclear.

METHODS

The present study retrospectively examined 117 consecutive esophageal cancer patients who received neoadjuvant chemotherapy followed by radical esophagectomy. All patients received perioperative steroid therapy and ERAS care. The utility of the CRP value in the early detection of serious infectious complications (SICs) was evaluated based on the area under the receiver operating characteristic curve (AUC). Univariate and multivariate logistic regression analyses were performed to identify the risk factors for SICs.

RESULTS

SICs were observed in 20 patients (17.1%). The CRP level on postoperative day (POD) 4 had superior diagnostic accuracy for SICs (AUC 0.778). The cut-off value for CRP was determined to be 4.0 mg/dl. A multivariate analysis identified CRP ≥ 4.0 mg/dl on POD 4 (odds ratio, 18.600; 95% confidence interval [CI], 4.610-75.200) and three-field lymph node dissection (odds ratio, 7.950; 95% CI, 1.900-33.400) as independent predictive factors.

CONCLUSIONS

CRP value on POD 4 may be useful for predicting SICs in esophageal cancer patients who receive radical esophagectomy with perioperative steroid therapy and ERAS care. This result may encourage the performance of imaging studies to detect the focus and thereby lead to the early medical and/or surgical intervention to improve short-term outcomes.

Nutritional aspects of enhanced recovery after esophagectomy with gastric conduit reconstruction

Enhanced Recovery After Surgery (ERAS) aims to accelerate recovery by a set of multimodality management strategies. For esophagectomy, several nutritional elements of ERAS can be safely introduced and are advised in routine practice, including preadmission counseling to screen and treat for potential malnutrition, shortened preoperative fasting, and carbohydrate loading. However, the timing of oral intake and the use of routine nasogastric decompression remain matter of debate after esophagectomy. Furthermore, more research is needed on future developments such as perioperative immunonutrition.

Component analysis of enhanced recovery pathways for esophagectomy

The objective of this systematic review is to identify key components of enhanced recovery protocols (ERP) that lead to improved length of hospital stay (LOS) following esophagectomy. Relevant electronic databases were searched for studies comparing clinical outcome from esophagectomy followed by a conventional pathway versus ERP. Relevant outcome measures were compared and metaregression was performed to identify the key ERP components associated with reduced in LOS. Thirteen publications were included, ERP was associated with no changes in in-hospital mortality, total complications, anastomotic leak, or pulmonary complications compared with a conventional pathway, however LOS was reduced in the ERP group. Metaregression identified that immediate extubation was associated with reduced LOS (OR = -0.51, 95%CI -0.77 to -0.25; P < 0.01). Several postoperative factors were associated with a significant reduction in length of hospital stay, and in order of most important were (i) gastrograffin swallow ≤5 days (OR = -4.27, 95%CI -4.50 to -4.03); (ii) mobilization on postoperative day ≤1 (OR = -2.49, 95%CI -2.63 to -2.34); (iii) removal of urinary catheter ≤2 days (OR = -0.99, 95%CI -1.15 to -0.84); (iv) oral intake with at least sips of fluid ≤1 day (OR = -0.96, 95%CI -1.24 to -0.68); (v) enteral diet with feeding jejunostomy or gastrostomy ≤ 1 day (OR = -0.57, 95%CI -0.80 to -0.35) and (vi) epidural removal ≤ 4 days (OR = -0.17, 95%CI -0.27 to -0.07). Several core ERP components and principles appear to be associated with LOS reduction. These elements should form a part of the core ERP for the specialty, while surgical teams incorporate other elements through an iterative process.

Nutrition in peri-operative esophageal cancer management

Nutritional status and dietary intake are increasingly recognized as essential areas in esophageal cancer management. Nutritional management of esophageal cancer is a continuously evolving field and comprises an interesting area for scientific research. Areas covered: This review encompasses the current literature on nutrition in the pre-operative, peri-operative, and post-operative phases of esophageal cancer. Both established interventions and potential novel targets for nutritional management are discussed. Expert commentary: To ensure an optimal pre-operative status and to reduce peri-operative complications, it is key to assess nutritional status in all pre-operative esophageal cancer patients and to apply nutritional interventions accordingly. Since esophagectomy results in a permanent anatomical change, a special focus on nutritional strategies is needed in the post-operative phase, including early initiation of enteral feeding, nutritional interventions for post-operative complications, and attention to long-term nutritional intake and status. Nutritional aspects of pre-optimization and peri-operative management should be incorporated in novel Enhanced Recovery After Surgery programs for esophageal cancer.

Enhanced recovery after surgery protocol in oesophageal cancer surgery: Systematic review and meta-analysis

Background

Enhanced Recovery After Surgery (ERAS) protocol are well established in many surgical disciplines, leading to decrease in morbidity and length of hospital stay. These multi-modal protocols have been also introduced to oesophageal cancer surgery. This review aimed to evaluate current literature on ERAS in oesophageal cancer surgery and conduct a meta-analysis on primary and secondary outcomes.

Methods

MEDLINE, Embase, Scopus and Cochrane Library were searched for eligible studies. We analyzed data up to May 2016. Eligible studies had to contain four described ERAS protocol elements. The primary outcome was overall morbidity. Secondary outcomes included length of hospital stay, specific complications, mortality and readmissions. Random effect meta-analyses were undertaken.

Results

Initial search yielded 1,064 articles. Thorough evaluation resulted in 13 eligible articles which were analyzed. A total of 2,042 patients were included in the analysis (1,058 ERAS group and 984 treated with traditional protocols). Analysis of overall morbidity as well as complication rate did not show any significant reduction. Non-surgical complications and pulmonary complications were significantly lower in the ERAS group, RR = 0.71 95% CI 0.62–0.80, p < 0.00001 and RR = 0.75, 95% CI 0.60–0.94, p = 0.01, respectively. Meta-analysis on length of stay presented significant reduction Mean difference = -3.55, 95% CI -4.41 to -2.69, p for effect<0.00001.

Conclusions

This systematic review with a meta-analysis on ERAS in oesophageal surgery indicates a reduction of non-surgical complications and no negative influence on overall morbidity. Moreover, a reduction in the length of hospital stay was presented.

Fast-Track Surgery Could Improve Postoperative Recovery in Patients with Laparoscopy D2 Gastrectomy

The objective of this study is to evaluate the safety and efficacy of fast track surgery (FTS) management in gastric cancer (GC) with laparoscopy D2 gastrectomy. FTS is the integration of different medical intervention activities during the perioperative period to accelerate the recovery of patients undergoing surgery. It has been used for colorectal cancer. The present study focuses on evaluating FTS in GC with laparoscopy D2 gastrectomy. Seventy-five patients diagnosed with GC between June 2014 and December 2016 were enrolled in this study and were divided into FTS and conventional care groups. All patients received elective standard D2 gastrectomy. The clinical parameters and serum indicators were compared. FTS was associated with shorter postoperative hospital stay (17.17 ± 9.27 versus 14.06 ± 5.05 days; P = 0.046), shorter time to bowel function return (4.56 ± 1.16 versus 3.12 ± 0.88 days; P &lt; 0.01), less stress response on postoperative day 1 (108.13 ± 40.55 versus 79.01 ± 37.10; P &lt; 0.01), and accelerated decrease in serum albumin (30.76 ± 4.10 versus 32.56 ± 3.20 g/L; P = 0.04) and lymphocyte count (0.78 ± 0.34 versus 0.78 ± 0.34 g/L; P = 0.016). The postoperative complications, including ileus, anastomotic leakage, and infection, were similar (all P &gt; 0.05). FTS combined with laparoscopy D2 gastrectomy can promote faster postoperative recovery, improve early postoperative nutritional status, and more effectively reduce postoperative stress reaction and is safe and effective for GC patients.

Nasogastric decompression following esophagectomy: a systematic literature review and meta-analysis

Routine use of nasogastric tubes for gastric decompression has been abolished in nearly all types of gastro-intestinal surgery after introduction of enhanced recovery after surgery programs. However, in esophagectomy the routine use of nasogastric decompression is still a matter of debate. To determine the effects of routine nasogastric decompression following esophagectomy compared with early or peroperative removal of the nasogastric tube on pulmonary complications, anastomotic leakage, mortality, and postoperative recovery. A systematic literature review and meta-analysis of studies comparing early or peroperative versus late removal of nasogastric tubes. A total of seven comparative studies were included (n = 608). In two randomized trials, and one retrospective cohort study, peroperative removal of the nasogastric tube was compared with routine nasogastric decompression. In one randomized trial early removal of the nasogastric tube (on postoperative day 2) was compared with removal of the nasogastric tube on the 6th-10th postoperative day. In the remaining three trials a fast-track protocol without a nasogastric tube was compared with conventional care with a nasogastric tube during the first postoperative days. Peroperative or early removal of the nasogastric tube did not result in a significantly different rate of anastomotic leakage, pulmonary complications or mortality in individual studies, nor in the meta-analysis. In the meta-analysis, hospital stay was significantly shorter with peroperative or early removal of the nasogastric tube when all studies were included, but not when the meta-analysis was limited to randomized trials. This systematic review did not find a difference in adverse outcomes between nasogastric decompression or no nasogastric decompression following esophagectomy.

Fast-track surgery versus conventional perioperative management of lung cancer-associated pneumonectomy: a randomized controlled clinical trial

Background

The aim of this study is to investigate the effects of fast-track surgery (FTS) on postoperative recovery, hospital stay, total medical costs, and the complications of pneumonectomy in patients with non-small cell lung cancer (NSCLC).

Methods

Studies were performed between June 2012 and March 2014 in 17 patients received FTS and 18 patients given conventional management (control) after pneumonectomy in the Department of Thoracic Surgery, the Fourth Affiliated Hospital of Harbin Medical University. Patients were evaluated based on their days to achieve the first postoperative flatus, C-reactive protein (CRP) at postoperative day (POD) 1–7, the length of hospital stay, the medical costs, and postoperative complications.

Results

The results showed that in the FTS group, latency to the first postoperative flatus (1.5 ± 0.6 versus 3.1 ± 0.8 s in controls, P < 0.0001), CRP (71.36 ± 5.48 versus 80.71 ± 8.32 mg/L in at POD 7, P < 0.0001), the length of hospital stay (18.1 ± 1.4 versus 27.4 ± 6.6 days, P < 0.0001), and the medical costs (29.9 ± 2.7 versus 37.2 ± 3.6 thousand Chinese Yuan, P < 0.0001) were significantly reduced compared to the group receiving conventional management. FTS group also had a relatively lower postoperative complication rate (23.5% of 17 versus 33.3% of 18 in control group) although it was statistically insignificant (P = 0.711).

Conclusions

These results indicate that application of the FTS in NSCLC pneumonectomy efficiently accelerates postoperative recovery, shortens hospital stay, reduces the total medical costs of the patients and thus is more acceptable than conventional management.

Fast-track surgery improves postoperative clinical recovery and cellular and humoral immunity after esophagectomy for esophageal cancer

Background

Our aim was to investigate the influence of FTS on human cellular and humoral immunity using a randomized controlled clinical study in esophageal cancer patients.

Methods

Between October 2013 and December 2014, 276 patients with esophageal cancer in our department were enrolled in the study. The patients were randomized into two groups: FTS pathway group and conventional pathway group. The postoperative hospital stay, hospitalization expenditure, and postoperative complications were recorded. The markers of inflammatory and immune function were measured before operation as well as on the 1st, 3rd, and 7th postoperative days (POD), including serum level of interleukin-6 (IL-6), C-reactive protein (CRP), serum globulin, immunoglobulin G (IgG), immunoglobulin M (IgM), immunoglobulin A (IgA) and lymphocyte subpopulations (CD3 lymphocytes, CD4 lymphocytes, CD8 lymphocytes and the CD4/CD8 ratio) in the patients between the two groups.

Results

In all, 260 patients completed the study: 128 in the FTS group and 132 in the conventional group. We found implementation of FTS pathway decreases postoperative length of stay and hospital charges (P < 0.05). In addition, inflammatory reactions, based on IL-6 and CRP levels, were less intense following FTS pathway compared to conventional pathway on POD1 and POD3 (P < 0.05). On POD1 and POD3, the levels of IgG, IgA, CD3 lymphocytes, CD4 lymphocytes and the CD4/CD8 ratio in FTS group were significantly higher than those in control group (All P < 0.05). However, there were no differences in the level of IgM and CD8 lymphocytes between the two groups.

Conclusions

FTS improves postoperative clinical recovery and effectively inhibited release of inflammatory factors via the immune system after esophagectomy for esophageal cancer.

Trial registration

ChiCTR-TRC-13003562, the date of registration: August 29, 2013.

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.