Usefulness of enhanced recovery after surgery protocol as compared with conventional perioperative care in gastric surgery

Adherence to Guidelines for Diagnosis, Staging, and Treatment for Gastric Cancer in Italy According to the View of Surgeons and Patients

Background: Despite the strong declining trends in incidence and mortality over the last decades, gastric cancer (GC) is still burdened with high mortality, even in high-income countries. To improve GC prognosis, several guidelines have been increasingly published with indications about the most appropriate GC management. The Italian Society of Digestive System Pathology (SIPAD) and Gastric Cancer Italian Research Group (GIRCG) designed a survey for both surgeons and patients with the purpose of evaluating the degree of application and adherence to guidelines in GC management in Italy. Materials and Methods: Between January and May 2022, a questionnaire has been administered to a sample of Italian surgeons and, in a simplified version, to members of the Patient Association "Vivere Senza Stomaco" (patients surgically treated for GC between 2008 and 2021) to investigate the diagnosis, staging, and treatment issues. Results: The survey has been completed by 125 surgeons and 125 patients. Abdominal CT with gastric hydro-distension before treatment was not widespread in both groups (47% and 42%, respectively). The rate of surgeons stating that they do not usually perform minimally invasive gastrectomy was 15%, but the rate of patients who underwent a minimally invasive approach was 22% (between 2011 and 2022). The percentage of surgeons declaring to perform extended lymphadenectomy (>D2) was 97%, although a limited lymph node dissection rate was observed in about 35% of patients. Conclusions: This survey shows several important discrepancies from surgical attitudes declared by surgeons and real data derived from the reports available to the patients, suggesting heterogeneous management in clinical practice and, thus, a not rigorous adherence to the guidelines.

A randomized controlled study to assess the effect of mosapride citrate on intestinal recovery following gastrectomy

The enhanced recovery after surgery (ERAS) protocol, including prokinetic medications, is commonly used to prevent postoperative ileus. Prospective studies evaluating the effectiveness of mosapride citrate, a prokinetic 5-hydroxytryptamine 4 receptor agonist, in patients undergoing gastrectomy within the ERAS framework are lacking. This double-blind randomized trial included patients who were scheduled for laparoscopic or robotic gastrectomy for gastric cancer. Participants were randomly assigned to either a control (placebo) or experimental (mosapride citrate) group, with drugs administered on postoperative days 1-5. Bowel motility was evaluated based on bowel transit time measured using radiopaque markers, first-flatus time, and amount of food intake. No significant differences were observed in baseline characteristics between the two groups. On postoperative day 3, no significant difference was observed in the number of radiopaque markers visible in the colon between the groups. All factors associated with bowel recovery, including the time of first flatus, length of hospital stay, amount of food intake, and severity of abdominal discomfort, were similar between the two groups. Mosapride citrate does not benefit the recovery of intestinal motility after minimally invasive gastrectomy in patients with gastric cancer. Therefore, routine postoperative use of mosapride citrate is not recommended in such patients.

Application of the quality of recovery-40 questionnaire to evaluate the effectiveness of enhanced recovery after surgery protocols in gastric cancer

Patient reported outcomes is currently considered to be an important supplement to evaluate the effectiveness of enhanced recovery after surgery (ERAS) clinical practice. The Quality of Recovery-40 Questionnaire (QoR-40) is one of the most frequently used and validation tool to assess the subjective feelings of quality of life after surgery. The present study aimed to use the QoR-40 to evaluate the effectiveness of ERAS protocols in gastric cancer from the perspective of patient-reported quality of recovery. The study was designed as a prospective, non-randomized clinical trial, conducted in a single center. Patients in our hospital who were scheduled to undergo radical surgery for gastric cancer were divided into ERAS group and control group (Contr group). The QoR-40 were administered one day before surgery (Baseline) and on postoperative day 1, 3, 6, and 30. The difference in QoR-40 scores between the ERAS and Contr groups was compared by repeated-measures ANOVA. A total of 200 patients completed the study, including 100 patients in the ERAS group and 100 patients in the Contr group. The Baseline time point QoR-40 scores of the ERAS and Contr groups were 179.68 ± 14.46 and 180.12 ± 17.12, respectively, and no significant difference was noted between the two groups (p = 0.845). The postoperative QoR-40 score of the ERAS group was significantly higher than that of the Contr group, and the difference was statistically significant (p = 0.006). This study demonstrated that, in terms of patient-reported quality of recovery, the postoperative recovery effect of ERAS protocols in gastric cancer is significantly better than that of the traditional treatment model.

Association of Malnutrition Diagnosed Using Global Leadership Initiative on Malnutrition Criteria with Severe Postoperative Complications After Gastrectomy in Patients with Gastric Cancer

Background: The purpose of this study was to investigate the relationship between malnutrition assessed by the Global Leadership Initiative on Malnutrition (GLIM) criteria and the occurrence of severe postoperative complications (SPCs) after gastrectomy in patients with gastric cancer. Methods: A total of 220 patients with gastric cancer were included in this retrospective study. According to the GLIM criteria, the first step was to use the Nutrition Risk Screening Score 2002 to conduct nutritional risk screening for patients and the second step was to diagnose and grade the severity of malnutrition in patients at risk of malnutrition. According to the Clavien-Dindo classification system, SPCs were defined as C-D Grade IIIa or higher. Results: Overall, 66 (30.0%) patients were diagnosed with malnutrition, including 32 (14.5%) with moderate malnutrition and 34 (15.5%) with severe malnutrition. The incidence of SPCs was 14.5%, and the most frequent postoperative event was anastomotic leakage. In the multivariate regression analysis, malnutrition was considered an independent risk factor for SPCs (P < .001). After adjusting for various factors, the grading association remained statistically significant. Compared with patients with normal nutrition, patients with moderate and severe malnutrition have a nearly 15-fold (OR = 15.682, 95% CI: 4.481-54.877, P < .001) and 20-fold (OR = 20.554, 95% CI: 5.771-73.202, P < .001) increased risk of developing SPCs, respectively. Conclusions: Malnutrition assessed by GLIM was an independent risk factor for SPCs in gastric cancer patients. Therefore, early identification of malnourished patients is crucial for timely implementation of nutritional treatment and reducing the occurrence of postoperative complications.

A low cumulative perioperative prognostic nutritional index predicts poor long-term outcomes in patients with gastric cancer: A single-center retrospective study in Japan

PURPOSE

Perioperative surgical stress and systemic inflammation resulting from complex interactions between cancer and the host play an important role in cancer progression. This retrospective study compared the prognostic impact of various perioperative cumulative inflammation- and nutrition-based markers in patients with gastric cancer (GC).

METHODS

This study included 301 patients with a histopathological diagnosis of gastric adenocarcinoma who underwent curative surgery. Perioperative cumulative markers were calculated using the newly developed trapezoidal area method.

RESULTS

The cumulative prognostic nutritional index (cum-PNI) had the highest area under the receiver operating characteristic (ROC) curve for predicting the overall survival (OS) as well as the relapse-free survival (RFS). The cum-PNI was significantly correlated with tumor-related factors, including tumor size, depth of invasion, lymph node metastasis, lymphatic involvement, vascular involvement, and TNM stage classification. The cum-PNI was also significantly correlated with surgical factors, including surgical approach, gastrectomy, lymphadenectomy, intraoperative blood loss, and postoperative complications. Furthermore, the OS and RFS were poorer in patients with a low cum-PNI (< 236.3) than in those with a high cum-PNI (> 236.3). A multivariate analysis indicated that a low cum-PNI was an independent prognostic indicator in patients with GC.

CONCLUSIONS

The cum-PNI might be useful for predicting the prognosis and guiding the perioperative management of patients with GC.

The application of enhanced recovery after surgery in total gastrectomy: a propensity score-matched analysis

BACKGROUND

This study aimed to investigate the feasibility and safety of our enhanced recovery after surgery protocol including early oral intake and omitting nasogastric tube (NGT) placement after total gastrectomy.

METHODS

We analyzed 182 consecutive patients who underwent total gastrectomy. The clinical pathway was changed in 2015, and patients were divided into 2 groups (conventional group and modified group). Postoperative complications, bowel movement, and postoperative hospital stays were compared in the two groups in all cases and propensity score matching (PSM).

RESULTS

Flatus and defecation were significantly earlier in the modified group compared with those in the conventional group (flatus: 2 (1-5) days vs 3 (2-12) days, p = 0.03; defecation: 4 (1-14) days vs 6 (2-12) days p = 0.04). The postoperative hospital stay was 18 (6-90) days in the conventional group and 14 (7-74) days in the modified group (p = 0.009). Days until discharge criteria were met were earlier in the modified group compared with that in the conventional group (10 (7-69) days vs 14 (6-84) days p = 0.01). Overall and severe complications occurred in nine patients (12.6%) and three patients (4.2%) in the conventional group and twelve patients (10.8%) and four patients (3.6%) in the modified group, respectively (p = 0.70 and p = 0.83) in all cases. In PSM, there is no significant difference between the two groups concerning the postoperative complications (overall complication 6 (12.5%) vs 8 (16.7%) p = 0.56, severe complications 1 (2%) vs 2 (4.2%) p = 0.83).

CONCLUSIONS

Modified ERAS for total gastrectomy may be feasible and safe.

Implementation of the ERAS program in gastric surgery: a nationwide survey in Italy

Enhanced recovery after surgery (ERAS) programs have been developed by combining several evidence-based techniques for perioperative care, with the intention of reducing the stress response and organ dysfunction, thus allowing improved clinical results. ERAS programs have been widely adopted for colorectal surgery; however, their adoption for upper gastrointestinal surgery has been challenging even though good results have been reported in the literature. Our intent was to investigate the adoption of ERAS programs for resective gastric surgery in Italy. A survey was conducted among 20 departments of surgery belonging to the Italian Group for Research on Gastric Cancer (GC). Analysis of our survey showed that several evidence-based practices and many items of the ERAS guidelines for gastric surgery are not implemented in real practice in Italian centers dedicated to GC. This situation may be related to the hesitation of surgeons to introduce radical changes to the traditional postoperative management after gastrectomy. A multidisciplinary approach to the perioperative care of these patients is not routinely applied in many Italian centers. A strict collaboration of all clinicians involved in the perioperative care of patients undergoing gastrectomy for GC is key for the future implementation of ERAS in gastric surgery in our departments.

Impact of gastrectomy on body composition within 1 month in patients with gastric cancer

PURPOSE

The present study examined the changes in and risk factors for body composition (BC) during the first postoperative month when dynamic biological reactions occur.

METHODS

We retrospectively assessed 202 patients who underwent gastrectomy. The BC was assessed using a bioelectrical impedance analysis and evaluated within 1 month preoperatively, 1 week postoperatively, and 1 month postoperatively. Multiple regression analyses were performed to identify predictive factors for BC change.

RESULTS

The mean reduction rate in BC at 1 month postoperatively was - 6.0, - 10.5, - 5.6, - 1.1, - 10.1, and + 1.2% for body weight, body fat, skeletal muscle, bone mineral, extracellular water/total body water, and the whole-body phase angle, respectively. A multiple regression analysis revealed that independent risk factors for weight loss were complications, operative time, and type of gastrectomy (P = 0.004, 0.011, 0.015, respectively), and those for skeletal muscle loss were complications and gastrectomy type (P = 0.002, 0.010, respectively). A segmental lean mass analysis revealed that the lower limbs were markedly reduced at 1 week postoperatively (- 8.0%), and these independent risk factors were the female sex and Stage II/III disease (P = 0.008, 0.036, respectively).

CONCLUSION

Detailed analyses of BC might help elucidate the mechanisms underlying postoperative physical changes, which might be useful for perioperative management.

The application of enhanced recovery after surgery in minimally invasive gastrectomy for gastric cancer: a meta-analysis of randomized controlled trials

OBJECTIVE

We aimed to investigate the efficacy and safety of enhanced recovery after surgery (ERAS) for patients with gastric cancer undergoing minimally invasive surgery (MIS).

METHODS

We searched the PubMed, Cochrane Library, Web of Science, Embase, CNKI, VIP, WanFang, and CBM for relevant RCTs from the database inception until December 2021, for studies that compared the ERAS and traditional care (TC) in MIS for gastric cancer.

RESULTS

A total of 25 RCTs comprising 2809 patients were included in this study. When compared with the traditional care TC group, the ERAS group had a shorter postoperative hospital stay [MD = -1.88,95%CI (-2.22, -1.55), P < 0.00001] and an earlier time at first postoperative flatus [MD = -18.12,95%CI (-21.45,-14.80), P < 0.00001] along with lower medical costs [SMD = -0.64, 95% CI (-0.85, -0.43), P < 0.00001] and an overall reduction in postoperative complication rates [RR = 0.55, 95% CI (0.44, 0.69), P < 0.00001]. However, the difference in the readmission rates    was not significant.

CONCLUSIONS

ERAS can shorten the postoperative hospital stay, hasten the first postoperative flatus and reduce medical costs and overall postoperative complication rate without increasing readmission rates. Therefore, the ERAS protocol is preferable for gastric cancer patients undergoing MIS.

Study protocol for feasibility and safety of adopting early oral feeding in post total laparoscopic total gastrectomy (overlap esophagojejunostomy): A multicentre randomized controlled trial

Background

Total laparoscopic total gastrectomy (TLTG) for gastric cancer, especially with overlap esophagojejunostomy, has been verified that it has advantages of minimally invasion, less intraoperative bleeding, and faster recovery. Meanwhile, early oral feeding (EOF) after the operation has been demonstrated to significantly promote early rehabilitation in patients, particularly with distal gastrectomy. However, due to the limited application of TLTG, there is few related research proving whether it is credible or safe to adopt EOF after TLTG (overlap esophagojejunostomy). So, it is urgent to start a prospective, multicenter, randomized clinical trials to supply high level evidence.

Methods/design

This study is a prospective, multicenter, randomized controlled trial with 200 patients (100 in each group). These eligible participants are randomly allocated into two different groups, including EOF group and delay oral feeding (DOF) group after TLTG (overlap esophagojejunostomy). Anastomotic leakage will be carefully observed and recorded as the primary endpoints; the period of the first defecation and exhaust, postoperative length of stay and hospitalization expenses will be recorded as secondary endpoints to ascertain the feasibility and safety of adopting EOF after TLTG (overlap esophagojejunostomy).

Discussion

Recently, the adoption of TLTG was limited due to its difficult anastomotic procedure, especially in vivo esophagojejunostomy. With the innovation and improvement of operating techniques, overlap esophagojejunostomy with linear staplers simplified the anastomotic steps and reduced operational difficulties after TLTG. Meanwhile, EOF had received increasing attention from surgical clinicians as a nutrition part of enhanced recovery after surgery (ERAS), which had shown better results in patients after distal gastrectomy. Considering the above factors, we implemented EOF protocol to evaluate the feasibility and safety of adopting EOF after TLTG (overlap esophagojejunostomy), which provided additional evidence for the development of clinical nutrition guidelines.

Clinical trial registration

[www.chictr.org.cn], identifier [ChiECRCT20200440 and ChiCTR2000040692].

The Comparison of the Dietary Intake Loss Between Elderly and Non-Elderly Patients After Gastrectomy for Gastric Cancer

BACKGROUND/AIM

The present study quantified the changes in the dietary and nutritional intake after gastrectomy between elderly and non-elderly patients.

PATIENTS AND METHODS

This prospective observational study enrolled patients who underwent curative gastrectomy for gastric cancer.

RESULTS

Twenty-three patients ≥ 75 years old were classified into the elderly group, and 127 patients < 75 years old were classified into the non-elderly group. The respective median % dietary intake losses at 1 and 3 months postoperatively were -12.4% and -5.3% in the elderly group and -8.3% and -2.8% in the non-elderly group (p = 0.075 and 0.080). On comparing the intake loss of three major nutrients, the respective median % lipid intake losses at 1 and 3 months postoperatively were -13.5% and -5.8% in the elderly group and -7.3% and 0% in the non-elderly group (p = 0.029 and 0.045).

CONCLUSION

Our results suggested that elderly patients experienced more serious lipid intake loss after gastrectomy than non-elderly patients.

Randomized Controlled Trial Comparing the Short-term Outcomes of Enhanced Recovery After Surgery and Conventional Care in Laparoscopic Distal Gastrectomy (GISSG1901)

OBJECTIVE

This study aimed to compare the effects of ERAS and conventional programs on short-term outcomes after LDG.

SUMMARY OF BACKGROUND DATA

Currently, the ERAS program is broadly applied in surgical areas. Although several benefits of LDG with the ERAS program have been covered, high-level evidence is still limited, specifically in advanced gastric cancer.

METHODS

The present study was designed as a randomized, multicenter, unblinded trial. The enrollment criteria included histologically confirmed cT2-4aN0-3M0 gastric adenocarcinoma. Postoperative complications, mortality, readmission, medical costs, recovery, and laboratory outcomes were compared between the ERAS and conventional groups.

RESULTS

Between April 2019 and May 2020, 400 consecutive patients who met the enrollment criteria were enrolled. They were randomly allocated to either the ERAS group (n = 200) or the conventional group (n = 200). After excluding patients who did not undergo surgery or gastrectomy, 370 patients were analyzed. The patient demographic characteristics were not different between the 2 groups. The conventional group had a significantly longer allowed day of discharge and postoperative hospital stay (6.96 vs 5.83 days, P < 0.001; 8.85 vs 7.27 days, P < 0.001); a longer time to first flatus, liquid intake and ambulation (3.37 vs 2.52 days, P < 0.001; 3.09 vs 1.13 days, P < 0.001; 2.85 vs 1.38 days, P < 0.001, respectively); and higher medical costs (6826 vs 6328 $, P = 0.027) than the ERAS group. Additionally, patients in the ERAS group were more likely to initiate adjuvant chemotherapy earlier (29 vs 32 days, P = 0.035). There was no significant difference in postoperative complications or in the mortality or readmission rates. Regarding laboratory outcomes, the procalcitonin and C-reactive protein levels on postoperative day 3 were significantly lower and the hemoglobin levels on postoperative day 5 were significantly higher in the ERAS group than in the conventional group.

CONCLUSION

The ERAS program provides a faster recovery, a shorter postoperative hospitalization length, and lower medical costs after LDG without increasing complication and readmission rates. Moreover, enhanced recovery in the ERAS group enables early initiation of adjuvant chemotherapy.

Enhanced Recovery After Surgery Protocol With Ultrasound-Guided Regional Blocks in Outpatient Plastic Surgery Patients Leads to Decreased Opioid Prescriptions and Consumption

BACKGROUND

Opioids are a mainstay of pain management. To limit the use of opioids, enhanced recovery after surgery (ERAS) protocols implement multimodal approaches to treat postoperative pain.

OBJECTIVES

The aim of this paper was to be the first to assess the efficacy of an ERAS protocol for plastic surgery outpatients that includes ultrasound-guided, surgeon-led regional blocks.

METHODS

A retrospective review of patients undergoing outpatient plastic surgery on an ERAS protocol was performed. These patients were compared to a well-matched group not on an ERAS protocol (pre-ERAS). Endpoints included the amounts of opioid, antinausea, and antispasmodic medication prescribed. ERAS patients were given a postoperative questionnaire to assess both pain levels (0-10) and opioid consumption. ERAS patients anticipated to have higher levels of pain received ultrasound-guided anesthetic blocks.

RESULTS

There were 157 patients in the pre-ERAS group and 202 patients in the ERAS group. Patients in the pre-ERAS group were prescribed more opioid (332.3 vs 100.3 morphine milligram equivalents (MME)/patient; P < 0.001), antinausea (664 vs 16.3 mg of promethazine/patient; P < 0.001), and antispasmodic (401.3 vs 31.2 mg of cyclobenzaprine/patient; P < 0.001) medication. Patients on the ERAS protocol consumed an average total of 22.7 MME/patient postoperatively. Average pain scores in this group peaked at 5.32 on postoperative day 1 and then decreased significantly daily.

CONCLUSIONS

Implementation of an ERAS protocol for plastic surgery outpatients with utilization of ultrasound-guided regional anesthetic blocks is feasible and efficacious. The ability to significantly decrease prescribed opioids in this unique patient population is noteworthy.

LEVEL OF EVIDENCE: 4

Is sufficient experience performing open gastrectomies necessary to start laparoscopic distal gastrectomy training?

INTRODUCTION

Laparoscopic gastrectomy has become a standard procedure for treatment of gastric cancer, and hence, the opportunity for trainees to perform open gastrectomies may decrease. We investigated whether laparoscopic distal gastrectomy, performed by surgical trainees without sufficient experience performing open gastrectomies, was feasible and safe.

PATIENTS AND METHODS

We compared short-term outcomes in patients when laparoscopic distal gastrectomies were performed by experienced trainees (ET group; n = 124) and inexperienced trainees (IT group; n = 98) from 2013 to 2019.

RESULTS

The operation time was significantly shorter in the ET group (median time: 253 minutes vs 286 minutes, P < 0.001). The incidence of grade ≥ 2 postoperative complications did not differ significantly between the groups. In the multivariate analysis, experience performing open gastrectomies was not an independent predictor of postoperative complications.

CONCLUSION

Laparoscopic distal gastrectomies performed by trainees, with insufficient experience performing open gastrectomies, are as feasible and safe as that performed by ET.

Comparison of the Dietary Intake Loss Between Total and Distal Gastrectomy for Gastric Cancer

BACKGROUND/AIM

The changes of dietary intake (DI) after gastrectomy have not been objectively reported. It has not been clear how much DI loss is experienced after total gastrectomy (TG) in comparison to after distal gastrectomy (DG). This study quantified the changes of DI after gastrectomy, and clarified how much DI loss is experienced after TG.

PATIENTS AND METHODS

This was a prospective observational study. Patients who underwent gastrectomy for gastric cancer were enrolled. The DI loss was evaluated at 1 and 3 months postoperatively.

RESULTS

Thirty-three patients underwent TG, and 117 patients underwent DG. The median %DI loss of the overall study population at 1 and 3 months after surgery was -9.3% and -3.6%. The median %DI loss at 1 and 3 months postoperatively was -15.6% and -5.3% in TG group, -8.9% and -3.3% in DG group (p=0.10 and 0.49, respectively).

CONCLUSION

The patients experienced DI loss of approximately 10% at 1 month after gastrectomy. Patients who received TG tended to show a greater %DI loss at 1 month postoperatively.

Probability of Postoperative Complication after Liver Resection: Stratification of Patient Factors,Operative Complexity, and Use of Enhanced Recovery after Surgery

BACKGROUND

The current study aimed to assess the performance of the 3-level complexity classification that stratified liver resection procedures into 3 complexity grades (grade I, low; grade II, intermediate; and grade III, high complexity) and to evaluate whether the Enhanced Recovery after Surgery (ERAS) protocol improves postoperative outcomes for each complexity grade.

STUDY DESIGN

Consecutive patients undergoing open liver resection and laparoscopic liver resection at Lausanne University Hospital during 2010 to 2020 were assessed.

RESULTS

A total of 437 patients were included. Operative time, estimated blood loss, and length of hospital stay increased significantly, with a stepwise increase of the grades from I to III in open liver resection and laparoscopic liver resection (all, p < 0.05). The same trend for Comprehensive Complication Index was found in open liver resection (p < 0.005). Age (p = 0.004), 3-level complexity classification (grade II vs I; p = 0.001; grade III vs I; p < 0.001), no use of the ERAS protocol (p = 0.016), and biliary reconstruction (p < 0.001) were significant predictors for postoperative complication, defined as Comprehensive Complication Index ≥ 26.2 in a multivariable logistic regression analysis. The prediction model incorporating the 4 factors had a calculated Concordance Index of 0.735 and 0.742 based on the bootstrapping method. The use of ERAS protocol was associated with lower probability of postoperative complication for each complexity grade and age.

CONCLUSIONS

The use of ERAS protocol can decrease the probability of postoperative complication for each surgical complexity of liver resection and patient age. This finding emphasized the importance of tailoring perioperative management according to surgical complexity and patient age to improve outcomes after liver resection.

ERAS pathway for gastric cancer surgery: adherence, outcomes and prognostic factors for compliance in a Western centre

Adherence to an ERAS program guarantees an evidence-based approach for patient care, but the compliance to ERAS in patients undergoing surgery for gastric cancer in Western countries has not been clearly investigated. Our Institution has implemented an ERAS pathway (EP) for gastric surgery, composed of 24 items, since December 2016. We retrospectively analyzed the data of all consecutive patients undergoing surgery with curative intent for gastric cancer between January 2017 and December 2019 at our Institution, and were eligible for our EP. The primary endpoint was patients' compliance to the EP. Secondary endpoints were patients' adherence to each ERAS item and detection of variables associated with compliance failure. Seventy-three patients were included. Among these, 75.3% completed the EP, with a median number of items accomplished per patient of 21. Items with critical adherence were restrictive intraoperative fluid infusion (37%), avoidance of abdominal drain (14%), first clear liquid intake (67%), first solid food intake (48%). At univariate analysis age > 75 years, ASA > 2 and total gastrectomy were associated with failure to complete the EP. At multivariate analysis, ASA Score > 2 was the only preoperative factor associated with EP failure. Application of an ERAS program for malignant gastric surgery seems to be feasible with an acceptable completion rate in a tertiary referral Western centre. Preoperative factors, such as old age, advanced stage at diagnosis and neoadjuvant chemotherapy should not be considered as exclusion criteria for ERAS.

Enhanced Recovery After Surgery can Improve Patient Outcomes and Reduce Hospital Cost of Gastrectomy for Cancer in the West: A Propensity-Score-Based Analysis

Background

Data on ERAS for gastrectomy are scarce, and the majority of the studies come from Eastern countries. Patients in the West are older and suffer from more advanced tumors that impair their clinical condition and often require neoadjuvant treatment. This retrospective study assessed the feasibility and safety of an Enhanced Recovery After Surgery (ERAS) protocol for gastrectomy in a Western center.

Methods

We conducted a single-center study of 351 patients operated for gastric cancer: 103, operated from January 2015 to December 2016, followed the standard pathway, while 248, operated from January 2017 to December 2019, followed the ERAS program. The primary outcomes considered were length of hospital stay (LOS) and direct costs. Secondary outcomes were 90-day morbidity and mortality, readmission rate, and compliance with ERAS items. A propensity score (PS) was built on confounding variables.

Results

Compliance with ERAS items after the program was ≥ 70%. Univariable analysis evidenced a 2-day median reduction in LOS and a median cost reduction of €826 per patient in the ERAS group. PS-based multivariable analysis confirmed a significant, 2-day decrease in median LOS and a €1097 saving after ERAS introduction. Ninety-day mortality decreased slightly in ERAS group, while complications and readmissions did not change significantly. When complications were included in the multivariable analysis, ERAS retained its significance, although the effects on LOS and cost were blunted to a median reduction of 1 day and €775, respectively.

Conclusions

ERAS for gastrectomy improved patients’ recovery and reduced hospital costs without changes in morbidity, mortality, or readmission.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-021-10079-x.

Enhanced recovery after surgery in laparoscopic distal gastrectomy: Protocol for a prospective single-arm clinical trial

BACKGROUND

The enhanced recovery after surgery (ERAS) programme is feasible and effective in reducing the length of hospital stay, overall complication rates and medical costs when applied to cases involving colonic and rectal resections. However, a recent prospective, randomised, open, parallel-controlled trial (Chinese Laparoscopic Gastrointestinal Surgery Study-01 trial), initiated by our team, indicated that under conventional peri-operative management, the reduction of the post-operative hospital stay of laparoscopic distal gastrectomy (LDG) is quite limited compared with open gastrectomy. Thus, if we could provide valuable clinical evidence for demonstrating the efficacy of the ERAS programme for gastric cancer patients undergoing LDG, it would significantly enhance the peri-operative management of gastrectomy and benefit the patients.

METHODS

In this prospective single-arm trial, patients who are 18-75 years of age with gastric adenocarcinoma diagnosed with cT1-4aN0-3M0 and expected to undergo curative resection through LDG, are considered eligible for this study. All participants underwent LDG with peri-operative management under the ERAS programme. The primary outcome measures included the post-operative hospital stays and rehabilitative rate of the post-operative day 4. The secondary outcome measures are morbidity and mortality (time frame: 30 days), post-operative recovery index (time frame: 30 days), post-operative pain intensity (time frame: 3 days) and the medical costs from surgery to discharge.

CONCLUSION

With reasonable and scientific designing, the trial may be a great help to further discuss the benefit of ERAS programme and thus improving the peri-operative management of patients with gastrectomy.

Short- and long-term outcomes associated with enhanced recovery after surgery protocol vs conventional management in patients undergoing laparoscopic gastrectomy

BACKGROUND

At present, the enhanced recovery after surgery (ERAS) protocol is widely implemented in the field of gastric surgery. However, the effect of the ERAS protocol on the long-term prognosis of gastric cancer has not been reported.

AIM

To compare the effects of ERAS and conventional protocols on short-term outcomes and long-term prognosis after laparoscopic gastrectomy.

METHODS

We retrospectively analyzed the data of 1026 consecutive patients who underwent laparoscopic gastrectomy between 2012 and 2015. The patients were divided into either an ERAS group or a conventional group. The groups were matched in a 1:1 ratio using propensity scores based on covariates that affect cancer survival. The primary outcomes were the 5-year overall and cancer-specific survival rates. The secondary outcomes were the postoperative short-term outcomes and inflammatory indexes.

RESULTS

The patient demographics and baseline characteristics were similar between the two groups after matching. Compared to the conventional group, the ERAS group had a significantly shorter postoperative hospital day (7.09 d vs 8.67 d, P < 0.001), shorter time to first flatus, liquid intake, and ambulation (2.50 d vs 3.40 d, P < 0.001; 1.02 d vs 3.64 d, P < 0.001; 1.47 d vs 2.99 d, P < 0.001, respectively), and lower medical costs ($7621.75 vs $7814.16, P = 0.009). There was a significantly higher rate of postoperative complications among patients in the conventional group than among those in the ERAS group (18.1 vs 12.3, P = 0.030). Regarding inflammatory indexes, the C-reactive protein and procalcitonin levels on postoperative day 3/4 were significantly different between the two groups (P < 0.001 and P = 0.025, respectively). The ERAS protocol was associated with significantly improved 5-year overall survival and cancer-specific survival rates compared with conventional protocol (P = 0.013 and 0.032, respectively). When stratified by tumour stage, only the survival of patients with stage III disease was significantly different between the two groups (P = 0.044).

CONCLUSION

Adherence to the ERAS protocol improves both the short-term outcomes and the 5-year overall survival and cancer-specific survival of patients after laparoscopic gastrectomy.

Early Outcome of Enhanced Recovery Programs Versus Conventional Perioperative Care in Elective Open Left Side Colonic Carcinoma Surgery: Analysis of 80 Cases

According to recent clinical practice guidelines, enhanced recovery programs (ERP) have been practiced to improve surgical outcomes and decrease cost. However, these are still opposed by the traditional measures in the treatment of colorectal carcinoma that is still practiced with the concept of protection of anastomosis and decrease postoperative complications. The aim of this study was to report our experience in ERP in elective open left side colonic carcinoma surgery in comparison with the conventional perioperative care. The current prospective multicenter randomized controlled study included a total of 80 adult patients with left side colonic cancer who were eligible for elective colonic resection. Included patients were randomly divided into two equal groups: group (A) where conventional perioperative care was performed and group (B) where ERP were applied. Follow-up was designed for at least 1 month to evaluate and compare hospital stay and postoperative complications. There was no statistically significant difference between the two groups as regards demographic data and preoperative comorbidities. There were statistically significant less pain (P = 0.24), less postoperative nausea and vomiting (P = 0.045), and less hospital stay (P < 0.001) in group B than group A. Otherwise, there was no statistically significant difference in comparing the rest of postoperative surgical or non-surgical complications or rates of readmissions between the two groups. ERP are safe, reliable, simple, and applicable in open left side cancer colon surgery with no negative impact over the postoperative complications in comparison with the conventional care.

Adapted ERAS Pathway Versus Standard Care in Patients Undergoing Emergency Small Bowel Surgery: a Randomized Controlled Trial

BACKGROUND

Emergency laparotomy for small bowel pathologies comprises a significant number of all emergency surgeries. Application of evidence-based adapted enhanced recovery after surgery (ERAS) protocol can potentially improve the perioperative outcome in these procedures.

AIMS

To determine the feasibility, safety, and efficacy of adapted ERAS pathway in emergency small bowel surgery.

METHODOLOGY

This was a single-center, prospective, open-labeled, superiority, randomized controlled trial. Patients suspected to have small bowel pathology by the emergency surgical team were randomized preoperatively into standard care and adapted ERAS group. Patients with American Society of Anesthesiologist class ≥ 3, polytrauma patients with associated other intra-abdominal organ injuries, duodenal ulcer perforations, patients presenting with refractory shock, and pregnant patients were excluded. Primary outcome parameter was the length of hospitalization (LOH). Morbidity and other functional recovery parameters were also assessed.

RESULTS

Thirty-five patients were included in the adapted ERAS and standard care group. The laboratory and demographic variables were comparable. Patients in the ERAS group had significantly earlier recovery (days) in terms of first fluid diet (1.48 ± 0.18, p < 0.001), solid diet (2.11 ± 0.17, p < 0.001), time to first flatus (1.25 ± 0.24, p < 0.001), and first stool (1.8 ± 0.27, p < 0.001). Postoperative nausea, vomiting (RR 0.69, p = 0.19), pulmonary complications (RR 0.38, p = 0.16), superficial (RR 0.79, p = 0.33), and deep surgical site infections (RR 0.65, p = 0.39) were similar. Compared with the standard care group, ERAS group had significantly shorter LOH (8 ± 0.38 vs. 10.83 ± 0.42; Mean difference, 2.83 ± 0.56; p < 0.001).

CONCLUSION

Adapted ERAS pathways are feasible, safe, and significantly reduces the LOH in select patients undergoing emergency small bowel surgery.

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

BACKGROUND

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

OBJECTIVES

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

DESIGN

An umbrella review of meta-analyses.

DATE SOURCES

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

RESULTS

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

CONCLUSION

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

The efficacy of clinical pathway in gastric cancer surgery

Objectives

Clinical pathways are useful tools for surgical quality improvement and better peri-operative clinical outcomes for patients undergoing major surgery. This study aimed to evaluate the influence of clinical pathway on early postoperative outcomes for gastric cancer patients.

Material and Methods

The study was designed as a retrospective cohort observational study. Patients who had undergone curative gastrectomy for gastric cancer were evaluated by using the gastric cancer database, which was prospectively maintained. The patients were divided into two groups based on the date when the clinical pathway was first used: The control group (May 2015-May 2016) and the clinical pathway group (June 2016-December 2017). Early postoperative outcomes including the length of hospital stay, start of the day of diet, and 30-day complications including reoperation, and operative mortality were compared after propensity score matching.

Results

A total of 101 patients were analyzed, and the data of 70 patients (35 patients in each group) were compared after matching. Clinical pathway group demonstrated shorter hospital stay, earlier nasogastric tube removal, and start of earlier liquid/soft diet. Overall complication rate was lower in the clinical pathway group, while there was no statistically significant difference in major complication rates. No statistically significant difference was observed between the groups in terms of reoperation and operative mortality.

Conclusion

Clinical pathway may shorten the postoperative length of hospital stay and reduce the overall complication rate without increasing major morbidity in patients undergoing elective gastric cancer surgery.

Tolerability of early oral nutrition and factors predicting early oral nutrition failure after gastrectomy

BACKGROUND & AIMS

Many studies have suggested the feasibility and safety of early oral nutrition after gastrectomy; however, the tolerability of early oral nutrition has rarely been investigated. This study aimed to investigate the tolerability of early oral nutrition and factors affecting early oral nutrition failure after gastrectomy.

METHODS

We retrospectively reviewed 565 patients with gastric cancer who had undergone gastrectomy and who had received oral nutrition on postoperative day 1. Failure of early oral nutrition was defined as cessation of at least one meal for any reason. Preoperative clinical information and operative factors were analyzed concerning an association with early oral nutrition failure.

RESULTS

The tolerability of early oral nutrition after gastrectomy was 74.7%. Of 565 patients, 72 (12.7%) failed early oral nutrition due to adverse gastrointestinal symptoms, 52 (9.2%) failed due to gastric stasis or ileus, and 19 (3.4%) patients failed due to other postoperative complications. In the univariate analysis, age (≥70 years), male sex, preoperative tumor obstruction, remnant stomach cancer, open surgery, operating time (≥4 h), and an advanced preoperative stage were associated with failed early oral nutrition. Multivariable analysis of these factors revealed that male sex, preoperative tumor obstruction, operating time, and advanced preoperative stage were independent predictive factors for early oral nutrition failure after gastrectomy.

CONCLUSIONS

The tolerability of early oral nutrition after gastrectomy was comparable to that of other gastrointestinal surgeries. A tailored approach for postoperative oral nutrition is required based on identified risk factors for early oral nutrition failure.

Clinical pathway for enhanced recovery after surgery for gastric cancer: A prospective single-center phase II clinical trial for safety and efficacy

BACKGROUND

We aimed to evaluate the safety and efficacy of a clinical pathway (CP) for enhanced recovery after surgery (ERAS) in gastric cancer patients, including early oral feeding and discharge on postoperative day 4.

METHODS

We performed a prospective, single-center, phase II clinical trial. Based on proposed indications for an ERAS CP in our retrospective study, we enrolled 133 patients younger than 65 years who were undergoing minimally invasive subtotal gastrectomy. The primary endpoint was the ERAS CP completion rate. Secondary endpoints included complication, mortality, hospital stay, and readmission.

RESULTS

Among 133 patients, six patients were dropped out from this study. The ERAS CP completion rate (77.2%, 98 of 127) was comparable to the historical control group that completed a conventional CP (85.4%, P = .085). The postoperative complication incidence (13.4%, 15 of 127) was also similar to that of the conventional CP group (9.5%, P = .174). We identified reduced hospital stays (4.7 ± 1.3 vs 7.2±2.3 days; P < .001) and lower hospital costs ($7771 vs 8539; P < .001) in the ERAS CP group compared with the conventional CP group.

CONCLUSIONS

An ERAS CP can be safely and effectively adopted for patients with gastric cancer without increasing the complication rate and could shorten hospital stays.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT01642953).

Enhanced recovery after surgery for gastric cancer (ERAS-GC): optimizing patient outcome

Significant advances were achieved, in last decades, in the management of surgical patients with gastric cancer. This has led to the concept of enhanced recovery after surgery (ERAS) with the objective of reducing the length of hospital stay, accelerating postoperative recovery and reducing the surgical stress. The ERAS protocols have many items, including the pre-operative patient education, early mobilization and feeding starting from the first postoperative day. This review aims to highlight possible advantages on postoperative functional recovery outcomes after gastrectomy in patients undergoing an ERAS program, current lack of evidences and future perspectives.

Evaluation of a Semi-Solidifying Liquid Formula for Nasogastric Tube Feeding After Oral and Maxillofacial Surgery

PURPOSE

The aim of this retrospective study was to evaluate a semi-solidifying liquid formula for nasogastric tube (NGT) feeding after oral and maxillofacial surgery.

MATERIALS AND METHODS

In total, 42 patients who underwent oral and maxillofacial surgery for malignant tumors, benign tumors, jaw reconstruction, or jaw fractures received postoperative NGT feeding for nutritional control between 2013 and 2019. Of these patients, 21 received a liquid diet (liquid group; administration rate, 100 mL/hour) and 21 received a semi-solidifying liquid formula (semisolid group [SSG]; administration rate, 400 mL/hour; Mermed Plus; Terumo, Tokyo, Japan). We retrospectively evaluated the complications of NGT feeding in both groups.

RESULTS

During the course of NGT feeding, the incidence of abdominal pain (P = .022), rate of probiotic prescription for diarrhea (P = .012), and Bristol stool form scale score (P = .014) were significantly lower in the SSG than in the liquid group. The maximum defecation frequency per day was also lower in the SSG, although the difference was not significant (P = .069).

CONCLUSIONS

Overall, the semi-solidifying formula was associated with a higher administration rate and a lower incidence of gastrointestinal complications. These findings will help oral and maxillofacial surgeons in the selection of appropriate diets for postoperative NGT feeding.

Postoperative D-dimer elevation affects tumor recurrence and the long-term survival in gastric cancer patients who undergo gastrectomy

INTRODUCTION

We retrospectively evaluated the blood coagulation activity using the D-dimer level in the early period after gastrectomy and investigated whether postoperative hypercoagulation affects tumor recurrence and long-term survival in gastric cancer patients.

METHODS

The study involved 650 patients who underwent curative resection for gastric cancer at Kanagawa Cancer Center between July 2009 and July 2013. They were divided into a low-D-dimer group (LD group) and high-D-dimer group (HD group) according to the median D-dimer level on postoperative day (POD) 7. The risk factors for overall survival (OS) and relapse-free survival (RFS) were identified.

RESULTS

Of the 448 enrolled patients, 218 were classified into the LD group and 230 into the HD group. The 5-year OS rates after surgery were 90.8% and 81.3% in the LD and HD groups, respectively (p < 0.001). The 5-year RFS rates after surgery were 89.9% and 76.1% in the LD and HD groups, respectively (p < 0.001). A high D-dimer level on POD 7 (≥ 4.9 μg/ml) was identified as an independent predictive factor for both the OS (hazard ratio [HR] 1.955, 95% confidence interval [CI] 1.158-3.303, p = 0.012) and RFS (HR 2.182, 95% CI 1.327-3.589, p = 0.002). Furthermore, hematological recurrence was significantly more frequent in the HD group than in the LD group (p = 0.014).

CONCLUSION

A high D-dimer level on POD 7 may predict tumor recurrence and the long-term survival in patients who undergo gastrectomy for locally advanced gastric cancer. Patients with an elevated postoperative D-dimer level need careful observation and diagnostic imaging to timely detect tumor recurrence.

Multicomponent hospital-led interventions to reduce hospital stay for older adults following elective surgery: a systematic review

Background

Elective older adult inpatient admissions are increasingly common. Older adults are at an elevated risk of adverse events in hospital, potentially increasing with lengthier hospital stay. Hospital-led organisational strategies may optimise hospital stay for elective older adult inpatients.

Objectives

To evaluate the effectiveness and cost-effectiveness of hospital-led multicomponent interventions to reduce hospital stay for older adults undergoing elective hospital admissions.

Data sources

Seven bibliographic databases (MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Health Management Information Consortium, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature and Allied and Complementary Medicine Database) were searched from inception to date of search (August 2017), alongside carrying out of web searches, citation searching, inspecting relevant reviews, consulting stakeholders and contacting authors. This search was duplicated, with an additional cost-filter, to identify cost-effectiveness evidence.

Review methods

Comparative studies were sought that evaluated the effectiveness or cost-effectiveness of relevant interventions in elective inpatients with a mean or median age of ≥ 60 years. Study selection, data extraction and quality assessment were completed independently by two reviewers. The main outcome was length of stay, but all outcomes were considered. Studies were sorted by procedure, intervention and outcome categories. Where possible, standardised mean differences or odds ratios were calculated. Meta-analysis was performed when multiple randomised controlled trials had the same intervention, treatment procedure, comparator and outcome. Findings were explored using narrative synthesis.

Findings

A total of 218 articles were included, with 80 articles from 73 effectiveness studies (n = 26,365 patients) prioritised for synthesis, including 34 randomised controlled trials conducted outside the UK and 39 studies from the UK, of which 12 were randomised controlled trials. Fifteen studies included cost-effectiveness data. The evidence was dominated by enhanced recovery protocols and prehabilitation, implemented to improve recovery from either colorectal surgery or lower limb arthroplasty. Six other surgical categories and four other intervention types were identified. Meta-analysis found that enhanced recovery protocols were associated with 1.5 days’ reduction in hospital stay among patients undergoing colorectal surgery (Cohen’sd = –0.51, 95% confidence interval –0.78 to –0.24;p < 0.001) and with 5 days’ reduction among those undergoing upper abdominal surgery (Cohen’sd = –1.04, 95% confidence interval –1.55 to –0.53;p < 0.001). Evidence from the UK was not pooled (owing to mixed study designs), but it echoed findings from the international literature. Length of stay usually was reduced with intervention or was no different. Other clinical outcomes also improved or were no worse with intervention. Patient-reported outcomes were not frequently reported. Cost and cost-effectiveness evidence came from 15 highly heterogeneous studies and was less conclusive.

Limitations

Studies were usually of moderate or weak quality. Some intervention or treatment types were under-reported or absent. The reporting of variance data often precluded secondary analysis.

Conclusions

Enhanced recovery and prehabilitation interventions were associated with reduced hospital stay without detriment to other clinical outcomes, particularly for patients undergoing colorectal surgery, lower limb arthroplasty or upper abdominal surgery. The impacts on patient-reported outcomes, health-care costs or additional service use are not well known.

Future work

Further studies evaluating of the effectiveness of new enhanced recovery pathways are not required in colorectal surgery or lower limb arthroplasty. However, the applicability of these pathways to other procedures is uncertain. Future studies should evaluate the implementation of interventions to reduce service variation, in-hospital patient-reported outcomes, impacts on health and social care service use, and longer-term patient-reported outcomes.

Study registration

This study is registered as PROSPERO CRD42017080637.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Effects of a stepwise, local patient-specific early oral feeding schedule after gastric cancer surgery: a single-center retrospective study from China

Nowadays, early oral feeding after gastrectomy has been gradually accepted and applied in the clinical practice, but there is still no specific uniform feeding regimen available which works best for patients in different regions with different races and eating habits. Aiming to establish an early oral feeding schedule suitable for local Chinese patients after gastric surgery, from May 2014 to May 2018, 87 gastric cancer patients undergoing various types of gastric resections were enrolled in an early feeding protocol and their clinical course was reviewed retrospectively. A stepwise, local patient-specific, early oral feeding schedule was proposed, implemented within an early recovery after surgery (ERAS) protocol and accessed in terms of its safety and tolerability. The primary surgical outcomes included: a median (interquartile range; IQR) postoperative hospital stay of 6 (3) days; 67 (77%) patients were well tolerant of this schedule from postoperative day (POD) 1 to POD 4; 20 (23%) patients had mild I/II grade complications (Clavien-Dindo classification); 3 (3%) patients had IIIB complications, zero cases of hospital mortality. Compared to similar studies in the past, our early oral feeding program is also safe and beneficial, and it can shorten the postoperative hospital stay without causing any increase in postoperative complications. In summary, our work herein reported the establishment of a detailed early oral feeding schedule embedded within an ERAS protocol which was found to be suitable for local Chinese patients after gastric surgery. Accordingly, this early oral feeding schedule is worth further research and promotion.

Application of enhanced recovery after surgery (ERAS) protocol in radical gastrectomy: a systemic review and meta-analysis

PURPOSE

This study aimed to assess the safety and efficiency of the enhanced recovery after surgery (ERAS) protocol in radical gastrectomy.

METHODS

Studies published before February 2019 were searched from EMBASE, PubMed, Cochrane Library and Quanfang databases without language and region restrictions. A total of 15 randomised controlled trials (RCTs) with 1216 participants were included in the analysis, of whom 605 underwent ERAS protocol and 611 received traditional perioperative treatment for radical gastrectomy.

RESULTS

There was a significant reduction in pulmonary infection (p=0.02) after radical gastrectomy. Further, there was a significant decrease in the length of postoperative hospital days (p<0.00001), first passage time of defection and flatus (p<0.00001), and medical cost (p<0.0001) in the group that received the ERAS protocol. However, the ERAS protocol group had a higher risk for readmission (p=0.007), vomiting (p=0.002) and gastric retention (p=0.0003) compared with the traditional treatment group.

CONCLUSIONS

ERAS protocol application for radical gastrectomy accelerated postoperative recovery, shortened postoperative hospital days and first passage time of defection and flatus, and saved on medical costs, and did not increase the occurrence rate of severe complications.

Long-term effects of an oral elemental nutritional supplement on post-gastrectomy body weight loss in gastric cancer patients (KSES002)

AIM

The present study aimed to evaluate the efficacy of short-term nutritional intervention with an oral elemental diet (ED; Elental; EA Pharma Co., Ltd, Tokyo, Japan) at 300 kcal/day for 6-8 weeks in the early post-gastrectomy period on postoperative long-term body weight loss (BWL).

METHODS

We analyzed consecutive patients who were randomly divided to receive the regular diet with or without ED. The control group received regular diet alone post-gastrectomy, whereas the ED group received 300 kcal ED plus regular diet for 6-8 weeks. Primary endpoint was percentage (%) BWL (body weight loss; body weight before surgery minus that at postoperative 1 year) by surgical type. Secondary endpoints included changes in nutrition-related blood parameters.

RESULTS

Of the patients in the original trial, 106 were eligible for efficacy analyses. %BWL at postoperative 1 year was significantly lower in the ED group than in the control group among patients who underwent total gastrectomy (TG) (n = 19 and n = 17, respectively; 9.66 ± 5.98% [95% confidence interval, CI: 6.77-12.54] vs 15.11 ± 6.78% [95% CI: 11.63-18.60], P = .015), but not in patients who underwent distal gastrectomy (n = 38 and n = 32, respectively; 5.81 ± 7.91% [95% CI: 3.21-8.41] vs 5.96 ± 6.20% [95% CI: 3.72-8.19], P = .933). In multivariate analysis, ED was the only factor affecting %BWL at postoperative 1 year among patients who underwent TG.

CONCLUSIONS

Daily nutritional intervention (300 kcal/day ED) for 6-8 weeks reduced %BWL not only at postoperative 6-8 weeks but also at 1 year in patients who underwent TG.

The postoperative lean body mass loss at one month leads to a poor survival in patients with locally advanced gastric cancer

Aims: We previously demonstrated that a loss of lean body mass loss at one month after gastrectomy was an independent risk factor for the continuation of adjuvant chemotherapy with S-1. However, it is unclear whether or not lean body mass loss after gastrectomy leads to a poor survival through poor compliance to adjuvant chemotherapy with S-1.

Methods: The recurrence free survival (RFS) overall survival (OS) and were examined in 115 patients who underwent curative gastrectomy and were pathologically diagnosed with stage II or III gastric cancer and who received postoperative adjuvant chemotherapy with S-1 between May 2011 and September 2016.

Results: The median follow-up period was 40.6 months. The RFS rates at 5 years after surgery were 57.8% in the lean body mass loss ≥5% group and 73.5% in the lean body mass loss <5% group. The univariate and multivariate analyses for the disease free survival (RFS) demonstrated that a lean body mass loss >5% was a significant risk factor. The OS rates at 5 years after surgery were 72.0% in the lean body mass loss ≥5% group and 77.3% in the lean body mass loss <5% group. The OS was slightly worse in the lean body mass loss ≥5% group than in the lean body mass loss <5% group (p=0.2062).

Conclusions: The lean body mass loss at one month, which is closely associated with poor S-1 compliance, was an important risk factor for the RFS. A prospective cohort study is necessary to confirm whether or not the lean body mass loss affects the gastric cancer survival.

Equivalent feasibility and safety of perioperative care by ERAS in open and laparoscopy-assisted distal gastrectomy for gastric cancer: a single-institution ancillary study using the patient cohort enrolled in the JCOG0912 phase III trial

BACKGROUND

Laparoscopy-assisted distal gastrectomy (LADG) has an advantage of earlier recovery after surgery due to having lower invasiveness and wound pain than open distal gastrectomy (ODG). However, whether the same enhanced recovery after surgery (ERAS) program for LADG is equally feasible and safe for ODG remains unclear.

METHODS

We retrospectively extracted the clinical data of the patients enrolled in JCOG0912 from the medical record system of our hospital and compared the treatment process and short-term surgical outcomes between LADG and ODG. Our ERAS program consisted of 13 elements (4 preoperative, 4 intraoperative, and 5 postoperative elements). The morbidity was defined as complications of grade 2 or more.

RESULTS

One hundred and sixty-three patients were entered from our hospital and randomized to undergo ODG (82 patients) or LADG (81 patients). The patient's backgrounds, surgical outcomes, and pathological outcomes were similar between the ODG and LADG groups. The rate of completing the clinical pathway was 95.1% in both groups, and the rates of completing each ERAS element were similar. However, the additional use of acetaminophen was significantly more frequent in the ODG group than in the LADG group (18.3% vs. 6.2%, p = 0.03). The median hospital stay after surgery was 9 days in both groups. Morbidity, defined as Clavien-Dindo classification > grade 2, was observed in 6.1% of the ODG group and 11.1% of the LADG group. No mortality occurred in either group.

CONCLUSION

This study showed that the regimen of perioperative care performed by the ERAS program for LADG was equally feasible and safe for ODG with additional pain control. Less pain observed in LADG was not so apparent advantage for completion and safety of ERAS care.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Perioperative body composition changes in the multimodal treatment of gastrointestinal cancer

Surgical resection and perioperative adjuvant therapy are widely accepted standard treatments for gastrointestinal cancer. However, body composition changes, such as weight loss and skeletal muscle loss, are unavoidable during these treatments. Several studies have shown that perioperative body composition changes are affected by multimodal treatment for gastrointestinal cancer. This review summarizes the background, current status, and future perspectives of perioperative body composition changes in the multimodal treatment of gastrointestinal cancer. Recent studies have described the body composition changes observed in the early period after surgery and during adjuvant therapy. Changes in the body composition might affect adjuvant chemotherapy toxicity after surgery and postoperative complications after neoadjuvant therapy. The mechanisms underlying body composition changes during multimodal therapy are multifactorial and include systemic inflammation, reduced nutrient intake, and physical inactivity. Several approaches have been tested to maintain the body composition, and especially prevent skeletal muscle wasting, during multimodal therapy. Although the ideal approach for managing body composition changes in gastrointestinal cancer patients remains unclear, recent studies support the combination of multiple approaches rather than a single approach.

Feasibility and safety of laparoscopy-assisted distal gastrectomy performed by trainees supervised by an experienced qualified surgeon

BACKGROUND

Laparoscopic gastrectomy is becoming more commonly performed, but acquisition of its technique remains challenging. We investigated whether laparoscopy-assisted distal gastrectomy (LDG) performed by trainees (TR) supervised by a technically qualified experienced surgeon (QS) is feasible and safe.

METHODS

The short-term outcomes of LDG were assessed in patients with gastric cancer between 2008 and 2018. We compared patients who underwent LDG performed by qualified experienced surgeons (QS group) with patients who underwent LDG performed by the trainees (TR group).

RESULTS

The operation time was longer in the TR group than in the QS group (median time: 270 min vs. 239 min, p < 0.001). The median duration of the postoperative hospital stay was 9 days in the QS group and 8 days in the TR group (p = 0.003). The incidence of postoperative complications did not differ significantly between the two groups. Grade 2 or higher postoperative complications occurred in 18 patients (12.9%) in the QS group and 47 patients (11.7%) in the TR group (p = 0.763). Grade 3 or higher postoperative complications occurred in 9 patients (6.4%) in the QS group and 17 patients (4.2%) in the TR group (p = 0.357). Multivariate analysis showed that the American Society of Anesthesiologist Physical Status was an independent predictor of grade 2 or higher postoperative complications and that gender was an independent predictor of grade 3 or higher postoperative complications. The main operator (TR/QS) was not an independent predictor of complications.

CONCLUSIONS

Laparoscopy-assisted distal gastrectomy performed by trainees supervised by an experienced surgeon is a feasible and safe procedure similar to that performed by experienced surgeons.

Does an enhanced recovery after surgery protocol change costs and outcomes of single-level lumbar microdiscectomy?

OBJECTIVE

Enhanced recovery after surgery (ERAS) is a multimodal approach that aims to improve perioperative surgical outcomes. The aim of this study was to evaluate the benefits of ERAS in terms of cost-effectiveness and postoperative outcomes in single-level lumbar microdiscectomy.

METHODS

This study was a single-center retrospective comparing costs and outcomes before and after implementation of the ERAS pathway. Data were collected from the electronic medical records of patients who had undergone single-level lumbar microdiscectomy during 2 time periods—during the 2 years preceding implementation of the ERAS pathway (pre-ERAS group) and after implementation of the ERAS pathway (ERAS group). Each group consisted of 60 patients with an American Society of Anesthesiologists (ASA) Physical Status Classification of class 1. Patients were excluded if their physical status was classified as ASA class II–V or if they were younger than 18 years or older than 65.

Groups were compared in terms of age, sex, body mass index (BMI), perioperative hemodynamics, operation time, intraoperative blood loss, intraoperative fluid administration, intraoperative opioid administration, time to first oral intake, time to first mobilization, postoperative nausea and vomiting (PONV), difference between preoperative and postoperative visual analog scale (VAS) scores, postoperative analgesic requirements, length of hospital stay, and cost of anesthesia.

RESULTS

The ERAS and pre-ERAS groups were comparable with respect to age, sex, and BMI. Operation time, intraoperative blood loss, intraoperative opioid administration, and intraoperative fluid administration were all less in the ERAS group. First oral intake and first mobilization were earlier in the ERAS group. The incidence of PONV was less in the ERAS group. Postoperative analgesic requirements and postoperative VAS scores were significantly less in the ERAS group. The length of hospital stay was found to be shorter in the ERAS group. The ERAS approach was found to be cost-effective.

CONCLUSIONS

ERAS had clinical and economic benefits and is associated with improved outcomes in lumbar microdiscectomy.

Development and validation of a nomogram predicting postoperative pneumonia after major abdominal surgery

PURPOSE

Postoperative pneumonia (POP) is a common complication that can adversely affect the outcomes after surgery. This study aimed to devise and validate a model for stratifying the probability of POP in patients undergoing abdominal surgery.

METHODS

We included 1050 patients who underwent major abdominal surgery between 2012 and 2013. A nomogram was devised by evaluating the predictive factors for POP.

RESULTS

Of the 1050 patients, 56 (5.3%) developed POP. Multivariable logistic regression analysis revealed that the independent predictive factors for POP were age, male sex, history of cerebrovascular disease, Brinkman Index (BI) ≥ 900, and upper midline incision. A nomogram was devised by employing these five significant predictive factors. The prediction model showed a relatively good discrimination performance, with a concordance index of 0.77.

CONCLUSIONS

A nomogram based on age, male sex, history of cerebrovascular disease, BI ≥ 900, and upper midline incision may be useful for identifying patients with a high probability of developing POP after major abdominal surgery.

Oncologic Outcomes after Laparoscopic and Open Distal Gastrectomy for Advanced Gastric Cancer: Propensity Score Matching Analysis

Purpose

This study aimed to compare the oncologic and short-term outcomes of laparoscopic distal gastrectomy (LDG) and open distal gastrectomy (ODG) for advanced gastric cancer (AGC).

Materials and Methods

From July 2006 to November 2016, 384 patients underwent distal gastrectomy for AGC. Data on short- and long-term outcomes were prospectively collected and reviewed. Propensity score matching was applied at a ratio of 1:1 to compare the LDG and ODG groups.

Results

The operative times were longer for the LDG group than for the ODG group. However, the time to resumption of diet and the length of hospital stay were shorter in the LDG group than in the ODG group (4.7 vs. 5.6 days, P=0.049 and 9.6 vs. 11.5 days, P=0.035, respectively). The extent of lymph node dissection in the LDG group was more limited than in the ODG group (P=0.002), although there was no difference in the number of retrieved lymph nodes between the 2 groups. The 3-year overall survival rates were 98% and 86.9% (P=0.018), and the 3-year recurrence-free survival rates were 86.3% and 75.3% (P=0.259), respectively, in the LDG and ODG groups.

Conclusions

LDG is safe and feasible for AGC, with earlier recovery after surgery and long-term oncologic outcomes comparable to those of ODG.

Comparison of Weight and Body Composition After Gastrectomy Between Elderly and Non-elderly Patients With Gastric Cancer

BACKGROUND

Body weight, especially lean body mass, significantly decreases after gastrectomy for gastric cancer due to surgical invasion, reduced food intake, and reduced mobility, which can reduce the quality of life and induce associated toxicity or reduce compliance with adjuvant chemotherapy. Such risks can be particularly high in elderly patients with gastric cancer. However, whether or not changes in the weight and body composition differ between elderly and non-elderly patients remains unclear.

PATIENTS AND METHODS

This retrospective study examined patients who underwent curative surgery for gastric cancer between May 2010 and February 2017. Body weight and composition were evaluated by a bioelectrical impedance analyzer within 1 week before surgery, at 1 week after surgery, and at 1 and at 3 months after surgery. Patients were classified as elderly (≥80 years) or non-elderly (<80 years).

RESULTS

Eight-hundred and eighty-eight patients (84 elderly and 804 non-elderly) were entered into the present study. Patient background, surgical and clinicopathological factors, and surgical complications did not significantly differ between the two groups. Body weight loss at 1 week, and at 1 and 3 months after surgery, defined as the decrease from the preoperative value, were -2.8%, -6.5%, and -9.0%, respectively, in the elderly and -3.5%, -6.0%, and -8.1%, respectively, in the non-elderly patients (p=0.111, 0.125, and 0.153, respectively). The corresponding losses of lean body mass were -2.6%, -6.0%, and -6.4%, respectively, in the elderly and -3.5%, -4.9%, and -4.7%, respectively, in the non-elderly patients, with p-values of 0.056, 0.036, and 0.029, respectively.

CONCLUSION

Decreases in lean body mass after gastrectomy were greater in elderly than in non-elderly patients. In order to maintain lean body mass among elderly patients, additional care and treatments are needed.

A Comparison of the Body Composition Changes Between Laparoscopy-assisted and Open Total Gastrectomy for Gastric Cancer

BACKGROUND/AIM

Laparoscopy-assisted total gastrectomy (LATG) for gastric cancer may prevent the loss of body weight or lean body mass after surgery due to its reduced surgical stress compared with open total gastrectomy (OTG).

PATIENTS AND METHODS

A total of 303 patients were examined in this study. All patients received the same perioperative care via fast-track surgery. The body weight and composition were evaluated using a bioelectrical impedance analyzer within 1 week before and at 1 week, 1 month, and 3 months after surgery.

RESULTS

Two hundred and eight patients received OTG, and 95 received LATG. Although the clinical T factor and N factor were significantly different between these two groups, other clinical factors were similar. The respective body weight loss (1 week/1 month/3 months) was -4.7%/-8.0%/-11.9% in the OTG group and -4.7%/-8.2%/-11.6% in the LATG group, that were not significantly different between the two groups at any time point of measurement (p=0.698/0.528/0.534, respectively). The respective lean body mass loss (1 week/1 month/3 months) was -4.2%/-6.4%/-7.4% in the OTG group and -4.0%/-5.8%/-6.2% in the LATG group, that were not significantly different between the groups (p=0.503/0.588/0.946, respectively).

CONCLUSION

The body composition changes were similar between the OTG and LATG groups using the same perioperative care of fast-track surgery. Adopting a laparoscopic approach would not help in reducing loss of body weight or lean body mass after gastric cancer surgery.

Enhanced recovery after surgery (ERAS) pathways in breast reconstruction: systematic review and meta-analysis of the literature

PURPOSE

Enhanced recovery after surgery (ERAS) pathways are increasingly promoted in post-mastectomy reconstruction, with several articles reporting their benefits and safety. This meta-analysis appraises the evidence for ERAS pathways in breast reconstruction.

METHODS

A systematic search of Medline, EMBASE, and Cochrane databases was performed to identify reports of ERAS protocols in post-mastectomy breast reconstruction. Two reviewers screened studies using predetermined inclusion criteria. Studies evaluated at least one of the following end-points of interest: length of stay (LOS), opioid use, or major complications. Risk of bias was assessed for each study. Meta-analysis was performed via a mixed-effects model to compare outcomes for ERAS versus traditional standard of care. Surgical techniques were assessed through subgroup analysis.

RESULTS

A total of 260 articles were identified; 9 (3.46%) met inclusion criteria with a total of 1191 patients. Most studies had "fair" methodological quality and incomplete implementation of ERAS society recommendations was noted. Autologous flaps comprised the majority of cases. In autologous breast reconstruction, ERAS significantly reduces opioid use [Mean difference (MD) = - 183.96, 95% CI - 340.27 to 27.64, p = 0.02) and LOS (MD) = - 1.58, 95% CI - 1.99 to 1.18, p < 0.00001] versus traditional care. There is no significant difference in the incidence of complications (major complications, readmission, hematoma, and infection).

CONCLUSION

ERAS pathways significantly reduce opioid use and length of hospital stay following autologous breast reconstruction without increasing complication rates. This is salient given the current US healthcare climate of rising expenditures and an opioid crisis.

Enhanced Recovery after Surgery for Gastric Cancer Patients Improves Clinical Outcomes at a US Cancer Center

Purpose

Enhanced recovery after surgery (ERAS) protocols for gastric cancer patients have shown improved outcomes in Asia. However, data on gastric cancer ERAS (GC-ERAS) programs in the United States are sparse. The purpose of this study was to compare perioperative outcomes before and after implementation of an GC-ERAS protocol at a National Comprehensive Cancer Center in the United States.

Materials and Methods

We reviewed medical records of patients surgically treated for gastric cancer with curative intent from January 2012 to October 2016 and compared the GC-ERAS group (November 1, 2015–October 1, 2016) with the historical control (HC) group (January 1, 2012–October 31, 2015). Propensity score matching was used to adjust for age, sex, number of comorbidities, body mass index, stage of disease, and distal versus total gastrectomy.

Results

Of a total of 95 identified patients, matching analysis resulted in 20 and 40 patients in the GC-ERAS and HC groups, respectively. Lower rates of nasogastric tube (35% vs. 100%, P<0.001) and intraabdominal drain placement (25% vs. 85%, P<0.001), faster advancement of diet (P<0.001), and shorter length of hospital stay (5.5 vs. 7.8 days, P=0.01) were observed in the GC-ERAS group than in the HC group. The GC-ERAS group showed a trend toward increased use of minimally invasive surgery (P=0.06). There were similar complication and 30-day readmission rates between the two groups (P=0.57 and P=0.66, respectively).

Conclusions

The implementation of a GC-ERAS protocol significantly improved perioperative outcomes in a western cancer center. This finding warrants further prospective investigation.