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

EAES/SAGES evidence-based recommendations and expert consensus on optimization of perioperative care in older adults

BACKGROUND

As the population ages, more older adults are presenting for surgery. Age-related declines in physiological reserve and functional capacity can result in frailty and poor outcomes after surgery. Hence, optimizing perioperative care in older patients is imperative. Enhanced Recovery After Surgery (ERAS) pathways and Minimally Invasive Surgery (MIS) may influence surgical outcomes, but current use and impact on older adults patients is unknown. The aim of this study was to provide evidence-based recommendations on perioperative care of older adults undergoing major abdominal surgery.

METHODS

Expert consensus determined working definitions for key terms and metrics related to perioperative care. A systematic literature review and meta-analysis was performed using the PubMed, Embase, Cochrane Library, and Clinicaltrials.gov databases for 24 pre-defined key questions in the topic areas of prehabilitation, MIS, and ERAS in major abdominal surgery (colorectal, upper gastrointestinal (UGI), Hernia, and hepatopancreatic biliary (HPB)) to generate evidence-based recommendations following the GRADE methodology.

RESULT

Older adults were defined as 65 years and older. Over 20,000 articles were initially retrieved from search parameters. Evidence synthesis was performed across the three topic areas from 172 studies, with meta-analyses conducted for MIS and ERAS topics. The use of MIS and ERAS was recommended for older adult patients particularly when undergoing colorectal surgery. Expert opinion recommended prehabilitation, cessation of smoking and alcohol, and correction of anemia in all colorectal, UGI, Hernia, and HPB procedures in older adults. All recommendations were conditional, with low to very low certainty of evidence, with the exception of ERAS program in colorectal surgery.

CONCLUSIONS

MIS and ERAS are recommended in older adults undergoing major abdominal surgery, with evidence supporting use in colorectal surgery. Though expert opinion supported prehabilitation, there is insufficient evidence supporting use. This work has identified evidence gaps for further studies to optimize older adults undergoing major abdominal surgery.

ERAS following Gastrectomy for Octo- and Nonagenarians: A Single-Center Retrospective Analysis

Background: The safety and efficacy of enhanced recovery after surgery (ERAS) following elective gastrectomy for gastric cancer in patients >80 years of age are not well described. The aim of this study was to explore whether an ERAS protocol following gastrectomy in this age group can be safely implemented and reduce postoperative length of stay. Methods: A retrospective, single-center analysis was performed. All patients >80 years of age with gastric cancer undergoing elective subtotal and total gastrectomy between January 2010 and December 2021 were identified. With the implementation of an ERAS protocol in January 2016, patients treated beforehand were allocated to Group A (pre-ERAS) and Group B (ERAS). The length of stay, incidence of postoperative complications and representation/readmission to the hospital were compared between the groups. Results: Of the 221 patients identified, 56 met the inclusion criteria with 22 patients (39.3%) allocated to Group A and 34 patients (60.7%) to Group B. There were no differences with regard to the type of resection and surgical approach. Length of stay was shorter in Group B (5 days, range 2-27 versus 10 days, 3-109, P = .040). A trend toward more discharges by postoperative day 3 was noted among patients in Group B (7/34, 20.6% versus 2/22, 9.1%, P = .253). There were no differences in the incidence of postoperative complications or readmission hospital between the groups. Conclusion: Among patients >80 years of age, ERAS following gastrectomy for cancer is associated with a reduced length of stay and can be safely implemented.

"It's Incapacitated Me in so Many Ways": Older Adults' Lived Experience With Postoperative Symptoms at Home After Major Elective Surgery

OBJECTIVE

This qualitative study aimed to explore the challenges faced by older adults regarding the postoperative symptom experience after major elective surgery.

BACKGROUND

Although extensively studied in oncology settings, the impact of postoperative symptom burden remains largely underexplored in elective major surgery among older adults.

METHODS

We employed convenience sampling to recruit adults aged 65 years or above undergoing major elective surgery at the University of California, San Francisco. Semistructured interviews regarding the surgical experience were conducted at 1 and 3 months postoperatively. An inductive qualitative approach was used to identify emerging themes. Symptoms revealed by participants during interviews were also captured.

RESULTS

Nineteen participants completed a 1-month postoperative interview, and 17 additionally completed a 3-month interview. Three themes emerged: (1) postoperative symptoms significantly impacted valued life activities and psychosocial well-being, (2) participants felt "caught off guard" by the intensity and duration of postoperative symptoms, and (3) participants expressed the need for additional support, resources, and education on symptom management. The most frequently mentioned symptoms were postoperative pain (n=12, 63.1%), gastrointestinal discomfort (n=8, 42.1%), and anxiety/stress (n=8, 42.1%) at 1-month postsurgery compared with pain and depression (both n=6, 35.3%) at 3 months.

CONCLUSIONS

Study participants were surprised by the negative impact of postoperative symptoms on their psychosocial well-being and ability to engage in valued life activities. Symptom burden is an important patient-reported outcome that should be assessed postoperatively. Interventions to minimize postoperative symptom burden in older adults could optimize quality of life and participation in meaningful activities during surgical recovery.

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.

Effects of accelerated rehabilitation surgical care on the surgical site wound infection and postoperative complications in patients of lung cancer: A meta-analysis

To comprehensively evaluate the effect of accelerated rehabilitation surgical care on perioperative wound infections and complications in patients undergoing lung cancer surgery. A comprehensive computerised search for randomised controlled trials (RCTs) of accelerated rehabilitative surgical care applied to patients undergoing lung cancer surgery was conducted using the Web of Science, PubMed, Cochrane Library, Embase, Wanfang and China National Knowledge Infrastructure databases from inception to September 2023. The literature was screened and evaluated by two investigators, and data were extracted from the final included literature. Stata software (version 17.0) was used for data analysis. Overall, 21 RCTs involving 2187 patients were included, including 1093 cases in the accelerated rehabilitation surgical care group and 1094 cases in the conventional care group. The analyses revealed that patients with lung cancer surgery who implemented accelerated rehabilitation surgical care were significantly less likely to develop postoperative wound infections (odds ratio [OR] = 0.29, 95% confidence interval [CI]: 0.17-0.49, p < 0.001) and postoperative complications (OR = 0.26, 95% CI: 0.20-0.34, p < 0.001) and shortened the hospital length of stay (standardised mean differences [SMD] = -1.93, 95% CI: -2.32 to -1.53, and p < 0.001) compared with conventional care. The effect of accelerated rehabilitation surgical care intervention in the perioperative period of lung cancer surgery patients is remarkable, as it can effectively reduce the incidence of wound infection and complications, shorten hospitalisation time and promote patient recovery.

The Application of Enhanced Recovery After Surgery for Gastrectomy and Colorectal Resection: A Systematic Review and Meta-Analysis

Purpose: Enhanced recovery after surgery (ERAS) protocols not only positively affect gastrointestinal surgery outcomes but may also increase the risk of some complications. This meta-analysis was conducted to assess the impact of ERAS on the recovery and complications following gastrointestinal surgery. Materials and Methods: Studies published before December 2022 were retrieved from the following databases, EMBASE, PubMed, Cochrane Library, and Web of Science, without limitations of language or race. The endpoints included lung infection, surgical site infection, postoperative ileus, length of hospitalization, urinary tract infection, readmission, anastomotic leakage, and C-reactive protein serum levels. Results: A total of 23 studies were included. The results of the meta-analysis revealed that there was a decrease in incidence of the lung infection (risk ratio = 0.46, 95% confidence interval 0.27-0.74, P = .002) and postoperative length of hospitalization (P < .00001). However, ERAS protocol groups had higher readmission rates, nausea, and vomiting. There was no significant difference in the incidence of anastomotic leakage, ileus, surgical site infection, and urinary tract infection between the experimental and control groups. Conclusions: ERAS protocols can reduce the risk of postoperative lung infections, shorten hospital stays, and expedite patient recovery. Furthermore, ERAS protocols are not associated with serious complications following gastrointestinal surgeries.

Early Return to Intended Oncologic Therapy after implementation of an Enhanced Recovery After Surgery pathway for gastric cancer surgery

PURPOSE

Time to initiation and completion of adjuvant therapy are critical to improve postoperative oncologic outcomes. This study aims to determine whether an Enhanced Recovery After Surgery (ERAS) pathway for gastric cancer surgery promotes early Return to Intended Oncologic Therapy (RIOT).

METHODS

This is a before-after intervention study including patients with gastric adenocarcinoma who underwent surgery from January 2016 to January 2021. Two periods were denoted based upon the implementation date of our institutional ERAS pathway (June 2018). Our primary outcome was time to RIOT after surgery. Hodges-Lehmann analysis was used to estimate median differences of non-parametric outcomes.

RESULTS

Seventy patients with gastric adenocarcinoma were included (35 in pre-ERAS period and 35 in post-ERAS period). Fourteen of the pre-ERAS and twenty-two patients of the post-ERAS period received adjuvant therapy. Time to RIOT was reduced in the post-ERAS period (median 39 days, IQR 31-49) by 12 days (95% CI 3-14 days, p = 0.01) compared to the pre-ERAS period (median 51 days, IQR 42-62). Length of hospital stay (LOS) was lower in the ERAS group (6 days, IQR 5-11 vs 10 days, IQR 8-13, p < 0.01).

CONCLUSION

Our institutional ERAS pathway for gastric cancer surgery was associated with earlier RIOT and shorter LOS.

Prediction of total hospital expenses of patients undergoing breast cancer surgery in Shanghai, China by comparing three models

BACKGROUND

Breast cancer imposes a considerable burden on both the health care system and society, and becomes increasingly severe among women in China. To reduce the economic burden of this disease is crucial for patients undergoing the breast cancer surgery, hospital managers, and medical insurance providers. However, few studies have evidenced the prediction of the total hospital expenses (THE) for breast cancer surgery. The aim of the study is to predict THE for breast cancer surgery and identify the main influencing factors.

METHODS

Data were retrieved from the first page of medical records of 3699 patients undergoing breast cancer surgery in one tertiary hospital from 2017 to 2018. Multiple liner regression (MLR), artificial neural networks (ANNs), and classification and regression tree (CART) were constructed and compared.

RESULTS

The dataset from 3699 patients were randomly divided into training and test sets at a 70:30 ratio (2599 and 1100 records, respectively). The average total hospital expenses were 12520.54 ± 7844.88 ¥ (US$ 1929.20 ± 1208.11). MLR results revealed six factors to be significantly associated with THE: age, LOS, type of disease, having medical insurance, minimally invasive surgery, and receiving general anesthesia. After comparing three models, ANNs was the best model to predict THEs in patients undergoing breast cancer surgery, and its strong predictive performance was also validated.

CONCLUSIONS

To reduce the THEs, more attention should be paid to related factors of LOS, major and minimally invasive surgeries, and general anesthesia for these patient groups undergoing breast cancer surgery. This may reduce the information asymmetry between doctors and patients and provide more reliable cost, practical inpatient medical consumption standards and reimbursement standards reference for patients, hospital managers, and medical insurance providers ,respectively.

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 Major Gastrectomy for Cancer

Enhanced recovery after surgery (ERAS) protocols have gained increasing popularity over the past 10 years, and its overarching objectives are to improve perioperative morbidity and reduce postoperative length of stay. Consensus guidelines from the ERAS Society specific to major gastrectomy were published in 2014, however since that time, prospective and retrospective studies have expanded the collective evidence for both the content and efficacy of ERAS pathways for gastrectomy. This objective of this review was to summarize recent data pertinent to the preoperative, perioperative, and postoperative management of gastrectomy patients along an ERAS pathway.

[Enhanced recovery after surgery-Does the ERAS concept keep its promises]

INTRODUCTION

Perioperative enhanced recovery after surgery (ERAS) concepts or fast-track are supposed to accelerate recovery after surgery, reduce postoperative complications and shorten the hospital stay when compared to traditional perioperative treatment.

METHODS

Electronic search of the PubMed database to identify systematic reviews with meta-analysis (SR) comparing ERAS and traditional treatment.

RESULTS

The presented SR investigated 70 randomized controlled studies (RCT) with 12,986 patients and 93 non-RCT (24,335 patients) concerning abdominal, thoracic and vascular as well as orthopedic surgery. The complication rates were decreased under ERAS following colorectal esophageal, liver and pulmonary resections as well as after implantation of hip endoprostheses. Pulmonary complications were reduced after ERAS esophageal, gastric and pulmonary resections. The first bowel movements occurred earlier after ERAS colorectal resections and delayed gastric emptying was less often observed after ERAS pancreatic resection. Following ERAS fast-track esophageal resection, anastomotic leakage was diagnosed less often as well as surgical complications after ERAS pulmonary resection. The ERAS in all studies concerning orthopedic surgery and trials investigating implantation of a hip endoprosthesis or knee endoprosthesis reduced the risk for postoperative blood transfusions. Regardless of the type of surgery, ERAS shortened hospital stay without increasing readmissions.

CONCLUSION

Numerous clinical trials have confirmed that ERAS reduces postoperative morbidity, shortens hospital stay and accelerates recovery without increasing readmission rates following most surgical operations.

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.

Electronic supplementary material

The online version of this article (10.1007/s00595-020-02181-6) contains supplementary material, which is available to authorized users.

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.

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.

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.

Postoperative Outcomes Within an Enhanced Recovery after surgery protocol in gastric surgery for cancer (POWER.4): Study protocol for a prospective, multicentre, observational cohort study

BACKGROUND AND OBJECTIVE

Enhanced recovery pathways or ERAS have been applied in gastric cancer surgery extrapolated from colorectal surgery. The objective of the study is to assess postoperative complications 30 days after gastric surgery for cancer, with any level of compliance with the ERAS protocol. The secondary objectives are to assess 30-day mortality, the relationship between adherence to the ERAS protocol and complications, the impact of each of the items of the protocol on postoperative complications and hospital stay, and to describe the impact of complications on length of hospital stay.

MATERIALS AND METHODS

Multicenter, observational, prospective study including all consecutive patients undergoing scheduled gastric cancer surgery, over a period of 3 months, with a 30-day follow-up at participating centers, with any level of compliance with the protocol.

RESULTS

The approval of the Comité Autonómico de Ética de la Investigación de Aragón has been obtained (C.P. - C.I. PI19 / 106, 27 th March 2019). POWER.4 was registered at www.clinicaltrials.gov on March 7, 2019 (NCT03865810).

CONCLUSIONS

The data as a whole will be published in peer-reviewed journals. The data will not be made public by identifying each participating center. It is expected that the results of this study will identify potential areas for improvement in which more targeted research is needed.

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.

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.

Enhanced Recovery After Surgery Programs for Laparoscopic Abdominal Surgery: A Systematic Review and Meta-analysis

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols or laparoscopic technique has been applied in various surgical procedures. However, the clinical efficacy of combination of the two methods still remains unclear. Thus, our aim was to assess the role of ERAS protocols in laparoscopic abdominal surgery.

METHODS

We performed a systematic literature search in various databases from January 1990 to October 2017. The results were analyzed according to predefined criteria.

RESULTS

In the present meta-analysis, the outcomes of 34 comparative studies (15 randomized controlled studies and 19 non-randomized controlled studies) enrolling 3615 patients (1749 in the ERAS group and 1866 in the control group) were pooled. ERAS group was associated with shorter hospital stay (WMD - 2.37 days; 95% CI - 3.00 to - 1.73; P 0.000) and earlier time to first flatus (WMD - 0.63 days; 95% CI - 0.90 to - 0.36; P 0.000). Meanwhile, lower overall postoperative complication rate (OR 0.62; 95% CI 0.51-0.76; P 0.000) and less hospital cost (WMD 801.52 US dollar; 95% CI - 918.15 to - 684.89; P 0.000) were observed in ERAS group. Similar readmission rate (OR 0.73, 95% CI 0.52-1.03, P 0.070) and perioperative mortality (OR 1.33; 95% CI 0.53-3.34; P 0.549) were found between the two groups.

CONCLUSIONS

ERAS protocol for laparoscopic abdominal surgery is safe and effective. ERAS combined with laparoscopic technique is associated with faster postoperative recovery without increasing readmission rate and perioperative mortality.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Enhanced recovery after surgery in gastric cancer: which are the main achievements from the Italian experience?

In the last years, the concept of 'enhanced recovery after surgery' (ERAS) has become a routine in the perioperative care of patients undergoing colorectal resection. The application of ERAS programs in gastric surgery had a more difficult penetration into clinical practice, mainly for the introduction of radical changes in the traditional postoperative management. The aim of the study was to analyze the rate of compliance to a standardized ERAS protocol in different Italian centers and evaluate the results in terms of postoperative outcomes. From April 2015 to July 2017, a prospective observational study was conducted among seven centers participating in the Italian Group for Research for Gastric Cancer (GIRCG), in patient candidates to elective gastrectomy for cancer. A standardized ERAS perioperative protocol was approved by all centers. Compliance to the protocol was then evaluated and postoperative outcomes (morbidity and mortality rate, duration of hospital stay and readmission rate) were analyzed. Two-hundred and seventy unselected patients operated on for gastric cancer were enrolled. The median age was 73 years; 40.4% of patients were female; 24.1% had a nutritional risk score ≥ 3. Perioperative chemotherapy was used in 23.7% of cases. Total gastrectomy was performed in 57.4% of patients; minimally invasive approach was adopted in 28.1% of patients. Adherence to the protocol varied between 23 and 88% for single items. It was quite low for pre- and intraoperative items, mainly for items related to nutritional care. Postoperative complications occurred in 35.5% of patients, mortality was 0.7%. Median length of hospital stay was 8 days (range 4-72) and the readmission rate was 6.3%. There is a growing attention on the implementation of ERAS protocol for gastric cancer surgery, but several elements of this protocol are still not routinely adopted, among them items regarding nutritional care.

Is ERAS effective and safe in laparoscopic gastrectomy for gastric carcinoma? A meta-analysis

BACKGROUND

It is still unclear whether enhanced recovery after surgery is effective and safe in laparoscopic gastrectomy for gastric carcinoma.

METHODS

Cochrane library databases, Medline, Embase, and Pubmed were searched from January 1, 1986, to December 31, 2016. Randomized controlled trials (RCTs) comparing fast-track recovery with conventional recovery strategies in laparoscopic radical gastrectomy for gastric carcinoma were included. The main outcomes measured were postoperative hospital stay, time to first flatus, hospital charge, and overall complication rate.

RESULTS

Six RCTs with 400 patients were included in this study. Fast-track surgery has shorter postoperative hospital stays (weighted mean difference (WMD) - 2.65; 95% CI, - 4.01 to - 1.29, z = 3.82, P < 0.01) and less hospitalization expenditure (WMD - 523.43; 95% CI, - 799.79 to - 247.06, z = 3.71, P < 0.01) than conventional recovery strategies. There was no significant difference with respect to duration to first flatus (WMD - 17.72; 95% CI, - 39.46-4.02, z = 1.60, P = 0.11) and complication rate (OR 1.57; 95% CI, 0.82-2.98, z = 1.37, P = 0.17).

CONCLUSIONS

Enhanced recovery after surgery is effective and safe and is thus recommended in laparoscopic radical gastrectomy for gastric carcinoma.

The impact of fast track protocols in upper gastrointestinal surgery: A meta-analysis of observational studies

BACKGROUND

Fast track surgery has been implemented in colorectal procedures during the last decade and is accompanied by significant improvement in patient outcomes during the early postoperative period. However, to date, its adoption in upper gastrointestinal surgery remains a matter of debate. In this context, we aimed to summarize the existing evidence in the international literature.

MATERIALS AND METHODS

We searched Medline, Scopus, ClinicalTrials.gov and Cochrane Central Register databases for published randomized controlled trials. The meta-analysis was performed with the RevMan 5.3.5 software.

MAIN FINDINGS

Thirty studies were finally included in the present meta-analysis. The post-operative morbidity was not influenced by the implementation of fast track surgery (FTS) (OR 0.84, 95% CI 0.64-1.09). However, in cases treated with laparoscopic surgery fast track surgery seemed to reduce morbidity by 50% (p = .006). The overall mortality of patients was low in the majority of included studies and was not influenced by fast track surgery (OR 1.12, 95% CI 0.50-2.52). The duration of postoperative hospitalization was significantly reduced with the adoption of FTS (MD -2.24, 95% CI -2.63 to -1.85 days). Concurrently, the overall cost was significantly reduced in cases treated with FTS (MD -982.30, 95% CI -1367.68 to -596.91 U.S dollars).

CONCLUSION

According to the findings of our meta-analysis suggest that FTS seems to be safe in patients undergoing upper gastrointestinal surgery and reduce both the days of postoperative hospitalization and the overall cost. This observation should be taken into account in future recommendations to enhance the implementation of FTS protocols in current clinical practice.

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.

Influence of enhanced recovery after surgery programs on laparoscopy-assisted gastrectomy for gastric cancer: a systematic review and meta-analysis of randomized control trials

Background

This meta-analysis is aimed to evaluate the feasibility and safety of enhanced recovery after surgery (ERAS) programs in gastric cancer patients undergoing laparoscopy-assisted gastrectomy (LAG).

Methods

We performed a meta-analysis of randomized control trials involving either enhanced recovery after surgery (ERAS)/fast track surgery (FTS) for patients underwent LAG. EMBASE, Pubmed, Web of science, and Cochrane Library were searched. Primary outcomes included the length of postoperative hospital stay, cost of hospitalization, postoperative complications, and readmission rate.

Results

Five randomized control trials were eligible for analysis. There were 159 cases in FTS group and 156 cases in conventional care group. Compared with conventional care group, FTS group relates to shorter postoperative hospital stay (WMD − 2.16; 95% CI − 3.05 to − 1.26, P < 0.00001), less cost of hospitalization (WMD − 4.72; 95% CI − 6.88 to − 2.55, P < 0.00001), shorter time to first flatus (WMD − 9.72; 95% CI − 13.75 to − 5.81, P < 0.00001), lower level of C-reaction protein on postoperative days 3 or 4 (WMD − 19.66; 95% CI − 28.98 to − 10.34, P < 0.00001), higher level of albumin on postoperative day 4 (WMD 3.45; 95% CI 2.01 to 4.89, P < 0.00001), and postoperative day 7 (WMD 5.63; 95% CI 1.01 to 10.24, P = 0.02). Regarding postoperative complications, no significant differences were observed between FTS group and conventional care group (OR 0.63, 95% CI 0.37 to 1.09, P = 0.10). The readmission rate of FTS group was comparable to conventional care group (WMD 3.14; 95% CI 0.12 to 81.35, P = 0.49).

Conclusions

Among patients undergoing LAG, FTS is associated with shorter postoperative hospital stay, rapid postoperative recovery, and decreased cost without increasing complications or readmission rate. The combined effects of the two methods could further accelerate clinical recovery of gastric cancer patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A comparative study on the efficacy of fast-track surgery in the treatment of esophageal cancer patients combined with metabolic syndrome

The purpose of our study was to evaluate the clinical efficacy of fast-track surgery (FTS) in the treatment of esophageal cancer patients combined with metabolic syndrome. Ninety-four esophageal cancer patients with metabolic syndrome were selected in Affiliated Hospital of Jining Medical University from March, 2016 to February, 2017. Patients were randomly divided into control group and observation group with 47 cases in each group. Patients in observation group were treated with FTS, while patients in control group were treated with traditional method. Intraoperative blood loss, the number of dissected lymph nodes, operation time, postoperative hospital stay, the cost of hospitalization, postoperative readmission rate, and incidence of postoperative complications were compared between the groups. Levels of serum inflammatory cytokines (TNF-α and hs-CRP), fat cell factor chemerin and leptin (LP) were detected by enzyme-linked immunosorbent assay (ELISA) at 1 month after surgery. Levels of serum total cholesterol (TC), triglyceride (TG), low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C) at 1 month after surgery were compared between groups. Levels of hemoglobin (Hb), albumin (Alb), prealbumin (PAB) and transferrin (TRF) at 1 month after surgery were also compared between the two groups. Treatment of cancer quality-of-life questionnaire-esophageal cancer (OES-18) module was used to evaluate the symptoms of patients at one month after surgery. It turned out that no significant differences in intraoperative blood loss, operation time and the number of dissected lymph nodes were found between groups (p>0.05). Postoperative hospital stay, the cost of hospitalization, postoperative readmission rate and the incidence of postoperative complications were significantly lower in observation group than in control group (p<0.05). Levels of TNF-α, hs-CRP, chemerin and LP in observation group were significantly lower than those in control group at one month after surgery (p<0.05). Levels of TC, TG and LDL-C were significantly lower and HDL-C level was significantly higher in observation group than in control group at one month after surgery (p<0.05). Levels of Hb and Alb were significantly lower and levels of PAB and TRF were significantly higher in observation group than in control group at one month after surgery (p<0.05). OES-18 score of observation group was significantly better than that of control group at one month after surgery (p<0.05). As a conclusion, FTS can promote postoperative rehabilitation, shorten hospital stay, reduce economic burden and reduce the rehospitalization rate of esophageal cancer patients. At the same time, FTS can also improve the lipid metabolism, nutritional status and regulate the differentiation of adipocytes, alleviate the low inflammatory response state, which in turn promotes metabolic syndrome.

The Development of Enhanced Recovery After Surgery Across Surgical Specialties

BACKGROUND

Enhanced recovery after surgery (ERAS^®) principles have gained traction in variety of surgical disciplines. The promise of a reduced length of stay without compromising patient safety or increasing readmission rates has produced a body of literature examining the implementation of ERAS in the care of general, thoracic, urologic, and gynecologic surgery patients.

METHODS

We performed a review of the literature pertaining to studies of ERAS implementation across colorectal surgery, general surgery, thoracic surgery, urology, and gynecology. The extent of ERAS implementation and reported outcomes across key studies as well as systematic reviews and meta-analyses in each field were summarized.

RESULTS

The implementation of ERAS protocols has not been uniform across surgical specialties. Despite this, ERAS has produced improvements in patient outcomes. The most commonly described benefit of ERAS application has been reduced length of stay; complication and readmission rates are most consistently decreased in the colorectal literature. Studies have started to measure more nuanced measures of postoperative patient well-being. Efforts are growing to standardize ERAS protocols across diverse fields and call attention to the need for quality control.

CONCLUSIONS

Challenges remain in the study and execution of ERAS. Controlling for adherence to ERAS components and implementing uniform ERAS protocols across studies are burgeoning topics that have significant implications for study design. The practice of ERAS and its benefits to patients are expected to evolve. Assessing improvements in postdischarge quality of life, timing of return to work and independent living, and adherence to scheduled delivery of adjuvant treatments will strengthen future ERAS investigations.

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.

Major abdominal surgery in octogenarians: should high age affect surgical decision-making?

BACKGROUND

Over the last decades longevity has increased significantly, with more octogenarians undergoing surgery. Here, we assess surgical outcomes after major abdominal surgery in octogenarians.

METHODS

Observational cohort of 874 patients undergoing major abdominal elective surgery between January 2009 and March 2014. Seventy-six octogenarians were propensity matched to 76 younger patients, corrected for sex, body mass index, American Society of Anesthesiologists classification, comorbidity, indication, and type of surgery.

RESULTS

Minor complications were more prevalent in octogenarians (P = .01) and consisted mainly of respiratory complications; progressing to respiratory insufficiency requiring intubation in 28.6%. Preoperative weight loss (odds ratio 3 [1.1 to 8.3]) and upper gastrointestinal surgery (odds ratio 11 [2 to 60]) were associated with minor complications.

CONCLUSIONS

Octogenarians are at increased risk of minor complications after major abdominal surgery. Major complication rates were similar, indicating the importance of preoperative assessment and standardized surgical techniques. Taking into account preoperative morbidities and type of surgery and techniques. Implementation of quality control algorithms may further improve outcomes in octogenarians.

Poor nutritional status is associated with other geriatric domain impairments and adverse postoperative outcomes in onco-geriatric surgical patients - A multicentre cohort study

BACKGROUND

Nutritional status (NS), though frequently affected in onco-geriatric patients, is no standard part of a geriatric assessment. The aim of this study was to analyse the association between a preoperatively impaired NS and geriatric domain impairments and adverse postoperative outcomes in onco-geriatric surgical patients.

METHODS

309 patients ≥70 years undergoing surgery for solid tumours were prospectively recruited. Nine screening tools were preoperatively administered as part of a geriatric assessment. NS was based on BMI, weight loss and food intake. Odds ratio's (OR) and 95% confidence intervals (95% CI) were estimated using logistic regression analysis. The occurrence of 30-day adverse postoperative outcomes was recorded.

RESULTS

At a median age of 76 years, 107 patients (34.6%) had an impaired NS. Decreased performance status and depression were associated with an impaired NS, when adjusted for tumour characteristics and comorbidities (ORPS>1 3.46; 95% CI 1.56-7.67. ORGDS>5 2.11; 95% CI 1.05-4.26). An impaired NS was an independent predictor for major complications (OR 3.3; 95% CI 1.6-6.8). Ten out of 11 patients who deceased had an impaired NS.

CONCLUSION

An impaired NS is prevalent in onco-geriatric patients considered to be fit for surgery. It is associated with decreased performance status and depression. An impaired NS is a predictor for adverse postoperative outcomes. NS should be incorporated in a geriatric assessment.

Fast Track Surgery in the Elderly: Avoid or Proceed with Caution?

The feasibility of applying fast track surgery in its current form in the elderly still remains to be proven. It is important to identify the reasons for failure and carve out programs suited to the impaired physiology in this patient population. There needs to be a consensus among practitioner regarding the definitions of failure and flexibility of fast track programs at institutional as well as regional levels.