Enhanced recovery programs in gastrointestinal surgery: Actions to promote optimal perioperative nutritional and metabolic care

History and evidence for state of the art of lymphadenectomy in esophageal cancer surgery

The current curative multimodal treatment of advanced esophageal cancers consists of neoadjuvant or perioperative chemo(radio)therapy followed by a radical surgical resection of the primary tumor and a 2- or 3-field lymphadenectomy. One of the most important predictors of long-term survival of esophageal cancer patients is lymph node involvement. The distribution pattern of lymph node metastases in esophageal cancer is unpredictable and depends on the primary tumor location, histology, T-stage and application of neoadjuvant or perioperative treatment. The optimal extent of the lymphadenectomy remains controversial; there is no global consensus on this topic yet. Some surgeons advocate an aggressive and extended lymph node dissection to remove occult metastatic disease, to optimize oncological outcomes. Others promote a more restricted lymphadenectomy, since the benefit of an extended lymphadenectomy, especially after neoadjuvant chemoradiotherapy, has not been clearly demonstrated, and morbidity may be reduced. In this review, we describe the development of lymphadenectomy, followed by a summary of current evidence for lymphadenectomy in esophageal cancer treatment.

Application of Enhanced Recovery After Surgery in Patients with Osteoporotic Vertebral Compression Fractures Undergoing Percutaneous Kyphoplasty

BACKGROUND

The enhanced recovery after surgery (ERAS) program helps patients recover faster and better, postoperatively. The aim of this retrospective study was to assess the clinical effectiveness of the ERAS program after percutaneous kyphoplasty (PKP) for osteoporotic vertebral compression fractures.

METHODS

We enrolled patients with osteoporotic vertebral compression fracture who had undergone PKP between January 2019 and June 2021 and divided them into the control group (CG; n = 296), without the ERAS program, and the intervention group (IG; n = 306), with the ERAS program. The visual analog scale (VAS), Oswestry Disability Index (ODI), and Barthel Index scores of the 2 groups were compared on admission and 2 days and 1, 6, and 12 months postoperatively. Perioperative evaluation parameters included the mean surgery time, length of stay (LOS), and hospitalization expenses. In addition, postoperative complications were compared.

RESULTS

Regarding perioperative parameters, LOS and hospitalization expenses were significantly better in IG than in CG (P < 0.001), but the mean surgery time did not differ significantly (P > 0.05). The VAS, Barthel Index, and ODI scores were significantly better in IG than in CG at 2 days and 1 month postoperatively (P < 0.001). None of the clinical effectiveness parameters (VAS, Barthel Index, and ODI scores) differed between IG and CG at 6 or 12 months postoperatively. In addition, 141 patients in CG and 56 patients in IG experienced postoperative complications, including pressure ulcers, deep vein thrombosis, nausea and vomiting, and refracture (P = 0.970, P = 0.036, P < 0.001, P = 0.002 respectively).

CONCLUSIONS

For patients undergoing PKP, the ERAS program is a reliable and effective perioperative management method that can effectively reduce LOS, postoperative pain, and economic burden and promote recovery of patients.

ERAS with or without supplemental artificial nutrition in open pancreatoduodenectomy for cancer. A multicenter, randomized, open labeled trial (RASTA study protocol)

Purpose

The role of supplemental artificial nutrition in patients perioperatively treated according to enhanced recovery programs (ERAS) on surgery-related morbidity is not known. Therefore, there is a need of a clinical trials specifically designed to explore whether given a full nutritional requirement by parenteral feeding after surgery coupled with oral food “at will” compared to oral food “at will” alone, within an established ERAS program, could achieve a reduction of the morbidity burden.

Materials and analysis

RASTA will be a multicenter, randomized, parallel-arm, open labeled, superiority trial. The trial will be conducted in five Italian Institutions with proven experience in pancreatic surgery and already applying an established ERAS program. Adult patients (age ≥ 18 and &lt; 90 years of age) candidate to elective open pancreatoduodenectomy (PD) for any periampullary or pancreatic cancer will be randomized to receive a full ERAS protocol that establishes oral food “at will” plus parenteral nutrition (PN) from postoperative day 1 to day 5 (treatment arm), or to ERAS protocol without PN (control arm). The primary endpoint of the trial is the complication burden within 90 days after the day of surgery. The complication burden will be assessed by the Comprehensive Complication Index, that incorporates all complications and their severity as defined by the Clavien-Dindo classification, and summarizes postoperative morbidity with a numerical scale ranging from 0 to 100. The H0 hypothesis tested is that he administration of a parenteral nutrition added to the ERAS protocol will not affect the CCI as compared to standard of care (ERAS). The H1 hypothesis is that the administration of a parenteral nutrition added to the ERAS protocol will positively affect the CCI as compared to standard of care (ERAS). The trial has been registered at ClinicalTrials.gov (number: NCT04438447; date: 18/05/2020).

Conclusion

This upcoming trial will permit to establish if early postoperative artificial nutritional support after PD may improve postoperative outcomes compared to oral nutrition alone within an established ERAS program.

Immunonutrition and prehabilitation in pancreatic cancer surgery: A new concept in the era of ERAS® and neoadjuvant treatment

Pancreatic cancer (PC) is an aggressive disease, with a growing incidence, and a poor prognosis. Neoadjuvant treatments in PC are highly recommended in borderline resectable and recently in upfront resectable PC. PC is characterized by exocrine insufficiency and nutritional imbalance, leading to malnutrition/sarcopenia. The concept of malnutrition in PC is multifaceted, as the cancer-related alterations create an interplay with adverse effects of anticancer treatments. All these critical factors have a negative impact on the postoperative and oncological outcomes. A series of actions and programs can be implemented to improve resectable and borderline resectable PC in terms of postoperative complications, oncological outcomes and patients' quality of life. A timely nutritional evaluation and the implementation of appropriate evidence-based nutritional interventions in onco-surgical patients should be considered of importance to improve preoperative physical fitness. Unfortunately, nutritional care and its optimization are often neglected in real-world clinical practice. Currently available studies and ERAS® guidelines mostly support the use of pre- or perioperative medical nutrition, including immunonutrition, in order to decrease the rate of postoperative infections and length of hospital stay. Further data also suggest that medical nutrition should be considered proactively in PC patients, to possibly prevent severe malnutrition and its consequences on disease and treatment outcomes. This narrative review summarizes the most recent data related to the role of prehabilitation, ERAS® program, medical nutrition, and the timing of intervention on clinical outcomes of upfront resectable and borderline PC, and their potential implementation within the timeframe of neoadjuvant treatments.

Conventional regression analysis and machine learning in prediction of anastomotic leakage and pulmonary complications after esophagogastric cancer surgery

Background and Objectives

With the current advanced data‐driven approach to health care, machine learning is gaining more interest. The current study investigates the added value of machine learning to linear regression in predicting anastomotic leakage and pulmonary complications after upper gastrointestinal cancer surgery.

Methods

All patients in the Dutch Upper Gastrointestinal Cancer Audit undergoing curatively intended esophageal or gastric cancer surgeries from 2011 to 2017 were included. Anastomotic leakage was defined as any clinically or radiologically proven anastomotic leakage. Pulmonary complications entailed: pneumonia, pleural effusion, respiratory failure, pneumothorax, and/or acute respiratory distress syndrome. Different machine learning models were tested. Nomograms were constructed using Least Absolute Shrinkage and Selection Operator.

Results

Between 2011 and 2017, 4228 patients underwent surgical resection for esophageal cancer, of which 18% developed anastomotic leakage and 30% a pulmonary complication. Of the 2199 patients with surgical resection for gastric cancer, 7% developed anastomotic leakage and 15% a pulmonary complication. In all cases, linear regression had the highest predictive value with the area under the curves varying between 61.9 and 68.0, but the difference with machine learning models did not reach statistical significance.

Conclusion

Machine learning models can predict postoperative complications in upper gastrointestinal cancer surgery, but they do not outperform the current gold standard, linear regression

Early versus delayed oral feeding after gastrectomy for gastric cancer: A systematic review and meta-analysis

BACKGROUND

Early oral feeding has been shown to be safe and effective for most surgeries, while surgeons and nurses are still hesitant to implement it in gastric cancer patients who undergo gastrectomy.

OBJECTIVES

This review aimed to investigate the safety and feasibility of early versus delayed oral feeding in gastric cancer patients after gastrectomy.

DESIGN

A systematic review and meta-analysis of randomized controlled trials.

DATA SOURCES

The literature search was performed in 7 databases from inception to March 7, 2021.

REVIEW METHODS

Randomized controlled trials that compared the effects of early oral feeding and delayed oral feeding in gastric cancer patients who undergo gastrectomy were included. The primary outcome was hospital days, and secondary outcomes included hospital costs, postoperative complication rates, feeding intolerance rates, annal exhaust time, albumin levels and prealbumin levels. According to the presence of heterogeneity, fixed or random effect meta-analysis was applied.

RESULTS

Nine trials involving 1087 gastric cancer patients who undergo gastrectomy were pooled in this systemic review and meta-analysis. The results showed that early oral feeding significantly decreased hospital days (mean difference = -1.50, 95% confidence interval = -1.91 to -1.10, P < 0.001) and hospital costs (mean difference = -4.21, 95% confidence interval = -5.00 to -3.42, P < 0.001) compared to delayed oral feeding, while the incidences of postoperative complications (risk ratio = 0.96, 95% confidence interval = 0.72 to 1.26, P = 0.76) and feeding intolerance (risk ratio = 0.95, 95% confidence interval = 0.79 to 1.15, P = 0.62) were comparable between the two groups. In comparison to delayed oral feeding, early oral feeding was associated with shorter annal exhaust time (mean difference = -0.61, 95% confidence interval = -0.81 to -0.40, P < 0.001) and higher levels of albumin (mean difference = 3.77, 95% confidence interval = 2.42 to 5.12, P < 0.001) and prealbumin (mean difference = 18.11, 95% confidence interval = 15.33 to 20.88, P < 0.001). Furthermore, the results of distal gastrectomy subgroup analysis indicated that hospital days were shorter in the early oral feeding group than in the delayed oral feeding group.

CONCLUSIONS

For gastric cancer patients who undergo gastrectomy, early oral feeding was associated with shorter hospital days and lower hospital costs, but early oral feeding did not increase the incidences of postoperative complications or feeding intolerance. Moreover, early oral feeding also decreased the annal exhaust time but increased the levels of albumin and prealbumin.

Association Between Intraoperative Blood Glucose and Anastomotic Leakage in Colorectal Surgery

BACKGROUND

Perioperative hyperglycemia is a known risk factor for postoperative complications after colorectal surgery. The aim of this study was to investigate whether intraoperative blood glucose values are associated with colorectal anastomotic leakage in diabetic and non-diabetic patients undergoing colorectal surgery.

METHODS

This is an additional analysis of a previously published prospective, observational cohort study (the LekCheck study). Fourteen hospitals in Europe and Australia collected perioperative data. Consecutive adult patients undergoing colorectal surgery with primary anastomosis between 2016 and 2018 were included. From all patients, preoperative diabetic status was known and intraoperative blood glucose was determined just prior to the creation of the anastomosis. The primary outcome was the occurrence of anastomotic leakage within 30 days postoperatively.

RESULTS

Of 1474 patients (mean age 68 years), 224 patients (15%) had diabetes mellitus, 737 patients (50%) had intraoperative hyperglycemia (≥126 mg/dL, ≥7.0 mmol/L), and 129 patients (8.8%) developed anastomotic leakage. Patients with intraoperative hyperglycemia had higher anastomotic leakage rates compared to patients with a normal blood glucose level (12% versus 5%, P<0.001). Anastomotic leakage rate did not significantly differ between diabetic and non-diabetic patients (12% versus 8%, P=0.058). Logistic regression analyses showed that higher blood glucose levels were associated with an increasing leakage risk in non-diabetic patients only.

CONCLUSION

Incidence and severity of intraoperative hyperglycemia are associated with anastomotic leakage in non-diabetic patients. Whether hyperglycemia is an epiphenomenon, a marker for other risk factors or a potential modifiable risk factor per se for anastomotic leakage requires future research.

Enhanced recovery after surgery pathway reduces the length of hospital stay without additional complications in lumbar disc herniation treated by percutaneous endoscopic transforaminal discectomy

Background

Enhanced recovery after surgery (ERAS) pathway in spine surgery is increasingly popular which can reduce the length of hospital stay (LOS). However, there are few studies on the safety and effectiveness of ERAS pathway in the treatment of single-level lumbar disc herniation (LDH) by percutaneous endoscopic transforaminal discectomy (PETD). The aim of this study was to investigate whether ERAS can reduce LOS of patients with single segment LDH treated by PETD.

Methods

We reviewed the outcomes of all LDH patients (L4/5) who had been treated with PETD at our institution. Quasi-experimental study was adopted between patients treated in an ERAS after PETD with those rehabilitated on a traditional pathway. The two groups were analyzed for LOS, operation time, complications, visual analog scale (VAS), Oswestry Dysfunction Index (ODI), hospitalization expenses (HE), and improved MacNab efficacy assessment criteria (MacNab).

Results

A total of 120 single segment LDH patients (ERAS pathway 60 cases, traditional care pathway 60 cases) who were selected from January 2019 to January 2021 met the inclusion criteria. There was a significant difference in mean LOS postoperative VAS scores and ODI on the 3rd day after surgery between the two groups (P < 0.05). The incidence of complications and HE were similar in the two groups (P > 0.05). The mean LOS decreased from 3.47 ± 1.14 days to 5.65 ± 1.39 days after application of ERAS pathway (P < 0.05).

Conclusions

The ERAS pathway reduced LOS without resulting in additional complications after PETD. These findings support the application of the perioperative ERAS pathway in the treatment of single-level LDH with PETD.

Level of evidence

Level IV, therapeutic

Postoperative Complications and Long-Term Quality of Life After Multimodality Treatment for Esophageal Cancer: An Analysis of the Prospective Observational Cohort Study of Esophageal-Gastric Cancer Patients (POCOP)

BACKGROUND

Esophagectomy has major effects on health-related quality of life (HR-QoL). Postoperative complications might contribute to a decreased HR-QOL. This population-based study aimed to investigate the difference in HR-QoL between patients with and without complications after esophagectomy for cancer.

METHODS

A prospective comparative cohort study was performed with data from the Netherlands Cancer Registry (NCR) and Prospective Observational Cohort Study of Esophageal-Gastric Cancer Patients (POCOP). All patients with esophageal and gastroesophageal junction (GEJ) cancer after esophagectomy in the period 2015-2018 were enrolled. The study investigated HR-QoL at baseline, then 3, 6, 9, 12, 18, and 24 months postoperatively, comparing patients with and without complications as well as with and without anastomotic leakage.

RESULTS

The 486 enrolled patients comprised 270 patients with complications and 216 patients without complications. Significantly more patients with complications had comorbidities (69.6% vs 57.3%; p = 0.001). No significant difference in HR-QoL was found over time between the patients with and without complications. In both groups, a significant decline in short-term HR-QoL was found in various HR-QoL domains, which were restored to the baseline level during the 12-month follow-up period. No significant difference was found in HR-QoL between the patients with and without anastomotic leakage. The patients with grades 2 and 3 anastomotic leakage reported significantly more "choking when swallowing" at 6 months (ß = 14.5; 95% confidence interval [CI], - 24.833 to - 4.202; p = 0.049), 9 months (ß = 22.4, 95% CI, - 34.259 to - 10.591; p = 0.007), and 24 months (ß = 24.6; 95% CI, - 39.494 to - 9.727; p = 0.007) than the patients with grade 1 or no anastomotic leakage.

CONCLUSION

In general, postoperative complications were not associated with decreased short- or long-term HR-QoL for patients after esophagectomy for esophageal or GEJ cancer. The temporary decrease in HR-QoL likely is related to the nature of esophagectomy and reconstruction itself.

Objective recovery time with end-to-side versus side-to-side anastomosis after laparoscopic right hemicolectomy for colon cancer: a randomized controlled trial

BACKGROUND

Despite reports of the short-term benefits of end-to-side versus side-to-side anastomosis, we are aware of no prospective studies in which these methods were compared. We hypothesized the superiority of end-to-side over side-to-side anastomosis in terms of recovery after laparoscopic right hemicolectomy for colon cancer under an enhanced recovery program.

METHODS

From September 2016 to August 2019, 130 patients were randomly allocated to receive end-to-side or side-to-side anastomosis at a single tertiary hospital in Korea. The primary outcome was the cumulative recovery rate seven days after surgery, defined as the percentage of patients who met all four recovery criteria: diet tolerance, no analgesia, safe ambulation, and an afebrile status. Student's t test, the Mann-Whitney U test, the χ² test, and Fisher's exact test were used to compare variables, as applicable.

RESULTS

The cumulative recovery rate at seven days did not differ between patients receiving end-to-side (92.3%, 60/65) or side-to-side anastomosis (92.3%, 60/65; P ≥ 0.999). The end-to-side and side-to-side groups had similar cumulative recovery rates at postoperative days 4, 5, and 6 (end-to-side vs. side-to-side: 41.5% vs 35.4%, P = 0.589; 73.8% vs 63.1%, P = 0.257; and 86.2% vs 81.5%, P = 0.634, respectively). None of the secondary endpoints differed for end-to-side vs. side-to-side anastomosis: the median length of postoperative hospitalization (5 [IQR 5-7] vs. 6 [IQR 5-7] days, respectively, P = 0.376), the 30-day complication rate (16.9% vs. 12.3%, respectively, P = 0.620), the enhanced recovery protocol failure rate (10.8% vs. 7.7%, respectively, P = 0.763), and the 30-day readmission rate (4.6% vs. 3.1%, respectively, P ≥ 0.999).

CONCLUSIONS

End-to-side anastomosis was not superior to side-to-side anastomosis in terms of recovery criteria after laparoscopic right hemicolectomy. These findings do not provide evidence for a functional advantage of end-to-side compared to side-to-side anastomosis.

Enhanced Recovery: A Decade of Experience and Future Prospects at the Mayo Clinic

This work aims to describe the implementation and subsequent learnings from the first decade after the full implementation of enhanced recovery pathway for colorectal surgery at a single institution. This paper will describe the diffusion efforts and plans through the Define, Measure, Analyze, Improve, Control (DMAIC) process of ongoing quality improvement and through research efforts. The information applies to all readers that provide surgical care within their organization as the fundamental principles of enhanced recovery for surgery are applicable regardless of the setting.

Fasting habits over a 10-year period: An observational study on adherence to preoperative fasting and postoperative restoration of oral intake in 2 Dutch hospitals

BACKGROUND

Since 1999, international guidelines recommend fasting from solid foods up to 6 hours and clear liquids up to 2 hours before surgery. Early recovery after surgery programs recommend restoration of oral intake as soon as possible. This study determines adherence to these guidelines up to 20 years after its introduction.

METHODS

A 2-center observational study with a 10-year interval was performed in the Netherlands. In period 1 (2009), preoperative fasting time was observed as primary outcome. In period 2 (2019), preoperative fasting and postoperative restoration of oral intake were observed. Fasting times were collected using an interview-assisted questionnaire.

RESULTS

During both periods, 311 patients were included from vascular, trauma, orthopedic, urological, oncological, gastrointestinal, and ear-nose-throat and maxillary surgical units. Duration of preoperative fasting was prolonged in 290 (90.3%) patients for solid foods and in 208 (67.8%) patients for clear liquids. Median duration of preoperative fasting from solid foods and clear liquids was respectively 2.5 and 3 times the recommended 6 and 2 hours, with no improvements from one period to another. Postoperative food intake was resumed within 4 hours in 30.7% of the patients. Median duration of perioperative fasting was 23:46 hours (interquartile range 20:00-30:30 hours) for solid foods and 11:00 hours (interquartile range 7:53-16:00 hours) for clear liquids.

CONCLUSION

Old habits die hard. Despite 20 years of fasting guidelines, surgical patients are still exposed erroneously to prolonged fasting in 2 hospitals. Patients should be encouraged to eat and drink until 6 and 2 hours, respectively, before surgery and to restart eating after surgery.

The gut microbiota and colorectal surgery outcomes: facts or hype? A narrative review

BACKGROUND

The gut microbiota (GM) has been proposed as one of the main determinants of colorectal surgery complications and theorized as the "missing factor" that could explain still poorly understood complications. Herein, we investigate this theory and report the current evidence on the role of the GM in colorectal surgery.

METHODS

We first present the findings associating the role of the GM with the physiological response to surgery. Second, the change in GM composition during and after surgery and its association with colorectal surgery complications (ileus, adhesions, surgical-site infections, anastomotic leak, and diversion colitis) are reviewed. Finally, we present the findings linking GM science to the application of the enhanced recovery after surgery (ERAS) protocol, for the use of oral antibiotics with mechanical bowel preparation and for the administration of probiotics/synbiotics.

RESULTS

According to preclinical and translational evidence, the GM is capable of influencing colorectal surgery outcomes. Clinical evidence supports the application of an ERAS protocol and the preoperative administration of multistrain probiotics/synbiotics. GM manipulation with oral antibiotics with mechanical bowel preparation still has uncertain benefits in right-sided colic resection but is very promising for left-sided colic resection.

CONCLUSIONS

The GM may be a determinant of colorectal surgery outcomes. There is an emerging need to implement translational research on the topic. Future clinical studies should clarify the composition of preoperative and postoperative GM and the impact of the GM on different colorectal surgery complications and should assess the validity of GM-targeted measures in effectively reducing complications for all colorectal surgery locations.

Preoperative carbohydrates: what is new?

PURPOSE OF REVIEW

The aim of this review is to give an overview of recently published articles covering preoperative carbohydrate loading in surgical patients.

RECENT FINDINGS

Between January 1, 2017, and December 31, 2019, 26 publications addressing the effect of carbohydrate load were retrieved through a systematic search. Seventeen were randomized clinical trials, three prospective observational studies and six retrospective series with case-control comparison. Most of the studies were underpowered, addressed surrogate endpoints, and variability among dose and timing of carbohydrate (CHO) treatment was high. The most recent literature endorses preoperative carbohydrate loading up to 2 h before operations as a safe treatment. The new evidence confirm that this strategy is effective in reducing perioperative insulin resistance and the proportion of hyperglycemia episodes, and improving patient well-being and comfort but without affecting surgery-related morbidity.

SUMMARY

Further properly designed randomized clinical trials, addressing more clinically relevant endpoints such as length of hospitalization and morbidity rate, are warrant.