Enhanced recovery in gastrectomy for cancer

Tsang Man ForTuen Mun Hospital

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ContentIntroduction

ERAS society

Structures of fast tract surgery

Consensus guideline for enhanced recovery after gastrectomy

Items specific to Upper gastrointestinal surgery

Conclusion

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IntroductionGastric cancer:

-Sixth commonest cancer,

1113 new cases in 2012 ( 4% of all new cancer case )

-Fourth major cause of cancer death, 625 deaths in 2013 ( 4.6% of all cancer deaths )

Hong Kong Cancer Registry3

Gastric cancer

Surgery plays an important part in cure gastric cancer

ERAS / FTS program- maintain physiological function, facilitate postop recovery

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Literature review between September 2012 & April 2013Recommendations based on reports published between 1985 & 2013

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Fast Tract Surgery

Purpose:

Accelerate recovery from surgery in a cost effective manner

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Structures of FTS in gastrectomy

Reduction of hospital stay and cost after the implementation of a clinical pathway for radical gastrectomy for gastric cancer

JIMMY B.Y. SO, ZILIANG L. LIM, HENG-AN LIN, and THIOW-KONG TI

Department of Surgery, National University Hospital, Yong Loo Lin School of Medicine, National University of Singapore, Lower Kent Ridge Road, 119072 Singapore

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ERAS Society recommendations for gastrectomy

-Specific to gastrectomy

-General abdominal surgery items

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Procedure specific items

Recommendation Evidence

Preoperative nutrition Routine use of preoperative artificial nutrition is not warranted, but significant malnourished patient should be optimized with oral supplements or enteral nutrition before surgery

Nutrition and the surgical patient: triumphs and challenges. Surgeon 2005

Transverse Abdominis Plane block

Evidence is strong in support of TAP block in abdominal surgery in general, but no evidence is from gastrectomies

A meta-analysis on the clinical effectiveness of transversus abdominis plane block. J Clin Anesth 2011

Nasogastric tube / nasojejunal decompression

Nasogastric tube / nasojejunal decompression should not be used routinely in the setting of enhanced recovery protocols in gastric surgery

Necessity of routine nasogastric decompression after gastrectomy forgastric cancer: a meta analysis.] Zhonghua Yi Xue Za Zhi 2012

Early postoperative diet and artificial nutrition

Patients undergoing total gastrectomy should be offered drinks and food from post-operation day one. They should be advised to begin cautiously and increase intake according to tolerance. Patients who are malnourished should be given individualized nutritional support

Allowing normal food at will after major upper gastrointestinal surgery does not increase morbidity:a randomized multicenter trial. Ann Surg 2008

Perianastomotic drains Avoiding the use of abdominal drains may reduce drain-related complications and shorten hospital stay after gastrectomy

Drain versus no-drain after gastrectomy for patients with advanced gastric cancer: systematic review andmeta-analysis. Dig Surg 2011

General upper abdominal surgery items

Suggestions Evidence

Preoperative counselling Patients should receive dedicated preoperative counselling routinely

Optimizing postoperative outcomes with efficient preoperative assessment and management. Crit Care Med 2004

Preoperative smoking and alcohol consumption

For alcohol abusers, one month of abstinence before surgery.For daily smoker, one month of abstinence before surgery.

-Preoperative alcoholism andpostoperative morbidity. Br J Surg 1999-Effects of a perioperative smoking cessation intervention on postoperative complications: a randomized trial. Ann Surg 2008

Preoperative fasting and preoperative treatment with carbohydrates

Intake of clear fluids ≤ 2 hours before anaesthesia does not increase gastric residual volume and is recommendedbefore elective surgery. Intake of solids should be withheld 6 hours before anaesthesia

A meta-analysis of randomised controlled trials on preoperative oral carbohydrate treatment in elective surgery. Clin Nutrition

Antithrombotic prophylaxis

Reduce the risk of thromboembolic complications

Low molecular weight heparin and unfractionated heparin in thrombosis prophylaxis after major surgical intervention: update of previous meta-analyses. Br J Surg 1997

General upper abdominal surgery itemsRecommendation Evidence

Epidural analgesics Epidural analgesics on major abdominal surgery with superior pain relieve and fewer respiratory complications

Patient controlled intravenous opioid analgesia versus continuous epidural analgesia for pain after intra-abdominal surgery. Cochrane Database Syst Rev 2005

Avoid hypothermia Prevent hypothermia can reduce the occurrence of wound infection and cardiac complications.

Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events. A randomized clinical trial. JAMA 1997

Early removal of urinary catheter

To ensure early mobilization

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Early mobilization Patients should be mobilized actively in the postoperative period

Multimodal strategies to improve surgical outcome. Am J Surg 2002

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Items specific for gastrectomy

1. Preoperative carbohydrate therapy

2. Early removal of Nasogastric / Nasojejunal tube

3. Early oral feeding

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Preoperative carbohydrateSurgery->Stress hormones + inflammatory markers->Insulin resistance + enhance gluconeogenesis->Hyperglycemia postop->Postop complications

Preoperative carbohydrate ( POC )

-Decrease postop insulin resistance

-Reduce Fatigue

-Speed up recovery 14

Pre-operative oral carbohydratesand effects on clinical outcome

Preoperative carbohydrate treatment for enhancing recovery after elective surgery.

Cochrane Database Syst Rev, Smith MD, McCall J, Plank L, et al.

2014; 8:CD009161.

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-Reduced postoperative insulin resistance

-Reduced hospital length of stay

-No effects were found on postoperative complications. ( No events involving aspiration pneumonitis have been registered in any of the clinical trials of POC )

-A shorter time for return of flatus was demonstrated after POC

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Nasogastric tube decompression

Nasogastric intubation

decrease postoperative ileus

reduce the incidence of anastomotic leaks

Necessity of nasogastric decompression following elective abdominal surgery has been increasingly questioned over the last several years

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Is Nasogastric or Nasojejunal Decompression Necessary after Gastrectomy? A Prospective Randomized TrialNicolas Carre`re, MD, Patrick Seulin, MD, Charles Henri Julio, MD, Eric Bloom, MD,Jean-Luc Gouzi, MD, Bernard Prade`re, MDDepartment of Gastrointestinal Surgery (Pr Prade`re), Purpan University Hospital, CHU de Toulouse, Place du Dr Baylac, 31059 Toulouse Cedex, France

World J Surg (2007) in France

-Prospective randomized control trial

-84 patients underwent elective partial or total gastrectomy, randomized to NG (N=43)or No NG group (N=41)

-Assessed on gastrointestinal function, postoperative course and complications

Result:No significant differences in postoperative mortality & morbidity

Nasogastric tube:Delay passage of flatus & start of oral intakeLonger length of hospital

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Naso-gastric or naso-jejunal decompression after partial distal gastrectomy for gastric cancer. Final results of a multicenter prospective randomized trialFabio Pacelli • Fausto Rosa • Daniele Marrelli • Paolo Morgagni • Massimo Framarini • Luigi Cristadoro • Corrado Pedrazzani • Riccardo Casadei • Luca Cozzaglio • Marcello Covino • Annibale Donini • Franco Roviello • Giovanni de Manzoni • Giovanni Battista Doglietto

-2014, Italy

Results

No significant differences in postoperative mortality or morbidity, especially anastomotic leakage or intra-abdominal sepsis, were observed between the groups.

Routine placement of an NG/NJT after BII and RY PDG is not necessary in elective surgery for gastric cancer.

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270 patients undergoing PDG for gastric cancerJanuary 2010 to June 2012They were randomly assigned NG/NJT placement (NG/NJT group, N=134) or not (no-NG/NJT group, N=136) with either Billroth II gastrojejunostomy or Roux-en-Y gastrojejunostomy. They were monitored for postoperative complications, mortality, and postoperative course.

In patient underwent gastrectomy, nasogastric tube decompression is not necessary and it does not improve the postop outcome

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Is early oral feeding after gastrectomy feasible and safe?

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Feasibility and Outcomes of Early Oral Feeding After Total Gastrectomy for CancerMarek Sierzega & Ryszard Choruz & Szymon Pietruszka & Piotr Kulig & Piotr Kolodziejczyk & Jan Kulig

J Gastrointest Surg (2015) in Italy

Medical records of 353 patients who underwent total gastrectomy for gastric cancer between 2006 and 2012 were retrospectively analyzed.

Initially, patients received oral fluids starting on POD 4, followed by a soft diet on day 5 and regular solid diet afterwards. From 2009, operative protocol was modified by introducing liquids on POD 1, followed by a soft diet on POD 2, and solid foods on day 3.

Results 185 patients have early oral feeding (52 %). No significant differences in postoperative mortality or morbidity.Early feeding tended to be associated with fewer surgical (15 vs 24 %, P=0.027) and general (8 vs 23 %, P<0.001) complications

Conclusion: Early oral feeding is feasible and safe after total gastrectomy for gastric cancer.

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Is Early Oral Feeding after Gastric Cancer Surgery Feasible? A Systematic Review and Meta-Analysis of Randomized Controlled TrialsXiaoping Liu1,2.", Da Wang1.", Liansheng Zheng1, Tingyu Mou1, Hao Liu1*, Guoxin Li1* 1 Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, P.R. China, 2 Department of Gastrointestinal Surgery, The first affiliated hospital of Gannan medical university, Gannan medical university, Ganzhou, Jiangxi, P.R. China-2014

No significant differences were observed for postoperative complication, the tolerability of oral feeding, readmission rate and incidence of anastomotic leakage between two groups.

EOF after gastrectomy for gastric cancer was associated with significant shorter duration of the hospital stay and time to first flatus

Effect of early oral feeding after gastric cancer surgery: A result of randomized clinical trialHoon Hur, MD,a Sung Geun Kim, MD,b Jung Ho Shim, MD,b Kyo Young Song, MD,b Wook Kim, MD,b Cho Hyun Park, MD,b and Hae Myung Jeon, MD, PhD,b Suwon and Seoul, Korea

-Korea, in 2008

Early oral feeding is recommended after gastrectomy

ConclusionFast tract surgery in Gastrectomy:

Standardize the care for patient & minimize the variations in management by different care providers

Risk of gastrectomy increased by comorbidities of patient

Multimodal care for patients: Involve dietitian, surgeons, nurse, physiotherapist & anaesthetist.

More study is needed to evaluate the effectiveness of ERAS for gastrectomy in Hong Kong

Q&A