Enhanced recovery in

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Enhanced recovery in gastrectomy for
cancer Tsang Man For Tuen Mun Hospital
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Content

• Introduction
• 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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Introduction

• Gastric 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 Registry

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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
2013 Recommendations 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 for gastric 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 and meta-analysis. Dig Surg 2011
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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 recommended before 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
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General upper abdominal surgery items
Recommendation 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 /
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 carbohydrate

• Surgery
• -gtStress hormones inflammatory markers
• -gtInsulin resistance enhance gluconeogenesis
• -gtHyperglycemia postop
• -gtPostop complications
• Preoperative carbohydrate ( POC )
• -Decrease postop insulin resistance
• -Reduce Fatigue
• -Speed up recovery

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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 8CD009161.

-Reduced postoperative insulin resistance -Reduce
d 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 Carrere, MD, Patrick
Seulin, MD, Charles Henri Julio, MD, Eric Bloom,
MD,Jean-Luc Gouzi, MD, Bernard Pradere,
MDDepartment of Gastrointestinal Surgery (Pr
Pradere), Purpan University Hospital, CHU de
Toulouse, Place du Dr Baylac, 31059 Toulouse
Cedex, FranceWorld J Surg (2007) in France
Result No significant differences in
postoperative mortality morbidity Nasogastric
tube Delay passage of flatus start of oral
intake Longer length of hospital

• -Prospective randomized control trial
• -84 patients underwent elective partial or total
  gastrectomy, randomized to NG (N43)or No NG
  group (N41)
• -Assessed on gastrointestinal function,
  postoperative course and complications

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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
270 patients undergoing PDG for gastric
cancer January 2010 to June 2012 They were
randomly assigned NG/NJT placement (NG/NJT group,
N134) or not (no-NG/NJT group, N136) with
either Billroth II gastrojejunostomy or Roux-en-Y
gastrojejunostomy. They were monitored for
postoperative complications, mortality, and
postoperative course.

• 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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• 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 KuligJ
Gastrointest Surg (2015) in Italy
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 ,
P0.027) and general (8 vs 23 , Plt0.001)
complications Conclusion Early oral feeding is
feasible and safe after total gastrectomy for
gastric cancer.

• 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.

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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
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

• 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

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• Early oral feeding is recommended after
  gastrectomy

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Conclusion

• Fast 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

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Health economics in enhanced recovery after
surgery programsNew Zealand, 2014
Author Country Study type Number (EG/CG) Surgery type Length of stay Comparativ-e cost analysis
Yu China System-atic review and meta-analysis 199.201 Proximal, distal gastrecto-my WMD-1.87 days ( Plt0.00001 ) Favours FT group Cost savings per patient (WMD) 505.87USD
Feng China RCT 59/60 Total gastrect-omy EG ( mean ) 5.68 days CG means 7.1 days Cost savings per patient 4.185.63 RMB