Transcript Enhanced recovery for gastrectomy

Enhanced recovery in
gastrectomy for cancer
Tsang Man For
Tuen Mun Hospital
Content
Introduction
ERAS society
Structures of fast tract surgery
Consensus guideline for enhanced recovery
after gastrectomy
Items specific to Upper gastrointestinal
surgery
Conclusion
2
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
3
Gastric cancer
Surgery plays an
important part in cure
gastric cancer
ERAS / FTS program
- maintain physiological
function, facilitate postop
recovery
5
Literature review between September 2012 & April 2013
Recommendations based on reports published between 1985 & 2013
Fast Tract Surgery
Purpose:
Accelerate recovery from surgery in a cost
effective manner
7
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
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Department of Surgery, National University Hospital, Yong Loo Lin School of Medicine, National University of Singapore, Lower Kent Ridge Road,
119072 Singapore
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 and the surgical patient:
nutrition is not warranted, but
triumphs and challenges. Surgeon 2005
significant malnourished patient should
be optimized with oral supplements or
enteral nutrition before surgery
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
General upper abdominal surgery items
Suggestions
Evidence
Preoperative counselling Patients should receive
Optimizing postoperative
outcomes with efficient
preoperative assessment and
management. Crit Care Med 2004
For alcohol abusers, one
Preoperative smoking
and alcohol consumption month of abstinence before
-Preoperative alcoholism
andpostoperative morbidity. Br J
Surg 1999
-Effects of a perioperative
smoking cessation intervention on
postoperative complications: a
randomized trial. Ann Surg 2008
dedicated preoperative
counselling routinely
surgery.
For daily smoker, one
month of abstinence before
surgery.
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
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
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
->Stress hormones + inflammatory
markers
->Insulin resistance + enhance
gluconeogenesis
->Hyperglycemia postop
->Postop complications
Preoperative carbohydrate ( POC )
-Decrease postop insulin
resistance
-Reduce Fatigue
-Speed up recovery
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Pre-operative oral carbohydrates
and 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.
-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 Trial
Nicolas Carre`re, MD, Patrick Seulin, MD, Charles Henri Julio, MD, Eric Bloom, MD,
Jean-Luc Gouzi, MD, Bernard Prade`re, MD
Department 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)
Result:
No significant differences in
postoperative mortality & morbidity
Nasogastric tube:
Delay passage of flatus & start of oral
intake
Longer length of hospital
-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 trial
Fabio 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, 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.
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
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elective surgery for gastric cancer.
In patient underwent gastrectomy, nasogastric tube
decompression is not necessary and it does not improve
the postop outcome
Is early oral feeding after
gastrectomy feasible and safe?
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Feasibility and Outcomes of Early Oral Feeding After Total Gastrectomy
for Cancer
Marek 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.
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.
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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Effect of early oral feeding after
Is Early Oral Feeding after
Gastric Cancer Surgery Feasible? gastric cancer surgery: A result of
randomized clinical trial
A Systematic Review and MetaHoon Hur, MD,a Sung Geun Kim, MD,b Jung Ho Shim, MD,b
Analysis of Randomized
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
Controlled Trials
Xiaoping 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
-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
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
Q&A