Association of adherence to the enhanced recovery after surgery pathway and outcomes after laparoscopic total gastrectomy

Application of laparoscopic gastrectomy (LG) to advanced gastric cancer is still controversial due to lack of sufficient surgical and oncological outcomes. The purpose of this study was to elucidate the feasibility of LG for advanced gastric cancer by multicenter prospective cohort study. A total of 98 patients with clinical stage II or III gastric cancer from 8 institutes were analyzed in this study. The primary endpoint was incidence of severe postoperative complications of Clavien-Dindo classification grade Ⅲa or higher. Sixty-six patients underwent laparoscopic distal gastrectomy (LDG), 10 patients laparoscopic proximal gastrectomy (LPG), 21 patients laparoscopic total gastrectomy (LTG), and 1 patient received gastro-jejunostomy. Seven patients had positive lavage cytology (CY1) and R0 rate was 90.8%. Three patients (3.1%) required conversion to open surgery. The incidence of overall postoperative complications and severe postoperative complications were 17.3% and 9.2%, respectively, those were comparable to the data of open surgery for advanced gastric cancer previously published. By surgical procedure, the incidence of severe postoperative complications of LDG, LPG, and LTG were 4.6, 0, and 28.6% and the rate of severe anastomotic leakage of LDG, LPG, and LTG were 0, 0, and 9.5%, respectively. Total gastrectomy was an only independent risk factor of severe postoperative complications in LG for advanced gastric cancer (odds ratio 8.75; 95% confidence interval 1.70-56.69, P = .0092). The incidence of severe postoperative complications after LG performed by qualified surgeons was acceptable even in cases of advanced gastric cancer; however, careful attention is required to adopt LTG. (UMIN000025733).

To develop a predictive model based on the perioperative plasma concentration of amino-terminal pro-brain natriuretic peptide (NT-pro BNP) in elderly patients to assess the risk of severe postoperative complications. Elderly patients (age ≥ 65years) enrolled in this prospective observational study underwent general surgery. Plasma NT-Pro BNP concentration was measured before surgery and 2h after surgery. Univariate and multivariate logistic regression analyses were used to identify the significant predictors. To evaluate the model performance, we applied the receiver operating characteristic (ROC) curve, Hosmer-Lemeshow test, and decision curve analysis (DCA) to evaluate the net clinical benefit. Prediction model was visualised by drawing nomogram and establishing web calculator. A total of 174 elderly patients were enrolled; 15 patients (8.6%) developed severe complications. The area under the ROC curve, sensitivity, and specificity of the two prediction models were 0.899 (95% CI 0.845-0.940), 86.67%, 91.82%, 0.956 (95% CI 0.902-0.985), 100%, and 81.42%, respectively. The net benefit of the post-model was higher than pre-model. We established two postoperative severe complication assessment models based on perioperative NT-Pro BNP levels for elderly patients with reliable accuracy. The nomogram and web calculator will be easy to use by clinicians and other researchers.Clinical significance: The biomarker, NT-pro BNP seem to correlate with some postoperative complications, however no studies have evaluated its relationship with severe postoperative complications in elderly patients. In this study, we evaluated the relationship between NT-pro BNP and severe postoperative complications in elderly patients, and established a prediction model and a web calculator based on the prediction model. Clinicians can easily use this prediction model to identify high-risk patients at an early stage.

Background: Although laparoscopic gastrectomy is becoming more popular as a curative therapy for gastric cancer, there are concerns about its oncological adequacy. We have compared the outcomes of laparoscopic total gastrectomy (LTG) and laparoscopic subtotal gastrectomy (LSG), both with modified D2 lymphadenectomies for the treatment of advanced gastric cancers. Aim: To compare the outcomes of laparoscopic (total and subtotal) gastrectomy with modified D2 lymphadenectomy for the treatment of gastric cancer, contributing to the literature regarding the overall survival of these patients and postoperative complications. Methods: From 1993 to 2014, 239 patients were operated on laparoscopic gastrectomy at our department. The routinely laparoscopic gastrectomy was performed in all patients with gastric cancer including those presenting with obstruction and bleeding. Data could be collected, on a retrospective way, from 2006 to 2014, from the medical records of 103 patients who underwent LSG (n = 72) or LTG (n = 31). We excluded patients with metastatic disease and those who could not have a complete tumor resection. Results: Most patients were in advanced stages of cancer. Adenocarcinoma was the most common find, with 43% of cases in stage IIA and 31% in stage IIIB. Intracorporeal Roux-en-Y or Billroth II anastomoses were employed. Postoperative complications, for LSG and LTG, were 18% and 35.4%; mortality rate, during hospital stay, was 4.9% and 7.7%; three-year survival rate, 53.1% and 59.3%; and five-year survival rate, 46.9% and 40.7%. Mean hospital stay was 7.08 days, being significantly lower in LSG group (p < 0.05). Hospital acquired pneumonia was the most prevalent clinical complication, while deaths arising from surgical complications were caused mainly by gastro-jejunal or esophago-jejunal anastomosis leaks. Conclusions: Both LSG and LTG with modified D2 lymphadenectomy are feasible alternatives to open surgery and survival rates were comparable. The increased risk of complications observed in LTG did not influence the overall mortality rate. We hope that these findings should contribute to improve the acceptance of laparoscopic gastrectomy as a safe procedure for gastric cancer treatment.

To explore the risk factors of unplanned reoperation after radical resection for colorectal cancer. A retrospective analysis of 60 patients (within 14 to 24 days after the initial surgery) receiving unplanned reoperation after colorectal cancer surgery in the First Affiliated Hospital of Xinjiang Medical University from January 2010 to January 2014 was carried out, comparing with 120 randomly paired patients without reoperation during the same period. Univariate and multivariate Logistic regression analysis was performed to investigate the clinicopathologic characteristics of patients in both groups. Univariate logistic regression analysis showed that male, massive blood loss, diabetes, high BMI, hypertension and poorer tumor staging were selected as possible risk factors, and surgeon and laparoscopic surgery as conservative factors (all P<0.05). Multivariate logistic regression analysis revealed that massive blood loss (OR=12.935, 95% CI: 2.267 to 73.806, P=0.004), diabetes (OR=1.747, 95% CI: 1.098 to 2.777, P=0.018) and male (OR=1.805, 95% CI: 1.074 to 3.034, P=0.026) were the independent risk factors of unplanned reoperation after radical resection for colorectal cancer. For heavy bleeding, diabetes and male gender in patients with colorectal cancer, surgeon should pay attention to prevent the risk of postoperative unplanned reoperation.

ObjectiveThis study aimed to investigate risk factors associated with severe postoperative complications following hip fracture surgery in elderly patients and to develop a nomogram-based risk prediction model for these complications.MethodsA total of 627 elderly patients with hip fractures treated at Yongchuan Hospital of Chongqing Medical University from January 2015 to April 2024 were collected. 439 patients were assigned to the training cohort for model development, and 188 to the validation cohort for model assessment. The training cohort was stratified based on the presence or absence of severe complications. We employed LASSO regression, as well as univariate and multivariate logistic regression analyses, to identify significant factors. A nomogram was constructed based on the outcomes of the multivariate regression. The model’s discriminative ability was assessed using the area under the receiver operating characteristic curve (AUC), while calibration plots and decision curve analysis (DCA) evaluated its calibration and stability. Internal validation was performed using the validation cohort.ResultsOut of the 627 patients, 118 (18.82%) experienced severe postoperative complications. Both LASSO regression and multivariate logistic analysis identified the modified 5-item frailty index (mFI-5) and the preoperative C-reactive protein to albumin ratio (CAR) as significant predictors of severe complications. The nomogram model, derived from the multivariate analysis, exhibited strong discriminative ability, with an AUC of 0.963 (95% CI: 0.946–0.980) for the training cohort and 0.963 (95% CI: 0.938–0.988) for the validation cohort. Calibration plots demonstrated excellent agreement between the nomogram’s predictions and actual outcomes. Decision curve analysis (DCA) indicated that the model provided clinical utility across all patient scenarios. These findings were consistent in the validation cohort.ConclusionsBoth the mFI-5 and CAR are predictive factors for severe postoperative complications in elderly patients undergoing hip fracture surgery.

This study aimed to investigate risk factors associated with severe postoperative complications following hip fracture surgery in elderly patients and to develop a nomogram-based risk prediction model for these complications. A total of 627 elderly patients with hip fractures treated at Yongchuan Hospital of Chongqing Medical University from January 2015 to April 2024 were collected. 439 patients were assigned to the training cohort for model development, and 188 to the validation cohort for model assessment. The training cohort was stratified based on the presence or absence of severe complications. We employed LASSO regression, as well as univariate and multivariate logistic regression analyses, to identify significant factors. A nomogram was constructed based on the outcomes of the multivariate regression. The model's discriminative ability was assessed using the area under the receiver operating characteristic curve (AUC), while calibration plots and decision curve analysis (DCA) evaluated its calibration and stability. Internal validation was performed using the validation cohort. Out of the 627 patients, 118 (18.82%) experienced severe postoperative complications. Both LASSO regression and multivariate logistic analysis identified the modified 5-item frailty index (mFI-5) and the preoperative C-reactive protein to albumin ratio (CAR) as significant predictors of severe complications. The nomogram model, derived from the multivariate analysis, exhibited strong discriminative ability, with an AUC of 0.963 (95% CI: 0.946-0.980) for the training cohort and 0.963 (95% CI: 0.938-0.988) for the validation cohort. Calibration plots demonstrated excellent agreement between the nomogram's predictions and actual outcomes. Decision curve analysis (DCA) indicated that the model provided clinical utility across all patient scenarios. These findings were consistent in the validation cohort. Both the mFI-5 and CAR are predictive factors for severe postoperative complications in elderly patients undergoing hip fracture surgery.

Background: The early oral feeding after the laparoscopic total gastrectomy contributes to the enhanced treatment efficiency and improved quality of life of gastric cancer patients. To evaluate the efficiency of early oral feeding after laparoscopic total gastrectomy in gastric cancer patients at the Nghe An General Friendship Hospital. Methods: A retrospective observational study, performed in patients who underwent laparoscopic total gastrectomy from 2014 to 2020. Results: 126 patients were recruited. The mean age was 60.6 ± 11.1 years. The male/female ratio was 2.8/1. 15.9% of patients had the tumor at the one-third upper stomach, 81.7% at the middle of the stomach. 70.6% of patients contracted adenocarcinoma and ductal carcinoma, 24.6% of patients had ring cell carcinoma. The percent of tumor at stages I, II, III were respectively 19.0%, 49.2%, 31.7%. There were 71.4% of cases underwent laparoscopic total gastrectomy and were made the anastomosis by linear staplers. No case presented complications relating to the anastomosis after the surgery. The mean oral feeding time was 4.4 ± 1.9 (2 – 8 days), 27.8% of cases started at the second postoperative date, 8.7% of cases at the third postoperative date, 29.4% of cases from the fourth and fifth date, and 34.1% of cases started from the sixth date and further. The later the oral feeding time was, the slower recovery of the peristalsis was and vice versa (p 0.05). The more early the feeding time was, the shorter duration of antibiotic therapy observed and vice versa (p < 0.05). The more early the feeding time was, the short duration of hospital stay was and vice versa (p < 0.05). Conclusions: The early oral feeding after laparoscopic total gastrectomy was safe and contributed to improving the efficiency of the treatment, the quality of life in gastric cancer patients. Keywords: Early oral feeding, gastric cancer.

Background: The early oral feeding after the laparoscopic total gastrectomy contributes to the enhanced treatment efficiency and improved quality of life of gastric cancer patients. To evaluate the efficiency of early oral feeding after laparoscopic total gastrectomy in gastric cancer patients at the Nghe An General Friendship Hospital.&#x0D; Methods: A retrospective observational study, performed in patients who underwent laparoscopic total gastrectomy from 2014 to 2020.&#x0D; Results: 126 patients were recruited. The mean age was 60.6 ± 11.1 years. The male/female ratio was 2.8/1. 15.9% of patients had the tumor at the one-third upper stomach, 81.7% at the middle of the stomach. 70.6% of patients contracted adenocarcinoma and ductal carcinoma, 24.6% of patients had ring cell carcinoma. The percent of tumor at stages I, II, III were respectively 19.0%, 49.2%, 31.7%. There were 71.4% of cases underwent laparoscopic total gastrectomy and were made the anastomosis by linear staplers. No case presented complications relating to the anastomosis after the surgery. The mean oral feeding time was 4.4 ± 1.9 (2 – 8 days), 27.8% of cases started at the second postoperative date, 8.7% of cases at the third postoperative date, 29.4% of cases from the fourth and fifth date, and 34.1% of cases started from the sixth date and further. The later the oral feeding time was, the slower recovery of the peristalsis was and vice versa (p &lt; 0.05). There was no difference between the feeding time and the complications (p &gt; 0.05). The more early the feeding time was, the shorter duration of antibiotic therapy observed and vice versa (p &lt; 0.05). The more early the feeding time was, the short duration of hospital stay was and vice versa (p &lt; 0.05).&#x0D; Conclusions: The early oral feeding after laparoscopic total gastrectomy was safe and contributed to improving the efficiency of the treatment, the quality of life in gastric cancer patients.&#x0D; Keywords: Early oral feeding, gastric cancer.

BackgroundAfter Laparoscopic total gastrectomy (LTG), gastric cancer (GC) patients often face malnutrition. Early oral feeding (EOF) has emerged as a key strategy in enhanced recovery after surgery (ERAS) protocols. However, the impact of EOF on post-LTG nutritional status requires further investigation. This study aimed to compare the nutritional status of EOF, nasogastric tube (NGT) and nasojejunal tube (NJT) to figure out the status of EOF. MethodsA retrospective comparative analysis of a single center (Second Hospital of Lanzhou University) of a total of 116 patients with LTG was performed. These included 40 NGT patients, 40 patients with NJT and 36 patients with EOF. Postoperative (7 days after surgery) nutritional status was examined as the primary endpoint, including weight, BMI, total protein, albumin, hemoglobin and total lymphocyte count (TLC). In addition, bowel sounds, abdominal distension and pain were evaluated as secondary endpoints. ResultsThe collective shows no significant differences between the three groups regarding various demographic and clinical information (All, p > 0.05). There was no significant difference in the patients' nutritional status and bowel sound recovery 7 days after surgery (All, p > 0.05). The rate of abdominal distension shows to be significantly reduced with EOF compared to NJT (mean difference = 0.342; p < 0.001). The incidence of abdominal pain was significantly different between EOF and NGT groups (mean difference = 0.228; p < 0.001). ConclusionAmong GC patients after LTG, EOF and traditional tube feeding had a similar risk of postoperative nutritional status. However, EOF was associated with a lower risk of abdominal distension.

To assess the safety and feasibility of laparoscopic gastrectomy (LG) for gastric cancer patients with a history of abdominal surgery (HAS). This retrospective study analyzed data collected from gastric cancer patients with HAS, who underwent LG between 2004 and 2015. We compared the clinicopathological features that correlated with conversion to open surgery and the development of severe postoperative complications (Clavien-Dindo classification of grade III or higher). Of the 41 patients identified, 6 (14.6%) required conversion to open surgery. The incidence of conversion to open surgery was associated with a history of lower gastrointestinal tract surgery (p = 0.009), attempted laparoscopic total gastrectomy (p = 0.002), and excessive blood loss (p < 0.001). Severe postoperative complications developed in six patients (14.6%). Although the development of complications was associated with high postoperative serum C-reactive protein, the type of past abdominal surgery was not significantly correlated with severe complications. LG was feasible for gastric cancer patients with a HAS, but for those with a history of lower abdominal surgery or those who require total gastrectomy, surgeons should carefully consider the indications for LG.

BackgroundPostoperative severe complications are always associated with prolonged hospital stays, increased economic burdens, and poor prognoses in patients with colorectal cancer (CRC). This present study aimed to investigate potential risk factors including serum albumin (Alb) for severe complications in CRC patients.MethodsEligible patients with primary CRC undergoing elective laparoscopic colectomy from July 2015 to July 2017 were included. Postoperative severe complications were defined as grade III and IV according to the Clavien–Dindo classification. ∆Alb was defined as (preoperative Alb − nadir Alb within POD2)/preoperative Alb × 100%. The baseline characteristics, intraoperative data, and laboratory data were obtained from the database for the analysis. Univariate and multivariate logistic regression analyses were utilized for the assessment of the association between risk factors and postoperative severe complications. The predictive value of ∆Alb for postoperative severe complications was evaluated by receiver operating characteristic (ROC) curve analysis.ResultsA total of 193 patients were finally included in the analysis data set, of which 38 (19.7%) patients had postoperative severe complications. In the final multivariate logistic regression analysis, ∆Alb was the only independent factor associated with postoperative severe complications (OR 1.66, 95%CI 1.18–2.33, p = 0.003). The area under the curve (AUC) of ∆Alb was 0.916, with the sensitivity and specificity of 0.842 and 0.858 (p < 0.001).ConclusionsThe ∆Alb was an independent risk factor for severe complications in CRC patients after curative laparoscopic surgery.

Background and Objectives: This study aimed to investigate the potential risk factors for severe postoperative complications after oncologic right colectomy. Materials and Methods: All consecutive patients with right colon cancer who underwent right colectomy in our department between 2016 and 2021 were retrospectively included in this study. The Clavien-Dindo grading system was used to evaluate postoperative complications. Univariate and multivariate logistic regression analyses were used to investigate risk factors for postoperative severe complications. Results: Of the 144 patients, there were 69 males and 75 females, with a median age of 69 (IQR 60-78). Postoperative morbidity and mortality rates were 41.7% (60 patients) and 11.1% (16 patients), respectively. The anastomotic leak rate was 5.3% (7 patients). Severe postoperative complications (Clavien-Dindo grades III-V) were present in 20 patients (13.9%). Univariate analysis showed the following as risk factors for postoperative severe complications: Charlson score, lack of mechanical bowel preparation, level of preoperative proteins, blood transfusions, and degree of urgency (elective/emergency right colectomy). In the logistic binary regression, the Charlson score (OR = 1.931, 95% CI = 1.077-3.463, p = 0.025) and preoperative protein level (OR = 0.049, 95% CI = 0.006-0.433, p = 0.007) were found to be independent risk factors for postoperative severe complications. Conclusions: Severe complications after oncologic right colectomy are associated with a low preoperative protein level and a higher Charlson comorbidity index.

BackgroundGastric cancer is the third most common cause of cancer-related deaths and has the fifth highest incidence worldwide, especially in eastern Asia, central and Eastern Europe, and South America. Currently, surgery is the only curative treatment for gastric cancer; however, there is an increasing trend toward laparoscopic radical gastrectomy. Early oral feeding (EOF) has been shown to benefit clinical outcomes compared with open gastrectomy under conditions of enhanced recovery after surgery. There are a lack of guidelines and evidence for the safety and feasibility of EOF in patients undergoing laparoscopic radical gastrectomy. Thus, a prospective randomized trial is warranted.Methods/designThe EOF after total laparoscopic radical gastrectomy (SOFTLY) study is a single-center, parallel-arm, non-inferiority randomized controlled trial which will enroll 200 patients who are pathologically diagnosed with gastric cancer and undergo laparoscopic radical gastrectomy. The primary endpoint, incidence of anastomotic leakage, is based on 1.9% in the control group in the CLASS-01 study. The patients will be randomized (1:1) into two groups: the EOF group will receive a clear liquid diet on post-operative day 1 (POD1) and the delayed oral feeding (DOF) group will receive a clear liquid diet on post-operative day 4 (POD4). The demographic and pathologic characteristics will be recorded. Total and oral nutritional intake, general data, total serum protein, serum albumin, blood glucose, and temperature will be recorded before surgery and at the time of hospitalization. Adverse events will also be recorded. The occurrence of post-operative fistulas, including anastomotic leakage, will be recorded as the main severe post-operative adverse event and represent the primary endpoint.DiscussionThe safety and feasibility of EOF after gastrectomy has not been established. The SOFTLY trial will be the first randomized controlled trial involving total laparoscopic radical gastrectomy, in which the EOF group (POD1) will be compared with the DOF group (POD4). The results of the SOFTLY trial will provide data on the safety and feasibility of EOF after total laparoscopic radical gastrectomy.Trial registrationChinese Clinical Trial Registry, ChiCTR-IOR-15007660. Registered on 28 December 2015. The study has full ethical and institutional approval.

Enhanced recovery: joining the dots

BackgroundSystemic pro-inflammatory factors play a critical role in mediating severe postoperative complications (SPCs) in upper abdominal surgery (UAS). The systemic immune-inflammation index (SII) has been identified as a new inflammatory marker in many occasions. The present study aims to determine the association between SII and the occurrence of SPCs after UAS.MethodsIncluded in this study were 310 patients with upper abdominal tumors who received UAS and subsequently were transferred to the anesthesia intensive care unit between November 2020 and November 2021 in Nanjing Drum Hospital. SPCs, including postoperative pulmonary complications (PPCs), major adverse cardiac and cardiovascular events, postoperative infections and delirium, were recorded during the hospital stay. The clinical features of the patients with and without SPCs were compared by Student’s t-test or Fisher’s exact test as appropriate. Risk factors associated with SPC occurrence were evaluated by univariable and multivariable logistic regression analyses. Receiver operating characteristic (ROC) curve analysis was used to establish a cut-off level of SII value to predict SPCs.ResultsOf the 310 patients receiving UAS, 103 patients (33.2%) presented at least one SPC, including PPCs (n = 62), adverse cardiovascular events (n = 22), postoperative infections (n = 51), and delirium (n = 5). Both preoperative SII and 1-h postoperative SII in patients with SPCs were significantly higher than those in patients without SPCs. Multivariate analysis showed that 1-h postoperative SII was an independent predictor for SPC occurrence (OR = 1.000, 95% CI 1.000–1.000, P = 0.007), together with postoperative C-reactive protein, postoperative arterial lactate, postoperative oxygenation-index and older age. The ROC curve showed that the optimal cutoff value of 1-h postoperative SII to predict SPCs was 754.6078 × 109/L, with an 88.3% sensitivity and a 29% specificity. Multivariate analysis also confirmed that 1-h postoperative SII > 754.6078 × 109/L was associated with increased SPC occurrence (OR = 2.656, 95% CI 1.311–5.381, P = 0.007).ConclusionOur findings demonstrated an association between the higher level of 1-h postoperative SII and SPCs, suggesting that 1-h postoperative SII, especially categorized 1-h postoperative SII using cutoff value, may be a useful tool for identifying patients at risk of developing SPCs.