Implementation of a preoperative pathway for patients undergoing major oncologic gastrointestinal surgery

Abstract

Background: In recent year, a constant increase in life expectancy has occurred in the Western world, leading more elder and frail patients to require major abdominal surgery. These frail patients are more prone to develop postoperative complications and are at higher risk of postoperative mortality. A multimodal, multidisciplinary approach has the potential to improve the perioperative care of these patients. Methods: A cohort of consecutive frail patients undergoing major abdominal surgery for pancreatic and esophago-gastric malignancies between March 2015 and February 2016 was selected and retrospectively evaluated using the modified Frailty Index. Surgical outcomes of this group (experimental group) were compared to a control group of frail patients selected according to main diagnosis, surgical procedures, and surgical team, who underwent major abdominal surgery before the introduction of the multidisciplinary approach (March 2013 to February 2014). Results: Between March 2015 and February 2016, 41 frail patients undergoing major abdominal surgery were identified (experimental group) and compared to similar frail patients receiving similar procedures between March 2013 and February 2014 (control group). The two groups were similar in terms of baseline characteristics (age, gender, American Society of Anesthesiology score, and comorbidities, all P > 0.050), main surgical interventions (P = 0.156), main diagnosis (P = 0.060), and tumor stage (P = 0.420). Modified frailty index and other frailty parameters were similar between the two groups (all P > 0.050). Thirty-days and 3-months mortality rates were lower in the experimental group (0% vs. 14% and 0% vs. 28%, P = 0.010 and P < 0.001 respectively). Similarly, patients in the experimental group showed a lower rate of postoperative overall (41% vs. 74%, P = 0.005) and severe (17% vs. 43%, P = 0.020) complications, while postoperative length of stay, readmission rate and post discharge institutionalization were similar between the two groups (all P > 0.05). Conclusion: The development of a multidisciplinary preoperative pathway for frail patients undergoing major oncologic gastrointestinal surgery for esophago-gastric and pancreatic surgery seems to effectively improve postoperative outcomes, with a significant reduction in the rate of postoperative mortality and complications. Furthermore, the implementation of such a pathway could help the perioperative management of these complex patients and facilitates their territorial take in charge.