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A Nomogram for Prediction of Survival in Patients After Gastrectomy Within Enhanced Recovery After Surgery (ERAS): A Single-Center Retrospective Study. Sun Yuqi,Li Zequn,Liu Xiaodong,Cao Shougen,Liu Xuechao,Hu Chuan,Tian Yulong,Xu Jianfei,Wang Daoshen,Zhou Xin,Zhou Yanbing Medical science monitor : international medical journal of experimental and clinical research BACKGROUND Enhanced Recovery After Surgery (ERAS) programs can optimize clinical outcomes and have been widely used across multiple specialties, but a personalized prediction model involving ERAS for the prognosis of gastric cancer is lacking. MATERIAL AND METHODS We retrospectively collected clinical data on 725 gastric cancer patients within ERAS who underwent curative gastric resection in the Affiliated Hospital of Qingdao University from 2007 to 2014. Kaplan-Meier method, log-rank test, and Cox proportional risk model were used to determine the independent prognostic factors of patients. The accuracy of model was evaluated by C-index, calibration curve, and Decision Curve Analysis (DCA), and the receiver operator characteristic (ROC) curve was used to compare the nomogram model with the predictive value of TNM staging system. RESULTS The 5-year overall survival (OS) of 725 patients within ERAS was 72.5%. Age at diagnosis, T stage, N stage, and postoperative complications were determined to be independent factors affecting the prognosis of patients within ERAS, and nomogram model was constructed. The C-index of the training group was 0.809 and that of the verification group was 0.804; the calibration curves and DCA of the 2 groups showed good accuracy. Through verification, we found that, compared with the TNM staging assessment method, the nomogram model was more accurate in predicting the prognosis of gastric cancer. CONCLUSIONS This study identified factors affecting the prognosis of patients with gastric cancer, and we constructed the first prognostic nomogram model in ERAS mode to facilitate postoperative personalized prognostic evaluation. 10.12659/MSM.926347
Nutritional management of gastric cancer. Carrillo Lozano Elena,Osés Zárate Virginia,Campos Del Portillo Rocío Endocrinologia, diabetes y nutricion Gastric cancer is the third leading cause of cancer mortality and is frequently associated with nutritional disorders, the detection and proper management of which can contribute to improving quality of life and survival. Being aware of the consequences and of the different treatments for this neoplasm allows us to offer an adequate nutritional approach. In surgical candidates, integration into ERAS-type programs (Enhanced Recovery after Surgery) is increasingly frequent, and includes a pre-surgical nutritional approach and the initiation of early oral tolerance. After gastrectomy, the new anatomical and functional state of the digestive tract may lead to the appearance of «post-gastrectomy syndromes», the management of which may require diet modification and medical treatment. Those who receive neoadjuvant or adjuvant antineoplastic therapy benefit from specific dietary recommendations based on intercurrent symptoms and/or artificial nutrition. In palliative patients, the nutritional approach should be carried out while respecting the principle of autonomy and weighing the risks and benefits of the intervention. The objective of this review is to highlight the importance and role of nutrition in patients with gastric cancer and to provide guidelines for nutritional management based on the current evidence. 10.1016/j.endinu.2020.09.004
Enhanced recovery after surgery in laparoscopic distal gastrectomy: Protocol for a prospective single-arm clinical trial. Journal of minimal access surgery BACKGROUND:The enhanced recovery after surgery (ERAS) programme is feasible and effective in reducing the length of hospital stay, overall complication rates and medical costs when applied to cases involving colonic and rectal resections. However, a recent prospective, randomised, open, parallel-controlled trial (Chinese Laparoscopic Gastrointestinal Surgery Study-01 trial), initiated by our team, indicated that under conventional peri-operative management, the reduction of the post-operative hospital stay of laparoscopic distal gastrectomy (LDG) is quite limited compared with open gastrectomy. Thus, if we could provide valuable clinical evidence for demonstrating the efficacy of the ERAS programme for gastric cancer patients undergoing LDG, it would significantly enhance the peri-operative management of gastrectomy and benefit the patients. METHODS:In this prospective single-arm trial, patients who are 18-75 years of age with gastric adenocarcinoma diagnosed with cT1-4aN0-3M0 and expected to undergo curative resection through LDG, are considered eligible for this study. All participants underwent LDG with peri-operative management under the ERAS programme. The primary outcome measures included the post-operative hospital stays and rehabilitative rate of the post-operative day 4. The secondary outcome measures are morbidity and mortality (time frame: 30 days), post-operative recovery index (time frame: 30 days), post-operative pain intensity (time frame: 3 days) and the medical costs from surgery to discharge. CONCLUSION:With reasonable and scientific designing, the trial may be a great help to further discuss the benefit of ERAS programme and thus improving the peri-operative management of patients with gastrectomy. 10.4103/jmas.JMAS_35_19
The benefits of enhanced recovery after surgery for gastric cancer: A large before-and-after propensity score matching study. Jeong Oh,Jang Aelee,Jung Mi Ran,Kang Ji Hoon,Ryu Seong Yeob Clinical nutrition (Edinburgh, Scotland) BACKGROUND & AIMS:The benefits of enhanced recovery after surgery (ERAS) in patients undergoing gastrectomy have been reported in several studies; however, there is limited evidence supporting the efficacy of ERAS in clinical settings. We aimed to identify the benefits of ERAS in the clinical setting by investigating short-term surgical outcomes before and after the implementation of ERAS in patients who underwent gastrectomy. METHODS:We searched our gastric cancer database from 2008 to 2018 to identify patients who underwent gastrectomy before ERAS was implemented (2008-2009) and after the final version of ERAS was implemented (2016-2018). We enrolled 424 patients who were treated before ERAS was implemented and 565 patients who received our completed version of ERAS. After propensity score matching, each group included 219 patients, and short-term surgical outcomes were compared between the two groups. RESULTS:The length of hospital stay was significantly shorter in the ERAS group (8.8 vs. 11.5 days, p = 0.001), but the readmission rates were similar in the two groups, at 2.3%. There were no significant differences in morbidity, mortality, and complications of ≥ grade III between the groups. Of the complications, intra-abdominal bleeding (0% vs. 4.1%, p = 0.002) and intra-abdominal abscess (0% vs. 2.7%, p = 0.038) were significantly lower, whereas postoperative ileus was significantly higher in the ERAS group (8.6% vs. 0.5%, p < 0.001). In subgroup analyses by age, operative approach, and the extent of gastric resection, the ERAS group experienced a shorter hospital stay without increased readmission in all subgroups. CONCLUSIONS:These results demonstrated that ERAS was associated with a 3-day reduction in hospital stay without increased readmission after gastrectomy. This study validated the benefits of ERAS in the clinical setting of gastrectomy. 10.1016/j.clnu.2020.09.042
Comparison of Outcomes between Obese and Non-Obese Patients in a Colorectal Enhanced Recovery After Surgery (ERAS) Program: A Single-Center Cohort Study. Iranmanesh Pouya,Delaune Vaihere,Meyer Jeremy,Liot Emilie,Konrad Beatrice,Ris Frederic,Toso Christian,Buchs Nicolas Christian Digestive surgery INTRODUCTION:Obese patients are considered at increased risk of postoperative adverse events after colorectal surgery. OBJECTIVE:The objective of the present study was to compare postoperative outcomes between obese and non-obese patients undergoing elective colorectal surgery in an Enhanced Recovery After Surgery (ERAS) program. METHODS:A retrospective analysis of a prospective cohort including patients who underwent elective colorectal surgery and were included in an ERAS protocol between February 2014 and December 2017 at Geneva University Hospital, Geneva, Switzerland, was performed. Postoperative outcomes of obese and non-obese patients were compared. RESULTS:Data of 460 patients were analyzed, including 374 (81%) non-obese and 86 (19%) obese patients. Overall, there was no difference in postoperative outcomes between the 2 groups. Among patients undergoing oncologic surgery, obese subjects had a significantly higher rate of conversion to laparotomy (11.9 vs. 2.1%, p = 0.01) and longer time until return of bowel function (2.38 vs. 1.98 days, p = 0.03), without increased morbidity or longer length of stay. CONCLUSION:Obese and non-obese patients had similar postoperative outcomes after elective colorectal surgery with ERAS management. ERAS can potentially reduce the increased morbidity usually observed in obese patients following elective colorectal surgery. 10.1159/000507545
Enhanced recovery after surgery (ERAS) versus standard recovery for elective gastric cancer surgery: A meta-analysis of randomized controlled trials. Lee Yung,Yu James,Doumouras Aristithes G,Li Jennifer,Hong Dennis Surgical oncology Enhanced recovery after surgery (ERAS) protocols have been effective in improving postoperative recovery after major abdominal surgeries including colorectal cancer surgery, however its impact after gastric cancer surgery is unclear. A systematic review and meta-analysis was conducted to evaluate the effect of ERAS after gastric cancer surgery. Medline, EMBASE, CENTRAL, and PubMed was searched from database inception to December 2018. Randomized controlled trials (RCTs) comparing ERAS versus standard care in gastric cancer surgery were included. Outcomes included the postoperative length of stay (LOS), hospital costs, time to first flatus, defecation, oral intake, and ambulation after surgery, and complications. Pooled estimates were calculated using random-effects meta-analysis. The GRADE approach assessed overall quality of evidence. 18 RCTs involving 1782 patients were included. ERAS significantly reduced the LOS (Mean Difference (MD) -1.78 days, 95%CI -2.17 to -1.40, P < 0.0001), reduced hospital costs (MD -650 U S. dollars, 95%CI -840 to -460, P < 0.0001), and reduced time to first flatus, defecation, ambulation, and oral intake. ERAS had significantly lower rates of pulmonary infections (Risk Ratio (RR) 0.48, 95%CI 0.28 to 0.82, P = 0.007), but not surgical site infections, anastomotic leaks, and postoperative complications. However, ERAS significantly increased readmissions (RR 2.43, 95%CI 1.09 to 5.43, P = 0.03). The quality of evidence was low to moderate for all outcomes. Implementation of an ERAS protocol may reduce LOS, costs, and time to return of function after gastric cancer surgery compared to conventional recovery. However, ERAS may increase the number of postoperative readmissions, albeit with no impact on the rate of postoperative complications. 10.1016/j.suronc.2019.11.004
Compliance with the ERAS Protocol and 3-Year Survival After Laparoscopic Surgery for Non-metastatic Colorectal Cancer. World journal of surgery INTRODUCTION:Enhanced recovery after surgery (ERAS) pathways have been proven to enhance postoperative recovery, reduce morbidity, and reduce length of hospital stay after colorectal cancer surgery. However, despite the benefits of the ERAS program on short-term results, little is known about its impact on long-term results. OBJECTIVE:The aim of the study was to determine the association between adherence to the ERAS protocol and long-term survival after laparoscopic colorectal resection for non-metastatic cancer. MATERIAL AND METHODOLOGY:Between 2013 and 2016, 350 patients underwent laparoscopic colorectal cancer resection in the 2nd Department of General Surgery, Jagiellonian University Medical College, and were enrolled for further analysis. The relationship between the rate of compliance with the ERAS protocol and 3-year survival was analyzed according to the Kaplan-Meier method with log-rank tests. Patients were divided into two groups according to their degree of adherence to the ERAS interventions: Group 1 (109 patients), < 80% adherence, and Group 2 (241 patients), ≥ 80% adherence. The primary outcome was overall 3-year survival. The secondary outcomes were postoperative complications, length of hospital stay, and recovery parameters. RESULTS:The groups were similar in terms of demographics and surgical parameters. The median compliance to ERAS interventions was 85.2%. The Cox proportional model showed that AJCC III (HR 3.28, 95% CI 1.61-6.59, p = 0.0021), postoperative complications (HR 2.63, 95% CI 1.19-5.52, p = 0.0161), and compliance with ERAS protocol < 80% (HR 3.38, 95% CI 2.23-5.21, p = 0.0102) were independent predictors for poor prognosis. Additionally, analysis revealed that adherence to the ERAS protocol in Group 2 with ≥ 80% adherence was associated with a significantly shorter length of hospital stay (6 vs. 4 days, p < 0.0001), a lower rate of postoperative complications (44.7% vs. 23.3%, p < 0.0001), and improved functional recovery parameters: tolerance of oral diet (53.4% vs. 81.5%, p < 0.0001) and mobilization (77.7% vs. 96.1%, p < 0.0001) on the first postoperative day. CONCLUSIONS AND RELEVANCE:This study reports an association between adherence to the ERAS protocol and long-term survival after laparoscopic colorectal resection for non-metastatic cancer. Lower adherence to the protocol, independent from stage of cancer and postoperative complications, was an independent risk factors for poorer survival rates. 10.1007/s00268-019-05073-0
Relationship between Gut Microbiota, Gut Hyperpermeability and Obesity. Gasmi Amin,Mujawdiya Pavan Kumar,Pivina Lyudmila,Doşa Alexandru,Semenova Yuliya,Benahmed Asma Gasmi,Bjørklund Geir Current medicinal chemistry Intestinal hyperpermeability is a complex metabolic process mediated by different pathways in close relation to the gut microbiota. Previous studies suggested that the gut microbiota is involved in different metabolic regulations, and its imbalance is associated with several metabolic diseases, including obesity. It is well known that intestinal hyperpermeability is associated with dysbiosis, and the combination of these two conditions can lead to an increase in the level of low-grade inflammation in obese patients due to an increase in pro-inflammatory cytokine levels. Inflammatory bowel syndrome often accompanies this condition causing an alteration of the intestinal mucosa and thus reinforcing the dysbiosis and gut hyperpermeability. The onset of metabolic disorders depends on violations of the integrity of the intestinal barrier as a result of increased intestinal permeability. Chronic inflammation due to endotoxemia is responsible for the development of obesity. Metabolic disorders are associated with dysregulation of the microbiota-gut-brain axis and with an altered composition of gut flora. In this review, we will discuss the mechanisms that illustrate the relationship between hyperpermeability, the composition of the gut microbiota, and obesity. 10.2174/0929867327666200721160313
Postoperative ERAS Interventions Have the Greatest Impact on Optimal Recovery: Experience With Implementation of ERAS Across Multiple Hospitals. Aarts Mary-Anne,Rotstein Ori D,Pearsall Emily A,Victor J Charles,Okrainec Allan,McKenzie Marg,McCluskey Stuart A,Conn Lesley Gotlib,McLeod Robin S, Annals of surgery BACKGROUND:Enhanced recovery after surgery (ERAS) programs incorporate evidence-based practices to minimize perioperative stress, gut dysfunction, and promote early recovery. However, it is unknown which components have the greatest impact. OBJECTIVE:This study aims to determine which components of ERAS programs have the largest impact on recovery for patients undergoing colorectal surgery. METHODS:An iERAS program was implemented in 15 academic hospitals. Data were collected prospectively. Patients were considered compliant if >75% of the preoperative, intraoperative, and postoperative predefined interventions were adhered to. Optimal recovery was defined as discharge within 5 days of surgery with no major complications, no readmission to hospital, and no mortality. Multivariable analysis was used to model the impact of compliance and technique on optimal recovery. RESULTS:Overall, 2876 patients were enrolled. Colon resections were performed in 64.7% of patients and 52.9% had a laparoscopic procedure. Only 20.1% of patients were compliant with all phases of the pathway. The poorest compliance rate was for postoperative interventions (40.3%) which was independently associated with an increase in optimal recovery (RR = 2.12, 95% CI 1.81-2.47). Compliance with ERAS interventions remained associated with improved outcomes whether surgery was performed laparoscopically (RR = 1.55, 95% CI 1.23-1.96) or open (RR = 2.29, 95% CI 1.68-3.13). However, the impact of ERAS compliance was significantly greater in the open group (P < 0.001). CONCLUSIONS:Postoperative compliance is the most difficult to achieve but is most strongly associated with optimal recovery. Although our data support that ERAS has more effect in patients undergoing open surgery, it also showed a significant impact on patients treated with a laparoscopic approach. 10.1097/SLA.0000000000002632
Factors associated with failure of Enhanced Recovery After Surgery (ERAS) in colorectal and gastric surgery. Zhang Yunpeng,Xin Yufang,Sun Peng,Cheng Daqing,Xu Ming,Chen Ji,Wang Jue,Jiang Jianling Scandinavian journal of gastroenterology The Enhanced Recovery After Surgery (ERAS) pathway is widely applied in the perioperative period of stomach and colorectal surgery, and can decrease the length of hospital stay of the patients without compromising the safety of the patients. However, some patients are removed from this pathway for various reasons. Here we found some factors that taking the patients out from the procedures. A retrospective analysis of collected data of 550 patients over a 3-year period was conducted, with 292 in the ERAS group and 258 in the conventional care group. Then various basic elements were analyzed to explore the reasons for the failure to complete the ERAS program. Total length of hospital stay after surgery was significantly shorter in the ERAS group, and a similar incidence of complication rates were observed in the two groups. In this study, the significant factors that associated with complications were advanced age (OR 2.18;  = .031), history of abdominal surgery (OR 2.03;  = .04), incomplete gastrointestinal obstruction (OR 3.42;  < .001), laparoscopic surgery (OR 0.39;  = .004) and intraoperative neostomy (OR 2.37;  = .006). We found that advanced age (>80 years old), history of abdominal surgery, gastrointestinal obstruction and stoma formation were the risk factors. We anticipated to design a risk assessment system upon the high-risk patients from the present ERAS pathway, and make a modified ERAS pathway for those patients. 10.1080/00365521.2019.1657176
Age is an independent risk factor for increased morbidity in elective colorectal cancer surgery despite an ERAS protocol. Chan Dedrick Kok Hong,Ang Jia Jun,Tan Jarrod Kah Hwee,Chia Daryl Kai Ann Langenbeck's archives of surgery INTRODUCTION:Elderly patients with colorectal cancer are high-risk surgical candidates. ERAS protocols have been developed to mitigate against these risks. We performed this study to quantify the risks which elderly patients face and then to determine independent risk factors for short-term ERAS-specific outcomes. METHODS:An analysis of a prospectively collected audit database of all patients who underwent elective colorectal cancer resection within an ERAS framework from January 2018 to December 2018 was performed. Elderly was defined in our study as age ≥ 65 years. RESULTS:There were 172 elective colorectal cancer resections performed. Ninety-seven (56.4%) were elderly. Elderly patients were at increased risk of developing post-operative complications (33.0% vs 16.0%, p = 0.011), longer time to diet (3.4 vs 2.2 days, p = 0.001), and longer hospital stay (10.9 vs 6.7 days, p = 0.007). Independent risk factors were determined for the abovementioned three outcomes. Elderly status was the only risk factor for increased complications (OR 2.61 95% CI (1.05-6.51), p = 0.040). For delayed time to soft diet, male gender (OR 6.67(1.92-20.0), p = 0.002), open approach (OR 9.06(2.26-36.30), p = 0.002), and increased operative time (OR 1.01(1.00-1.01) p = 0.014) were risk factors. Finally, elderly age (OR 5.53(1.82-16.84), p = 0.003), leucocyte count (OR 1.39(0.76-2.57), p = 0.038), open approach (OR 5.26(1.41-19.62), p = 0.013), operative time (OR 1.01(1.00-1.01), p = 0.021), and Clavien-Dindo classification (OR 7.97(1.27-49.88), p = 0.027) were risk factors for prolonged length of stay. CONCLUSION:Elderly patients are intrinsically at risk for increased complications, longer time to soft diet and longer hospital stay. ERAS protocols may need to be specifically tailored for elderly patients. 10.1007/s00423-020-01930-y
A retrospective study on efficacy of the ERAS protocol in patients undergoing surgery for Crohn disease: A propensity score analysis. Mineccia Michela,Menonna Francesca,Germani Paola,Gentile Valentina,Massucco Paolo,Rocca Rodolfo,Ferrero Alessandro Digestive and liver disease : official journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the Liver BACKGROUND:Enhanced Recovery After Surgery (ERAS) offers many benefits for patients with colorectal cancer. However, its application to patients with Crohn's disease (CD) is questioned. AIM:The aim of this propensity-matched study was to validate the results of ERAS protocol on CD patients. METHODS:Patients undergoing ileocolic resection for primary or relapsed CD from 2007 to 2018 were retrospectively analyzed and propensity-matched into two equal groups (ERAS vs standard of care). Demographic characteristics, length of stay, bowel function, oral intake, and perioperative morbidity were analyzed. RESULTS:Ninety four out of 299 patients were selected for analysis. No significant difference was observed for age, gender, American Society of Anesthesiologists score, body mass index, previous surgery and therapy, operative time and laparoscopy. The median length of stay in ERAS and non-ERAS groups was 6 and 8 days (p < 0.001). Median postoperative days of first bowel movement and solid oral intake were day 1 and day 2 p < 0,001, and day 2 and day 4.5 p < 0,001 in ERAS and non-ERAS group, respectively. No statistically differences in other postoperative outcomes were shown. CONCLUSIONS:ERAS implementation showed decreased length of stay, faster bowel function restoration and earlier solid oral intake in patients who underwent laparoscopic or open ileocolic resection for primary or relapsing CD. 10.1016/j.dld.2020.01.006
Less pain and earlier discharge after implementation of a multidisciplinary enhanced recovery after surgery (ERAS) protocol for laparoscopic sleeve gastrectomy. Jones Daniel B,Abu-Nuwar Mohamad Rassoul A,Ku Cindy M,Berk Leigh-Ann S,Trainor Linda S,Jones Stephanie B Surgical endoscopy BACKGROUND:Laparoscopic sleeve gastrectomy (LSG) may be complicated by postoperative pain, nausea, and vomiting, with consequent increases in length of stay (LOS), decreased patient satisfaction, and higher costs. While enhanced recovery after surgery (ERAS) protocols have been in circulation for many years, there is no standard ERAS protocol for bariatric surgery. METHODS:Data were collected prospectively and compared to a historical control. All patients undergoing LSG, ages 18 to 75, were included in the pathway; those with preoperative chronic opioid use were excluded from our results. Statistical analysis was performed using t-statistics and chi-squared test. Ninety patients undergoing LSG, performed by a single surgeon, were included in our ERAS group from November 26, 2018, to April 30, 2019, and were compared to a historical control of 570 patients who underwent LSG over the previous 5 years (pre-ERAS). Measured outcomes included discharge opioid prescriptions issued, hospital length of stay, 30-day readmissions, reoperations, morbidity, and mortality. RESULTS:Ten (11%) ERAS patients vs 100% of pre-ERAS patients received opioid prescriptions upon, or after, discharge (p < 0.001). The ERAS group LOS decreased to 1.36 days vs 2.40 days in the pre-ERAS group (p < 0.001). 30-day readmission rates were 0% for ERAS patients vs 3.09% for pre-ERAS patients (p = 0.149). 30-day reoperation rates were 0% for ERAS patients vs 0.54% for pre-ERAS patients (p = 1). Thirty-day morbidity rates were 3.33% (3) for ERAS patients vs 3.27% for pre-ERAS patients (p = 1); there was no 30-day mortality in either group. CONCLUSION:ERAS for LSG results in a clinical and statistically significant reduction in postoperative opioid use and LOS, without increasing 30-day readmissions, reoperations, morbidity, or mortality. 10.1007/s00464-019-07358-w
Impact of ERAS compliance on the delay between surgery and adjuvant chemotherapy in hepatobiliary and pancreatic malignancies. St-Amour Pénélope,St-Amour Pascal,Joliat Gaëtan-Romain,Eckert Aude,Labgaa Ismail,Roulin Didier,Demartines Nicolas,Melloul Emmanuel Langenbeck's archives of surgery BACKGROUND:Multidisciplinary approach with adjuvant chemotherapy is the key element to provide optimal outcomes in pancreas and liver malignancies. However, post-operative complications may increase the interval between surgery and chemotherapy with negative oncologic effects. HYPOTHESIS AND STUDY AIM:The aim of the study was to analyse whether compliance to Enhanced Recovery After Surgery (ERAS) pathway was associated with decreased interval to adjuvant chemotherapy. METHODS:Retrospective analysis of all consecutive ERAS patients with surgery for hepatobiliary or pancreatic malignancies at the University Hospital of Lausanne between 2012 and 2016. Multivariate analysis was performed to assess the impact of ERAS compliance on time to chemotherapy. RESULTS:A total of 133 patients with adjuvant chemotherapy were included (n = 44 liver and n = 89 pancreatic cancer). Median compliance to ERAS was 61% (IQR 55-67) for the study population, and median delay to chemotherapy was 49 days (IQR 39-61). Overall, compliance ≥ 67% to ERAS induced a significant reduction in the interval between surgery and chemotherapy for young patients (< 65 years old) with or without severe comorbidities (reduction of 22 and 10 days, respectively). High compliance in young ASA3 patients with liver colorectal metastases was associated with an increase of 481 days of DFS. CONCLUSIONS:ERAS compliance ≥ 67% tends to be associated with a reduction in the delay to adjuvant chemotherapy for young patients with hepatobiliary and pancreatic malignancies. More prospective studies with strict adhesion to the ERAS protocol are needed to confirm these results. 10.1007/s00423-020-01981-1
Guidelines for Perioperative Care for Pancreatoduodenectomy: Enhanced Recovery After Surgery (ERAS) Recommendations 2019. Melloul Emmanuel,Lassen Kristoffer,Roulin Didier,Grass Fabian,Perinel Julie,Adham Mustapha,Wellge Erik Björn,Kunzler Filipe,Besselink Marc G,Asbun Horacio,Scott Michael J,Dejong Cornelis H C,Vrochides Dionisos,Aloia Thomas,Izbicki Jakob R,Demartines Nicolas World journal of surgery BACKGROUND:Enhanced recovery after surgery (ERAS) pathways are now implemented worldwide with strong evidence that adhesion to such protocol reduces medical complications, costs and hospital stay. This concept has been applied for pancreatic surgery since the first published guidelines in 2012. This study presents the updated ERAS recommendations for pancreatoduodenectomy (PD) based on the best available evidence and on expert consensus. METHODS:A systematic literature search was conducted in three databases (Embase, Medline Ovid and Cochrane Library Wiley) for the 27 developed ERAS items. Quality of randomized trials was assessed using the Consolidated Standards of Reporting Trials statement checklist. The level of evidence for each item was determined using the Grading of Recommendations Assessment Development and Evaluation system. The Delphi method was used to validate the final recommendations. RESULTS:A total of 314 articles were included in the systematic review. Consensus among experts was reached after three rounds. A well-implemented ERAS protocol with good compliance is associated with a reduction in medical complications and length of hospital stay. The highest level of evidence was available for five items: avoiding hypothermia, use of wound catheters as an alternative to epidural analgesia, antimicrobial and thromboprophylaxis protocols and preoperative nutritional interventions for patients with severe weight loss (> 15%). CONCLUSIONS:The current updated ERAS recommendations for PD are based on the best available evidence and processed by the Delphi method. Prospective studies of high quality are encouraged to confirm the benefit of current updated recommendations. 10.1007/s00268-020-05462-w
Enhanced recovery after surgery for gastric cancer (ERAS-GC): optimizing patient outcome. Desiderio Jacopo,Trastulli Stefano,D'Andrea Vito,Parisi Amilcare Translational gastroenterology and hepatology Significant advances were achieved, in last decades, in the management of surgical patients with gastric cancer. This has led to the concept of enhanced recovery after surgery (ERAS) with the objective of reducing the length of hospital stay, accelerating postoperative recovery and reducing the surgical stress. The ERAS protocols have many items, including the pre-operative patient education, early mobilization and feeding starting from the first postoperative day. This review aims to highlight possible advantages on postoperative functional recovery outcomes after gastrectomy in patients undergoing an ERAS program, current lack of evidences and future perspectives. 10.21037/tgh.2019.10.04
The factors related to failure of Enhanced Recovery after Surgery (ERAS) in colon cancer surgery. Chen Jian-Sheng,Sun Si-Da,Wang Zhi-Sheng,Cai Tian-Hong,Huang Long-Kai,Sun Wen-Xing,Lin Chang-Qing,Zhou Jun-Feng,Wang Jia-Xing,He Qing-Liang Langenbeck's archives of surgery PURPOSE:Enhanced Recovery after Surgery has been proven effective for patients with gastrointestinal cancer. But radical enhanced recovery could also lead to adverse clinical outcomes. Compared with reports on the estimation of successful implementation of enhanced recovery, studies on risk factors of enhanced recovery failure are still lacking. METHODS:A retrospective analysis was carried out on 102 patients in ERAS who underwent elective colon cancer surgery. This study included 102 patients with colon cancer between 2015 and 2019, defining enhanced recovery failure as postoperative length of stay over 10 days, stay in ICU over 24 h after surgery, reoperation, death, or unplanned readmission within 30 days after surgery. Univariate and multivariate analyses were performed to explore potential risk factors of failure. RESULTS:Aged ≥ 75, open operation, number of drainage tube over 1, re-urethral catheterization, and Clavien-Dindo grade over 2 were associated with ERAS failure, according to univariate analysis. Multivariate analysis showed that age ≥ 75 [OR 7.231; P = 0.009]; open operation (OR 3.599; P = 0.021); and number of drainage tube over 1 (OR 3.202; P = 0.020) were independent risk factors for ERAS failure. CONCLUSIONS:We found age ≥ 75, open operation, and number of drainage tube over 1 are independent risk factors associated with ERAS failure after colon cancer surgery. 10.1007/s00423-020-01975-z
[The effect of perioperative ERAS pathway management on short-and long-term outcomes of gastric cancer patients]. Yang F Z,Wang H,Wang D S,Niu Z J,Li S K,Zhang J,Lü L,Chen D,Li Y,Jiang H T,Han H D,Chu H C,Cao S G,Zhou Y B Zhonghua yi xue za zhi To compare postoperative short-term outcomes and long-term prognosis between perioperative Enhanced Recovery After Surgery (ERAS) and conventional pathways protocols in gastric cancer patients. This is a single institute retrospective cohort study, all patients were pathologically proved to be gastric adenocarcinoma, underwent standard radical gastrectomy with D2 lymphadenectomy during the period of 2007-2012. Total 2124 cases were eligible to be analysed and divided into ERAS groups and Non-ERAS group according to the different perioperative pathway protocol. Propensity score matching method (in SPSS, 24.0 version, IBM Company) was used to balance the baseline characteristics. Two groups were matched in a 1∶1 ratio. There were 521 cases per group after matched. The short-term clinical outcomes (postoperative complications, length of hospital stay, blood loss, 30-day re-admission rate, etc.) and overall 5-year survival rates were compared between the two groups. The incidence of overall postoperative complications was similar between the two groups (ERAS group=18.4%, non-ERAS group=19.4%, 0.69), including anastomotic leakage, abdominal hemorrhage, etc. But the incidence of SSI, atelectasis, and thromboembolic disease in ERAS group was significant lower than that in Non-ERAS group. The number of lymph node harvested, operation time, intraoperative blood loss, postoperative hospital and cost in ERAS group were better than those in non-ERAS group. There were no significant differences in unplanned reoperation (ERAS group3.1%, non-ERAS group2.1%, 0.33), 30 day readmission rate of discharge (ERAS group6.1%, non-ERAS group5.6%, 0.69) and postoperative mortality (ERAS group0.4%, non-ERAS group0.2%, 0.56) between the two groups. The 5-year overall survival rates of non-ERAS group and ERAS group were 66.2% and 72.8% respectively (0.007). The subgroup analysis found that 5-year OS rates of stage I were 93.4% and 92.7% (0.73), these of stage Ⅱ and Ⅲ were 82.2% vs 75.2% (0.007) and 47.6% vs 35.7% (0.02) in ERAS group and non-ERAS group respectively. Perioperative ERAS pathway management is safe and feasible for patients with gastric cancer, without increasing the incidence of complications and 30-day readmission rate. This protocol can improve the prognosis of patients with gastric cancer. 10.3760/cma.j.cn112137-20190711-01325
ERas Enhances Resistance to Cisplatin-Induced Apoptosis by Suppressing Autophagy in Gastric Cancer Cell. Tian Huajian,Wang Wenjun,Meng Xiao,Wang Miaomiao,Tan Junyang,Jia Wenjuan,Li Peining,Li Jianshuang,Zhou Qinghua Frontiers in cell and developmental biology Gastric cancer (GC), a common type of malignant cancer, remains the fifth most frequently diagnosed cancer and the third leading cause of cancer-related deaths worldwide. Despite developments in the treatment of GC, the prognosis remains poor. Embryonic stem cell-expressed Ras (ERas), a novel member of the Ras protein family, has recently been identified as an oncogene involved in the tumorigenic growth of embryonic stem cells. A recent study reported that ERas is expressed in most GC cell lines and GC specimens, and it promotes tumorigenicity in GC through induction of the epithelial mesenchymal transition (EMT) and activation of the PI3K/AKT pathway. Here, we found that ERas blocked autophagy flux in BGC-823 and AGS GC cells, which may occur through activation of the AKT/mTOR signaling pathway. Moreover, ERas overexpression suppressed cisplatin-induced apoptosis, and rapamycin treatment significantly attenuated ERas-mediated cisplatin resistance in GC cells. These data suggest that ERas may be a potential therapeutic target to improve the outcomes of GC patients by regulating the autophagy process. 10.3389/fcell.2019.00375
ERAS protocol compliance impact on functional recovery in colorectal surgery. Barbero Macarena,García Javier,Alonso Isabel,Alonso Laura,San Antonio-San Román Belén,Molnar Viktoria,León Carmen,Cea Matías Cirugia espanola INTRODUCTION:Compliance to ERAS protocols is a process quality measure that is associated to better outcomes. The main objective of this study is to analyze the association between protocol compliance, surgical stress and functional recovery. The secondary objective is to identify independent factors associated to functional recovery. METHODS:A prospective observational single-centre study was performed. Patients who had scheduled colorectal surgery within an ERAS program from January 2017 to June 2018 were included. We analysed the relationship between protocol compliance percentage and surgical stress (defined by C reactive protein [CRP] blood levels on postoperative 3 day), and functional recovery (defined by the proportion of patients who meet the discharge criteria on the 5 PO day or before). Multivariate analysis was performed to asses independent factor associated to functional recovery. RESULTS:313 were included. For every additional percentage point of compliance to the protocol 3 day C reactive protein plasmatic level decreases 1,46 mg/dL and increases 7% the probability to meet the discharge criteria (p < 0.001 both). Independent factors associated to functional recovery were ASA III-IV (OR 0.26; 0.14-0.48), surgical CR-POSSUM score (OR 0.68; 0.57-0.83), early mobilization (OR 4.22; 1.43-12.4) and removal of urinary catheter (OR 3.35; 1.79-6.27), p < 0,001 each of them. CONCLUSION:Better compliance to ERAS protocol in colorectal surgery decreases surgical stress and accelerates functional recovery. 10.1016/j.ciresp.2020.05.010
Enhanced recovery versus conventional care in gastric cancer surgery: a meta-analysis of randomized and non-randomized controlled trials. Wee Ian Jun Yan,Syn Nicholas Li-Xun,Shabbir Asim,Kim Guowei,So Jimmy B Y Gastric cancer : official journal of the International Gastric Cancer Association and the Japanese Gastric Cancer Association INTRODUCTION:Enhanced recovery after surgery (ERAS) protocols have been successfully integrated into peri-operative management of different cancer surgeries such as colorectal cancer. Their value for gastric cancer surgery, however, remains uncertain. METHODS:A search for randomized and observational studies comparing ERAS versus conventional care in gastric cancer surgery was performed according to PRISMA guidelines. Random-effects meta-analyses with inverse variance weighting were conducted, and quality of included studies was assessed using the Cochrane risk-of-bias tool and Newcastle-Ottawa scale (PROSPERO: CRD42017080888). RESULTS:Twenty-three studies involving 2686 patients were included. ERAS was associated with reduced length of hospital stay (WMD-2.47 days, 95% CI - 3.06 to - 1.89, P < 0.00001), time to flatus (WMD-0.70 days, 95% CI - 1.02 to - 0.37, P < 0.0001), and hospitalization costs (WMD-USD$ 4400, 95% CI - USD$ 5580 to - USD$ 3210, P < 0.00001), with consistent results across open and laparoscopic surgery. Postoperative morbidity and 30-day mortality were similar, although a higher rate of readmission was observed in the ERAS group (RR = 1.95, 95% CI 1.03-3.67, P = 0.04). Patients in the ERAS arm had significantly attenuated C-reactive protein levels on days 3/4 and 7, interleukin-6 levels on days 1, and 3/4, and tumor necrosis factor-α levels on days 3/4 postoperatively. CONCLUSION:Compared to conventional care, ERAS reduces hospital stay, costs, surgical stress response and time to return of gut function, without increasing post-operative morbidity in gastric cancer surgery. However, precaution is necessary to reduce the increased risk of hospital readmission when adopting ERAS. 10.1007/s10120-019-00937-9
Evaluation of the application of laparoscopy in enhanced recovery after surgery (ERAS) for gastric cancer: a Chinese multicenter analysis. Annals of translational medicine BACKGROUND:Enhanced recovery after surgery (ERAS) has been successfully applied in general surgery, especially in colorectal resection. However, the effect of ERAS in gastric cancer resection in current studies are inconsistent and most of which were single center retrospective ones. Thus, our study was aimed to evaluate the application of laparoscopy in ERAS for gastric cancer based on Chinese multicenter data. METHODS:The clinical and pathological data of patients who underwent radical gastric cancer resection at three Chinese medical centers between January, 2015 and December, 2017 were retrospectively analyzed. The current application of laparoscopy in ERAS for gastric cancer was evaluated. RESULTS:A total of 1,434 patients were involved in the final analysis. The operation time was 265.7±79.1 min, blood loss was 200 [5-1,300] mL, and the number of lymph nodes dissected was 26.4±12.9. Time to first ambulation, flatus, and liquid food intake were 2.1±1.3, 4.4±2.7, and 6.1±3.6 days, respectively, and postoperative hospital stay was 9.0±1.5 days. The incidence of postoperative complications, Clavien-Dindo score ≥ II, was 10.0%, and the rate of readmission within 30 days of discharge was 1.4%. Of the patients who underwent total gastrectomy, those in the laparoscopic group had a higher number of lymph nodes retrieved than those in the open group (P<0.05), and also had earlier ambulation, oral intake and first flatus, as well as a shorter postoperative hospital stay time than the open group. There were no significant differences in intraoperative blood loss or postoperative complications between the two groups (P>0.05). Of the patients who underwent distal gastrectomy, the laparoscopic group had a lower volume of blood loss, shorter postoperative hospital stay time, and earlier ambulation, oral intake, and first flatus than the open group, and had a similar number of lymph nodes dissected compared to the open group (P>0.05). CONCLUSIONS:Laparoscopic surgery combined with ERAS can shorten the time to early ambulation, oral intake, and first flatus, and shorten the length of hospital stay. Laparoscopic surgery can achieve the same oncological outcomes as open surgery and is safe and feasible without increasing the incidence of postoperative complications. 10.21037/atm-20-2556