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

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

2. Content Introduction ERAS society Structures of fast tract surgery Consensus guideline for enhanced recovery after gastrectomy Items specific to Upper gastrointestinal surgery Conclusion 2 2

3. 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 3

4. Gastric cancer Surgery plays an important part in cure gastric cancer ERAS / FTS program - maintain physiological function, facilitate postop recovery

5. 5 5

6. Literature review between September 2012 & April 2013 Recommendations based on reports published between 1985 & 2013

7. Fast Tract Surgery Purpose: Accelerate recovery from surgery in a cost effective manner 7 7

8. 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 8 8

9. ERAS Society recommendations for gastrectomy -Specific to gastrectomy -General abdominal surgery items 9

10. Procedure specific items

11. General upper abdominal surgery items

12. General upper abdominal surgery items

13. Items specific for gastrectomy 1. Preoperative carbohydrate therapy 2. Early removal of Nasogastric / Nasojejunal tube 3. Early oral feeding 13 13

14. 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 14

15. 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; 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 15

16. 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 13 13

17. Is Nasogastric or Nasojejunal Decompression Necessary after Gastrectomy? A Prospective Randomized TrialNicolas Carre`re, MD, Patrick Seulin, MD, Charles Henri Julio, MD, Eric Bloom, MD,Jean-Luc Gouzi, MD, Bernard Prade`re, MDDepartment of Gastrointestinal Surgery (Pr Prade`re), Purpan University Hospital, CHU de Toulouse, Place du Dr Baylac, 31059 Toulouse Cedex, FranceWorld 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) -Assessed on gastrointestinal function, postoperative course and complications Result: No significant differences in postoperative mortality & morbidity Nasogastric tube: Delay passage of flatus & start of oral intake Longer length of hospital 14

18. 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 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. 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. 16 16

19. In patient underwent gastrectomy, nasogastric tube decompression is not necessary and it does not improve the postop outcome

20. Is early oral feeding after gastrectomy feasible and safe? 18 18

21. 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 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. 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. 19

22. 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 20

23. Early oral feeding is recommended after gastrectomy

24. 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

26. Q&A