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      Clinical Pathways for Oncological Gastrectomy: Are They a Suitable Instrument for Process Standardization to Improve Process and Outcome Quality for Patients Undergoing Gastrectomy? A Retrospective Cohort Study

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          Abstract

          (1) Background: Oncological gastrectomy requires complex multidisciplinary management. Clinical pathways (CPs) can potentially facilitate this task, but evidence related to their use in managing oncological gastrectomy is limited. This study evaluated the effect of a CP for oncological gastrectomy on process and outcome quality. (2) Methods: Consecutive patients undergoing oncological gastrectomy before ( n = 64) or after ( n = 62) the introduction of a CP were evaluated. Assessed parameters included catheter and drain management, postoperative mobilization, resumption of diet and length of stay. Morbidity, mortality, reoperation and readmission rates were used as indicators of outcome quality. (3) Results: Enteral nutrition was initiated significantly earlier after CP implementation (5.0 vs. 7.0 days, p < 0.0001). Readmission was more frequent before CP implementation (7.8% vs. 0.0%, p = 0.05). Incentive spirometer usage increased following CP implementation (100% vs. 90.6%, p = 0.11). Mortality, morbidity and reoperation rates remained unchanged. (4) Conclusions: After implementation of an oncological gastrectomy CP, process quality improved, while indicators of outcome quality such as mortality and reoperation rates remained unchanged. CPs are a promising tool to standardize perioperative care for oncological gastrectomy.

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          7th edition of the AJCC cancer staging manual: stomach.

          Kay M. Washington (2010)
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            Relevant prognostic factors in gastric cancer: ten-year results of the German Gastric Cancer Study.

            J Siewert, K Böttcher, H Stein … (1998)
            In 1986 a prospective multicenter observation trial in patients with resected gastric cancer was initiated in Germany. An analysis of prognostic factors based on the 10-year survival data is now presented. A total of 1654 patients treated for gastric cancer between 1986 and 1989 at 19 centers in Germany and Austria were included. The resected specimen were evaluated histopathologically according to a standardized protocol. The extent of lymphadenectomy was classified after surgery based on the number of removed lymph nodes on histopathologic assessment (25 or fewer removed nodes, D1 or standard lymphadenectomy; >25 removed nodes, D2 or extended lymphadenectomy). Endpoint of the study was death. Follow-up is complete for 97% of the included patients (median follow-up of the surviving patients is 8.4 years). Prognostic factors were assessed by multivariate analysis. A complete macroscopic and microscopic tumor resection (R0 resection according to the UICC 1997) could be achieved in 1182 of the 1654 patients (71.5%). The calculated 10-year survival rate in the entire patient population was 26.3% +/- 4.7%; it was 36.1% +/- 1.6% after an R0 resection. In the total patient population there was an independent prognostic effect of the ratio between invaded and removed lymph nodes, the residual tumor (R) category, the pT category, the presence of postsurgical complications, and the presence of distant metastases. Multivariate analysis in the subgroup of patients who had a UICC R0 resection confirmed the nodal status, the pT category, and the presence of postsurgical complications as the major independent prognostic factors. The extent of lymph node dissection had a significant and independent effect on the 10-year survival rate in patients with stage II tumors. This effect was present in the subgroups with (pT2N1) and without (pT3N0) lymph node metastases on standard histopathologic assessment. The beneficial effect of extended lymph node dissection for stage II tumors persisted when patients with insufficient lymph node dissection (<15 nodes) were excluded from the analysis. There was no difference in the postsurgical morbidity and mortality rates between patients with standard and extended lymph node dissection. Lymph node ratio and lymph node status are the most important prognostic factors in patients with resected gastric cancer. In experienced centers, extended lymph node dissection does not increase the mortality or morbidity rate of resection for gastric cancer but markedly improves long-term survival in patients with stage II tumors. This effect appears to be independent of the phenomenon of stage migration.
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              Strategies to reduce postoperative pulmonary complications after noncardiothoracic surgery: systematic review for the American College of Physicians.

              John Cornell, Gerald Smetana, Valerie A. Lawrence … (2006)
              Postoperative pulmonary complications are as frequent and clinically important as cardiac complications in terms of morbidity, mortality, and length of stay. However, there has been much less research and no previous systematic reviews of the evidence of interventions to prevent pulmonary complications. To systematically review the literature on interventions to prevent postoperative pulmonary complications after noncardiothoracic surgery. MEDLINE English-language literature search, 1 January 1980 through 30 June 2005, plus bibliographies of retrieved publications. Randomized, controlled trials (RCTs); systematic reviews; or meta-analyses that met predefined inclusion criteria. Using standardized forms, the authors abstracted data on study methods, quality, intervention and control groups, patient characteristics, surgery, postoperative pulmonary complications, and adverse events. The authors qualitatively synthesized, without meta-analysis, evidence from eligible studies. Good evidence (2 systematic reviews, 5 additional RCTs) indicates that lung expansion interventions (for example, incentive spirometry, deep breathing exercises, and continuous positive airway pressure) reduce pulmonary risk. Fair evidence suggests that selective, rather than routine, use of nasogastric tubes after abdominal surgery (2 meta-analyses) and short-acting rather than long-acting intraoperative neuromuscular blocking agents (1 RCT) reduce risk. The evidence is conflicting or insufficient for preoperative smoking cessation (1 RCT), epidural anesthesia (2 meta-analyses), epidural analgesia (6 RCTs, 1 meta-analysis), and laparoscopic (vs. open) operations (1 systematic review, 1 meta-analysis, 2 additional RCTs), although laparoscopic operations reduce pain and pulmonary compromise as measured by spirometry. While malnutrition is associated with increased pulmonary risk, routine total enteral or parenteral nutrition does not reduce risk (1 meta-analysis, 3 additional RCTs). Enteral formulations designed to improve immune status (immunonutrition) may prevent postoperative pneumonia (1 meta-analysis, 1 additional RCT). The overall quality of the literature was fair: Ten of 20 RCTs and 6 of 11 systematic reviews were good quality. Few interventions have been shown to clearly or possibly reduce postoperative pulmonary complications.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Cancers (Basel)
                Journal ID (iso-abbrev): Cancers (Basel)
                Journal ID (publisher-id): cancers
                Title: Cancers
                Publisher: MDPI
                ISSN (Electronic): 2072-6694
                Publication date (Electronic): 13 February 2020
                Publication date Collection: February 2020
                Volume: 12
                Issue: 2
                Electronic Location Identifier: 434
                Affiliations
                [1 ]Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; patrick.teoule@ 123456umm.de (P.T.); emrullah.birgin@ 123456umm.de (E.B.); st.post@ 123456icloud.com (S.P.); nuh.rahbari@ 123456umm.de (N.N.R.); christoph.reissfelder@ 123456umm.de (C.R.)
                [2 ]Department of General and Visceral Surgery, Städtisches Klinikum Karlsruhe, Moltkestr.90, 76133 Karlsruhe, Germany; christina.mertens@ 123456klinikum-karlsruhe.de
                [3 ]Department of General, Visceral, Vascular, and Thoracic Surgery, Klinikum Frankfurt Höchst, Gotenstraße 6-8, 65929 Frankfurt, Germany; matthias.schwarzbach@ 123456klinikumfrankfurt.de
                [4 ]Department of Visceral, Vascular and Endocrine Surgery, University Hospital Halle (Saale), Ernst-Grube-Str.40, 06120 Halle (Saale), Germany
                Author notes
                [* ]Correspondence: ulrich.ronellenfitsch@ 123456uk-halle.de ; Tel.: +49-345-557-2314; Fax: +49-345-557-2551
                Author information
                https://orcid.org/0000-0003-2280-0271
                https://orcid.org/0000-0002-0338-3727
                https://orcid.org/0000-0003-1107-813X
                Article
                Publisher ID: cancers-12-00434
                DOI: 10.3390/cancers12020434
                PMC ID: 7073178
                PubMed ID: 32069805
                SO-VID: bcfc1782-f75b-4ec4-af46-0d5ac72873f1
                Copyright © © 2020 by the authors.
                License:

                Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license ( http://creativecommons.org/licenses/by/4.0/).

                History
                Date received : 07 January 2020
                Date accepted : 12 February 2020
                Categories
                Subject: Article

                Keywords: clinical pathways,gastric surgery,oncological gastrectomy,quality of care,outcomes,standardization
                Data availability:
                Keywords: clinical pathways, gastric surgery, oncological gastrectomy, quality of care, outcomes, standardization

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