Fast-track surgery in gastrectomy for gastric cancer: a systematic review and meta-analysis

Purpose

Fast-track surgery aims to attenuate the surgical stress response, reduce complications, and shorten hospital stay. The goal of the present meta-analysis is to assess the safety and effectiveness of fast-track surgery in patients undergoing gastrectomy for gastric cancer compared with conventional perioperative care.

Methods

PubMed, Embase, the Cochrane Central Register of Controlled Trials, and reference lists of the identified studies were searched to identify randomized clinical trials that compared fast-track surgery with conventional perioperative care in patients undergoing gastrectomy for gastric cancer.

Results

Five studies with a total of 400 patients were included in the meta-analysis. Meta-analysis shows that postoperative hospital stay (weighted mean difference (WMD) ?1.87 days, 95 % confidence interval (CI), ?2.46 to ?1.28 days, P?<?0.00001), time to first passage of flatus (WMD ?0.71 days, 95 % CI, ?1.03 to ?0.39 days, P?<?0.0001), and hospital costs (WMD ?505.87 dollars, 95 % CI, ?649.91 to ?361.84 dollars, P?<?0.00001) were significantly reduced for fast-track surgery. No significant differences were found for readmission rates (relative risk (RR), 1.97 95 % CI, 0.37 to 10.64, P?=?0.43) and total postoperative complications (RR, 0.99 95 % CI, 0.56 to 1.76, P?=?0.97).

Conclusions

Fast-track surgery is safe and effective in gastrectomy for gastric cancer. Further randomized trials are needed to strengthen the conclusions.     

Preliminary Experience of Fast-Track Surgery Combined with Laparoscopy-Assisted Radical Distal Gastrectomy for Gastric Cancer

Objective

The aim of this study was to evaluate the safety and effectiveness of fast-track surgery combined with laparoscopy-assisted radical distal gastrectomy for gastric cancer.

Methods

Eighty-eight eligible patients were randomly assigned into four groups: (1) fast-track surgery (FTS) + laparoscopy-assisted radical distal gastrectomy (LADG), treated with LADG and FTS treatment; (2) LADG, treated with LADG and traditional treatment; (3) FTS + open distal grastectomy (ODG), treated with ODG and FTS treatment; and (4) ODG, treated with ODG and traditional treatment. The clinical parameters and serum indicators were compared.

Results

Compared with the ODG group, the other three groups had earlier first flatus and shorter postoperative hospital stay (all P?<0.01; all P?<0.05), especially in the FTS + LADG group. The level of ALB was higher in the FTS + LADG group than in the LADG group at 4 and 7 days after surgery (P?<0.05, P?<0.01). The level of CRP in the FTS + LADG group was lower than in the FTS+ODG group at 4 and 7 days after surgery (P?<0.05, P?<0.05). The FTS + ODG group had lowest medical costs.

Conclusion

Combination of FTS and LADG in gastric cancer is safe, feasible, and efficient and can improve nutritional status, lessen postoperative stress, and accelerate postoperative rehabilitation. Compared with FTS + ODG and LADG, its advantages were limited in short-term follow-up.     

Safety and Efficacy of Fast-track Surgery in Laparoscopic Distal Gastrectomy for Gastric Cancer: A Randomized Clinical Trial

Background

Fast-track surgery has been shown to enhance postoperative recovery in several surgical fields. This study aimed to evaluate the safety and efficacy of fast-track surgery in laparoscopic distal gastrectomy.

Methods

The present study was designed as a single-center, randomized, unblinded, parallel-group trial. Patients were eligible if they had gastric cancer for which laparoscopic distal gastrectomy was indicated. The fast-track surgery protocol included intensive preoperative education, a short duration of fasting, a preoperative carbohydrate load, early postoperative ambulation, early feeding, and sufficient pain control using local anesthetics perfused via a local anesthesia pump device, with limited use of opioids. The primary endpoint was the duration of possible and actual postoperative hospital stay.

Results

We randomized 47 patients into a fast-track group (n = 22) and a conventional pathway group (n = 22), with three patients withdrawn. The possible and actual postoperative hospital stays were shorter in the fast-track group than in the conventional group (4.68 ± 0.65 vs. 7.05 ± 0.65; P < 0.001 and 5.36 ± 1.46 vs. 7.95 ± 1.98; P < 0.001). The time to first flatus and pain intensity were not different between groups; however, a greater frequency of additional pain control was needed in the conventional group (3.64 ± 3.66 vs. 1.64 ± 1.33; P = 0.023). The fast-track group was superior to the conventional group in several factors of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, including: fatigue, appetite loss, financial problems, and anxiety. The complication and readmission rates were similar between groups.

Conclusions

Fast-track surgery could enhance postoperative recovery, improve immediate postoperative quality of life, and be safely applied in laparoscopic distal gastrectomy.     

Fast-track surgery decreases the incidence of postoperative delirium and other complications in elderly patients with colorectal carcinoma

Objective

This study aims to investigate the role of fast-track surgery in preventing the development of postoperative delirium and other complications in elderly patients with colorectal carcinoma.

Methods

A total of 240 elderly patients with colorectal carcinoma (aged ≥70 years) undergoing open colorectal surgery was randomly assigned into two groups, in which the patients were managed perioperatively either with traditional or fast-track approaches. The length of hospital stay (LOS) and time to pass flatus were compared. The incidence of postoperative delirium and other complications were evaluated. Serum interleukin-6 (IL-6) levels were determined before and after surgery.

Results

The LOS was significantly shorter in the fast-track surgery (FTS) group than that in the traditional group. The recovery of bowel movement (as indicated by the time to pass flatus) was faster in the FTS group. The postoperative complications including pulmonary infection, urinary infection and heart failure were significantly less frequent in the FTS group. Notably, the incidence of postoperative delirium was significantly lower in patients with the fast track therapy (4/117, 3.4 %) than with the traditional therapy (15/116, 12.9 %; p?=?0.008). The serum IL-6 levels on postoperative days 1, 2, and 3 in patients with the fast-track therapy were significantly lower than those with the traditional therapy (p?<?0.001).

Conclusions

Compared to traditional perioperative management, fast-track surgery decreases the LOS, facilitates the recovery of bowel movement, and reduces occurrence of postoperative delirium and other complications in elderly patients with colorectal carcinoma. The lower incidence of delirium is at least partly attributable to the reduced systemic inflammatory response mediated by IL-6.     

The effects of the Kampo medicine (Japanese herbal medicine) “Daikenchuto” on the surgical inflammatory response following laparoscopic colorectal resection

Purposes

The inflammatory response after surgery is associated with various postoperative complications. The aim of the present prospective study was to evaluate the effects of Daikenchuto (DKT) (a Japanese herbal medicine) on the inflammatory response in patients following laparoscopic colorectal resection.

Methods

Thirty patients who underwent laparoscopic colectomy for colorectal carcinoma were divided into two groups: a DKT intake group (D group, n?=?15) and a control group (C group, n?=?15). The D group took 7.5?g/day of DKT from the day after surgery until the 7th postoperative day. The body temperature, heart rate, WBC count, lymphocyte count, C-reactive protein (CRP) level, β-d-glucan level and Candida index were compared between the two groups.

Results

The patients’ mean age in the D group was significantly younger than that in the C group. D3 lymph node dissection was performed more often in the D group. The time until first flatus was significantly shorter in the D group (1.8?±?0.5?days) than in the C group (2.7?±?0.5?days). The CRP level was significantly lower in the D group (4.6?±?0.6?mg/dl) than in the C group (8.3?±?1.1?mg/dl) on the 3rd postoperative day.

Conclusions

Postoperative DKT administration significantly suppressed the CRP level and shortened the time until first flatus. DKT administration also significantly suppressed postoperative inflammation following surgery for colorectal cancer.     

Postoperative Nausea and Vomiting with Application of Postoperative Continuous Positive Airway Pressure after Laparoscopic Gastric Bypass

Background

This study was performed to assess postoperative nausea and vomiting (PONV) with application of postoperative continuous positive airway pressure (CPAP) for patients undergoing Roux-en-Y gastric bypass (RYGB).

Methods

The anesthesia database was searched for patients who underwent RYGB for 5 years. Three hundred fifty-six patients met the inclusive criteria. Wilcoxon two-sample rank test, Fisher’s exact test, and multivariate logistic regression were used to analyze the data and identify the potential factors. A p value less than 0.05 was considered significant.

Results

The overall incidence of the PONV (nausea or emesis or both) was 42%during the first 24 h postoperatively. Thirty-six percent and 35% in CPAP and no-CPAP groups respectively had reported nausea in postanesthesia care unit (PACU). There was no difference between groups (p?>?0.05). There was a less frequent occurrence of emesis in both groups. The incidence of emesis in PACU was 19% in CPAP group and 17% in no-CPAP group (p?>?0.05). No statistically significant differences of PONV in postoperative 24 h could be shown between the groups (p?>?0.05). The postoperative hypertension occurred more often and intravenous antihypertensive medications were required more in no-CPAP patients (p?=?0.013). More patients in no-CPAP group developed oxygenation disturbances (p?=?0.012).The mean length of PACU stay was significantly longer in this group (p?=?0.029). Reintubation and intensive care unit admission occurred more frequently in no-CPAP patients; however, the difference did not reach statistical significance.

Conclusions

There was no significantly increased risk of PONV with the use of postoperative CPAP. We recommend the routine use of postoperative CPAP for patients with obstructive sleep apnea undergoing RYGB to optimize their respiratory function.     

Effects of Modified Biliopancreatic Diversion on Glucose Tolerance of GK Rats

Background

The purpose of this study was to investigate the hypoglycemic effect of new biliopancreatic diversion and duodenal–jejunal bypass in Goto–Kakizaki rats and observe effects of the new surgical procedure on the glucose tolerance of GK rats.

Methods

Twenty-four 10-week-old rats (SPF grade) were randomly divided into groups A, B, and C, each with eight rats. Group A underwent duodenal–jejunal bypass, group B underwent modified biliopancreatic diversion, and group C underwent a sham operation. Median rat body weight, fasting blood glucose, OGTT, and blood lipids were measured in fasting 1 week before surgery and 1, 2, 4, and 8 weeks after surgery. Changes in gastric inhibitory polypeptide, glucagon P-like peptide-1, and insulin levels were measured by ELISA 1 week before surgery and 8 weeks after surgery.

Results

Rats’ mean body weight in groups A and B decreased significantly from 368.025?±?11.726 and 373.100?±?9.859 g preoperatively to 345.750?±?11.403 and 343.260?±?12.399 g at the early postoperative stage (P?<?0.05), and with statistically significant differences compared to the weight of rats in group C (P?<?0.05). Comparisons between fasting blood glucose before surgery and 8 weeks after surgery revealed no significant differences between all three groups (P?>?0.05). Glucose tolerance in groups A and B decreased from preoperative 21.175?±?3.684 and 20.820?±?1.671 mmol/L to postoperative 8.950?±?0.580 and 10.500?±?1.509 mmol/L, and both were better than that of group C (P?<?0.001).

Conclusions

Both new biliopancreatic diversion and duodenal–jejunal bypass improve glucose tolerance of Goto–Kakizaki rats.     

Braun Gastrointestinal Bypass Surgery Exerts Similar Hypoglycemic Effects, with Minimal Operation Time and Earlier Functional Recovery, than Roux-en-Y Bypass in Type 2 Diabetic Rats

Background

Despite the beneficial hypoglycemic and potentially curative effects in type 2 diabetes, large stomach volume deficits caused by Roux-en-Y gastrointestinal bypass (RYGB) surgery increase complications. Hypoglycemic effects of Braun surgery and RYGB surgery, both modified to maximally preserve stomach volume, were compared in rat type 2 diabetes models.

Methods

Three-month-old, male Goto-Kakizaki (GK) rats (n?=?40) were randomly divided into equal groups and not treated (control) or treated with sham surgery (sham group), modified stomach-preserving Braun gastrointestinal bypass (Braun group), or modified RYGB (RYGB group). Pre- and postoperative body weight and water intake were recorded, along with operative and defecation times. Fasting blood glucose at 12 h, and blood glucose 180 min after intragastric glucose administration, were measured at weeks 1, 2, 3, 4, 10, and 11 along with glycosylated hemoglobin (preoperatively, week 11).

Results

Statistically similar (P?>?0.05) increased body weight and decreased water intake, fasting blood glucose, blood glucose after intragastric glucose administration, and glycosylated hemoglobin were observed in Braun and RYGB groups compared with control and sham groups (P?<?0.05). By week 1, RYGB and Braun groups exhibited sustained reductions in fasting blood glucose from 13.0?±?4.1 to 6.9?±?1.4 mmol/L and 12.4?±?4.4 to 7.3?±?0.9 mmol/L, respectively (P?<?0.05); mean operative times were 139.1?±?4.9 and 81.6?±?6.4 min, respectively; and postoperative defecation times were 74.3?±?3.1 and 29.4?±?4.1 h, respectively (P?<?0.05).

Conclusions

Stomach volume-preserving Braun gastrointestinal bypass surgery was faster and produced hypoglycemic effects similar to RYGB bypass surgery, potentially minimizing metabolic disruption.     

Comparison of One-Stage Managements of Obstructing Left-Sided Colon and Rectal Cancer: Stent-Laparoscopic Approach vs. Intraoperative Colonic Lavage

Purpose

We evaluated the operative outcomes of laparoscopic surgery following self-expandable metallic stent compared to one-stage emergency surgical treatment.

Methods

From April 1996 to October 2007, 95 consecutive patients with left-sided malignant colorectal obstruction were enrolled. Twenty-five patients were assigned to the preoperative stenting and elective laparoscopic surgical treatment group (SLAP) and 70 to the emergency open surgery with intraoperative colon lavage group (OLAV).

Results

Among the 25 patients in the SLAP group, a primary anastomosis was possible in all patients and a diverting stoma was needed in one patient. The operative time was shorter in the SLAP group (198.53 vs. 262.17 min, P?=?0.002). Tumor size, number of retrieved lymph nodes, and pathological stage were similar in both groups. The rate of anastomotic failure was similar and postoperative complications occurred less in the SLAP group (5.9% vs. 31.4%, P?=?0.034). The passage of flatus and oral intake were resumed earlier in the SLAP group (2.88 vs. 3.68 days, P?=?0.046 and 5.18 vs. 6.65 days, P?<?0.001, respectively). The postoperative hospital stay was shorter in the SLAP group (10 vs. 15.4 days, P?=?0.013).

Conclusions

In patients with left-sided malignant colon and rectal obstruction, laparoscopic surgery after SEMS could be safely performed with successful early postoperative outcomes.     

C-reactive Protein as a Predictor of Postoperative Infective Complications after Curative Resection in Patients with Colorectal Cancer

Background

Infective complications particularly in the form of surgical site infections including anastomotic leak represent a serious morbidity after colorectal cancer surgery. Systemic inflammation markers, including C-reactive protein (CRP) and white cell count, have been reported to provide early detection. However, their relative predictive value is unclear. The aim of the present study was to examine the diagnostic accuracy of serial postoperative WCC, albumin and CRP in detecting infective complications.

Methods

White cell count, albumin and CRP were measured postoperatively for 7?days in 454 consecutive patients undergoing surgery for colorectal cancer. All postoperative complications were recorded. The diagnostic accuracy of the white cell count, albumin and CRP values were analyzed by receiver operating characteristics curve analysis with surgical site infective complications as outcome measures.

Results

One hundred four patients (23?%) developed infective complications, and 26 of them developed an anastomotic leak. CRP was most sensitive to the development of an infective complication, surgical site or at a remote site. On postoperative day 3 CRP the area under the receiver operating characteristic curve was 0.80 (p?<?0.001) and the optimal cutoff value was 170?mg/L. This threshold was also associated with an increase in the length of hospital stay (p?<?0.001), 30?day mortality (p?<?0.05) and 12?month mortality (p?<?0.10).

Conclusions

Postoperative CRP measurement on day 3 postoperatively is clinically useful in predicting surgical site infective complications, including an anastomotic leak, in patients undergoing surgery for colorectal cancer.     

Gum chewing enhances early recovery of bowel function following transperitoneal abdominal aortic surgery

Background and purpose

Postoperative bowel dysfunction is still a major unsolved problem following transperitoneal abdominal aortic surgery. We conducted this study to establish if gum chewing during the postoperative period promotes recovery of bowel function following abdominal aortic surgery.

Methods

The subjects were 44 patients who underwent elective abdominal aortic surgery. The patients were allocated to a control group (n?=?21), who received standard postoperative care, or a “gum group” (n?=?23), who received standard postoperative care and were also given gum to chew three times a day from postoperative day (POD) 0–5.

Results

The patient characteristics, intraoperative, and postoperative care were equivalent in both groups. Flatus was passed on POD 1.49 in the gum group and on POD 2.35 in the control group (P?=?.0004) and the time to oral intake was 3.09?days in the gum group and 3.86?days in the control group (P?=?.023). The number of days to full mobilization in the hospital room was 3.35 versus 5.59 for the gum and control groups, respectively (P?Conclusions Gum chewing enhances early recovery of bowel function following transperitoneal abdominal aortic surgery. Moreover, it is a physiologically sound, safe, and an inexpensive part of the postoperative care.     

Value of Geriatric Frailty and Nutritional Status Assessment in Predicting Postoperative Mortality in Gastric Cancer Surgery

Objectives

This study seeks to evaluate assessment of geriatric frailty and nutritional status in predicting postoperative mortality in gastric cancer surgery.

Methods

Preoperatively, patients operated for gastric adenocarcinoma underwent assessment of Groningen Frailty Indicator (GFI) and Short Nutritional Assessment Questionnaire (SNAQ). We studied retrospectively whether these scores were associated with in-hospital mortality.

Results

From 2005 to September 2012 180 patients underwent surgery with an overall mortality of 8.3 %. Patients with a GFI?≥?3 (n?=?30, 24 %) had a mortality rate of 23.3 % versus 5.2 % in the lower GFI group (OR 4.0, 95%CI 1.1–14.1, P?=?0.03). For patients who underwent surgery with curative intent (n?=?125), this was 27.3 % for patients with GFI?≥?3 (n?=?22, 18 %) versus 5.7 % with GFI?<?3 (OR 4.6, 95 % CI 1.0–20.9, P?=?0.05). SNAQ?≥?1 (n?=?98, 61 %) was associated with a mortality rate of 13.3 % versus 3.2 % in patients with SNAQ?=?0 (OR 5.1, 95 % CI 1.1–23.8, P?=?0.04). Given odds ratios are corrected in multivariate analyses for age, neoadjuvant chemotherapy, type of surgery, tumor stage and ASA classification.

Conclusions

This study shows a significant relationship between gastric cancer surgical mortality and geriatric frailty as well as nutritional status using a simple questionnaire. This may have implications in preoperative decision making in selecting patients who optimally benefit from surgery.     

Robot-assisted total gastrectomy is comparable with laparoscopically assisted total gastrectomy for early gastric cancer

Background

Laparoscopically assisted total gastrectomy (LATG) is technically difficult. Robot surgery has theoretical advantages such as increased degrees of freedom of instruments and a three-dimensional view. The current study aimed to determine whether a robot-assisted total gastrectomy (RATG) has a real benefit over LATG in terms of surgical and oncologic outcomes.

Methods

A single-center case–control study was conducted. The study included 36 patients who underwent RATG and 65 patients who underwent LATG at the National Cancer Center in Korea between February 2009 and May 2011. No patients were excluded from the analysis within the study period. Clinicopathologic data, operative data, postoperative morbidity, and pathologic data were analyzed by Student’s t-tests and Chi-square tests, as indicated.

Results

The mean age of the patients was 53.9?±?11.7?years in the RATG group and 56.9?±?12.3?years in the LATG group (P?=?0.236). The mean BMI was 23.2?±?2.5?kg/m² in the RATG group and 23.6?±?3.4?kg/m² in the LATG group (P?=?0.494). The mean postoperative hospital stay was 8.8?±?3.3?days in the RATG group and 10.3?±?10.8?days in the LATG group (P?=?0.416). The mean operative time was 305.8?±?115.8?min in the RATG group and 210.2?±?57.7?min in the LATG group (P?P?=?0.209). Postoperative complications were experienced by 6 patients (16.7%) in the RATG group and 10 patients (15.4%) in the LATG group (P?=?0.866).

Conclusion

Despite early experiences, RATG was shown to be comparable with LATG in terms of surgical and oncologic outcomes. However, no apparent benefit is associated with RATG to date.     

Different Features of Complications with Billroth-I and Roux-en-Y Reconstruction After Laparoscopy-Assisted Distal Gastrectomy

Background

This study investigated differences in the features of postoperative complications between Billroth-I (B-I) and Roux-en-Y (R-Y) reconstructions after laparoscopy-assisted distal gastrectomy (LADG) for early gastric cancer.

Material and methods

The study included 424 patients who underwent LADG for cT1, cN0 gastric cancer. Patient characteristics, surgical outcomes, postoperative complications including severity assessment using the Clavien?CDindo classification, and risk factors related to postoperative complications were analyzed.

Results

B-I and R-Y were performed in 329 and 95 patients, respectively. Total time in hospital was longer in R-Y (15.2?±?10.5 days) than in B-I (12.8?±?6.4 days; P?=?0.034). The incidence of severe complications was higher in R-Y (13.7%) than in B-I (5.2%; P?=?0.009). Three cases of internal hernia and three cases of duodenal stump leakage were observed in R-Y. Univariate analysis revealed the method of reconstruction was a risk factor for severe postoperative complications after LADG (P?=?0.006).

Conclusions

The features of postoperative complications are quite different between B-I and R-Y after LADG. Complications after R-Y were more severe than those after B-I. To avoid these severe complications in R-Y, it is necessary to understand these different features.     

Renal function and adaptive changes in patients after radical or partial nephrectomy

Introduction

Renal function after renal surgery depends on the volume of renal parenchyma loss and improves in the postoperative period. However, the knowledge on kidney function after radical (RN) and partial (PN) nephrectomy is still insufficient. The aim of this study is to analyze the global renal function and compensatory hyperfunction of the non-operated kidney in patients with renal cancer after RN or PN.

Methods

Fifty-one patients of mean age 62.2?years with renal cancer were included. Thirty-three RN and eighteen PN were performed. We measured creatinine serum concentrations, and we estimated glomerular filtration rate (eGFR) preoperatively and postoperatively at two time intervals: 3 and 12?months after surgery. Additionally, we assessed effective renal plasma flow (ERPF) in dynamic scintigraphy preoperatively and 12?months after surgery.

Result

At the baseline, all mean measured values were comparable in RN and PN groups (P?>?0.05). Three?months after surgery, creatinine level increased in both groups, more remarkably in RN group (128?mmol/l vs. 95?mmol/l; P?2 vs. 70?ml/min/1.73?m²; P?P?>?0.05). The mean ERPF of the operated kidney in PN group decreased by 24.7% (149?ml/min).

Conclusion

The deterioration of renal function after partial nephrectomy is nearly insignificant clinically. In 1-year postoperative observation, the renal function does not improve. This causes potential compensatory mechanisms to be insufficient.     

Evaluation of Pre- and Postoperative Physical Activity Participation in Laparoscopic Gastric Banding Patients

Background

Weight loss outcomes following laparoscopic adjustable gastric banding (LAGB) are widely variable, and physical activity (PA) participation improves these results. The purpose of this study was to retrospectively describe PA behaviors before and after LAGB and to evaluate the impact of PA on weight loss outcomes.

Methods

Participants were 172 individuals (145 females, mean age 43.3?±?12.0 years, mean body mass index [BMI] 43.8?±?5.1 kg/m²) who underwent LAGB at a university medical center. Height, weight, presence of comorbidities, and PA participation were assessed prior to and 3, 6, and 12 months after surgery. Those who reported engaging in ≥150 min of weekly moderate-to-vigorous PA (MVPA) were considered active.

Results

Less than 40 % of participants were active prior to surgery, while 31 % of those who were inactive before surgery became active at 6 months of follow-up. Unlike previous reports on gastric bypass patients, there was no statistically significant (p?>?0.05) relationship between postoperative PA status and weight loss outcomes at 3, 6, or 12 months in LAGB patients. Interestingly, participants who reported ≥150 min of MVPA prior to surgery achieved approximately 10 % greater excess weight loss (p?2 greater decrease in BMI (p?Conclusions In our sample, higher levels of preoperative PA participation were associated with improved weight loss outcomes following LAGB. We posit that higher preoperative volumes are indicative of habitual exercise and that those who report being active prior to surgery are likely to maintain these behaviors throughout follow-up.     

Pathway-controlled fast-track rehabilitation after total knee arthroplasty: a randomized prospective clinical study evaluating the recovery pattern, drug consumption, and length of stay

Purpose

To investigate fast-track rehabilitation concept in terms of a measurable effect on the early recovery after total knee arthroplasty (TKA).

Methods

This was an open, randomized, prospective clinical study, comparing the fast-track rehabilitation—a pathway-controlled early recovery program (Joint Care^?)—with standard postoperative rehabilitation care, after TKA. Overall, 147 patients had TKA (N?=?74 fast-track rehabilitation, N?=?73 standard rehabilitation). The fast-track rehabilitation patients received a group therapy, early mobilization (same day as surgery) and 1:1 physiotherapy (2?h/day). Patient monitoring occurred over 3?months (1 pre- and 4 post-operative visits). The standard rehabilitation group received individual postoperative care according to the existing protocol, with 1:1 physiotherapy (1?h/day). The cumulative American Knee Society Score (AKSS) was the primary evaluation variable, used to detect changes in joint function and perception of pain. The secondary evaluation variables were WOMAC index score, analgesic drug consumption, length of stay (LOS), and safety.

Results

After TKA, patients in the fast-track rehabilitation group showed enhanced recovery compared with the standard rehabilitation group, as based on the differences between the groups for the cumulative AKSS (p?=?0.0003), WOMAC index score (<0.0001), reduced intake of concomitant analgesic drugs, reduced LOS (6.75 vs. 13.20?days, p?Conclusion For TKA, implementation of pathway-controlled fast-track rehabilitation is achievable and beneficial as based on the AKSS and WOMAC score, reduced intake of analgesic drugs, and reduced LOS.     

Laparoscopic surgery for palliative resection of the primary tumor in incurable stage IV colorectal cancer

Background

The purpose of the study was to evaluate the feasibility and efficacy of laparoscopic palliative resection in patients with incurable stage IV colorectal cancer.

Methods

We reviewed 100 patients with incurable stage IV colorectal cancer who underwent palliative resection of the primary tumor between 2002 and 2009 at National Cancer Center Hospital East (NCCHE). Outcomes and postoperative course were compared between patients who underwent open and laparoscopic surgery.

Results

Of the 100 patients, 22 were treated with a laparoscopic procedure and 78 underwent an open surgical procedure. There was no difference in the preoperative characteristics of the two groups. In the laparoscopic group, the mean operation time was significantly longer (177 vs. 148?min, p?=?0.007) and the amount of blood loss was significantly lower (166 vs. 361?ml, p?=?0.002). Postoperative complications occurred in 5 patients (22.7?%) after laparoscopic surgery and in 21 patients (26.9?%) after open surgery, with no significant difference between the two groups. Time to flatus, time to start of food intake, and hospital stay were all shorter after laparoscopic surgery (3.0 vs. 3.8?days, p?=?0.003; 3.6 vs. 5.0?days, p?<?0.001; and 12.0 vs. 15.0?days, p?=?0.005; respectively). Significantly more patients in the laparoscopic group had >15?% lymphocytes on postoperative day 7 (p?=?0.049). Overall survival rates were 73.7 and 75.5?% at 1?year after laparoscopic surgery and open surgery, respectively (p?=?0.344).

Conclusions

A laparoscopic procedure should be considered for palliative resection of the primary tumor for incurable stage IV colorectal cancer, because the results of this study indicate that the procedure is safe and effective.     

Buprenorphine added to levobupivacaine enhances postoperative analgesia of middle interscalene brachial plexus block

Purpose

The aim of this study was to assess whether addition of epineural buprenorphine prolonged postoperative analgesia of middle interscalene brachial plexus block (MIB) with levobupivacaine.

Methods

One hundred and fifty consenting adult patients, scheduled for shoulder arthroscopic surgery for a rotator cuff tear under MIB with 29.5?ml of 0.75?% levobupivacaine, were randomized to receive additionally either saline or intramuscular buprenorphine 0.15?mg or epineural buprenorphine 0.15?mg. Onset of sensory and motor blocks, duration of postoperative analgesia, and consumption of postoperative analgesics were compared among the groups.

Results

There were significant (P?<?0.05) differences in the onset and the duration of the sensory block and in the duration of postoperative analgesia. Duration of both sensory block and postoperative analgesia was longer (P?<?0.05) in patients who had received epineural buprenorphine (856.1?±?215.2 and 1,049.7?±?242.2?min) than in patients who had received intramuscular buprenorphine (693.6?±?143.4 and 820.3?±?335.3?min) or saline (488.3?±?137.6 and 637.5?±?72.1?min). Requirement of postoperative rescue analgesics was lower in the epineural buprenorphine group than in the other two groups. Few complications occurred from MIB (<1?%) and none from buprenorphine.

Conclusions

Epineural buprenorphine prolonged postoperative analgesia of MIB more effectively than intramuscular buprenorphine, which suggests that buprenorphine acts at a peripheral nervous system site of action.     

Intraoperative Nefopam Reduces Acute Postoperative Pain after Laparoscopic Gastrectomy: a Prospective,Randomized Study

Background

We assessed whether intraoperative nefopam would reduce opioid consumption and relieve postoperative pain in patients undergoing laparoscopic gastrectomy.

Methods

The 60 enrolled patients were randomly assigned to the control (n?=?32) or nefopam (n?=?28) group. All patients were blinded to their group assignment. We administered 100 ml of normal saline only (control group) or 20 mg of nefopam mixed in 100 ml normal saline (nefopam group) after anesthesia induction and at the end of surgery. The cumulative amount of fentanyl via intravenous patient-controlled analgesia (PCA), incidence of rescue analgesic medication, and numerical rating scale (NRS) for postoperative pain were evaluated along with the total remifentanil consumption.

Results

The mean infusion rate of remifentanil was significantly lower in the nefopam group (0.08?±?0.05 μg/kg/min) than in the control group (0.13?±?0.06 μg/kg/min) (P?<?0.001). Patients in the nefopam group required less fentanyl via intravenous PCA than those in the control group during the first 6 h after surgery (323.8?±?119.3 μg vs. 421.2?±?151.6 μg, P?=?0.009). Additionally, fewer patients in the nefopam group than in the control group received a rescue analgesic during the initial 6 h postoperatively (78.6 vs. 96.9%, P?=?0.028). The NRS measured while patients were in the post-anesthetic care unit was significantly lower in the nefopam group than in the control group (3.8?±?1.1 vs. 4.8?±?1.4, P?=?0.012). The subsequent NRS obtained after patients had been transferred to the general ward was comparable between the two groups during the following postoperative period.

Conclusions

Intraoperative nefopam decreased postoperative pain and opioid consumption in the acute postoperative period after laparoscopic gastrectomy. Hence, nefopam may be considered as a component of multimodal analgesia after laparoscopic gastrectomy.