Journal of Gastric Cancer

The Korean Gastric Cancer Association (대한위암학회)
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Is a Fast-track Critical Pathway Possible in Gastric Cancer Surgery?

위암 수술 후 조기회복을 위한 임상진료 지침서의 활용이 가능한가?

  • Yi, Jeong-Min (Department of Surgery, The Catholic University of Korea College of Medicine) ;
  • Hur, Hoon (Department of Surgery, The Catholic University of Korea College of Medicine) ;
  • Kim, Sung-Keun (Department of Surgery, The Catholic University of Korea College of Medicine) ;
  • Song, Kyo-Young (Department of Surgery, The Catholic University of Korea College of Medicine) ;
  • Chin, Hyung-Min (Department of Surgery, The Catholic University of Korea College of Medicine) ;
  • Kim, Wook (Department of Surgery, The Catholic University of Korea College of Medicine) ;
  • Park, Cho-Hyun (Department of Surgery, The Catholic University of Korea College of Medicine) ;
  • Park, Seung-Man (Department of Surgery, The Catholic University of Korea College of Medicine) ;
  • Lim, Keun-Woo (Department of Surgery, The Catholic University of Korea College of Medicine) ;
  • Jeon, Hae-Myung (Department of Surgery, The Catholic University of Korea College of Medicine)
  • 이정민 (가톨릭대학교 의과대학 외과학교실) ;
  • 허훈 (가톨릭대학교 의과대학 외과학교실) ;
  • 김성근 (가톨릭대학교 의과대학 외과학교실) ;
  • 송교영 (가톨릭대학교 의과대학 외과학교실) ;
  • 진형민 (가톨릭대학교 의과대학 외과학교실) ;
  • 김욱 (가톨릭대학교 의과대학 외과학교실) ;
  • 박조현 (가톨릭대학교 의과대학 외과학교실) ;
  • 박승만 (가톨릭대학교 의과대학 외과학교실) ;
  • 임근우 (가톨릭대학교 의과대학 외과학교실) ;
  • 전해명 (가톨릭대학교 의과대학 외과학교실)
  • Received : 2008.12.11
  • Accepted : 2009.03.25
  • Published : 2009.03.31
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Abstract

Purpose: The postoperative hospital stay after gastric cancer surgery is usually 8 to 14 days. The main reason for a prolonged hospital stay may be the 3 to 4 day period of postoperative starvation. The aim of this study is to investigate the feasibility of a critical pathway for early recovery after gastric cancer surgery, and this pathway included early postoperative feeding. Materials and Methods: One hundred three consecutive patients who underwent gastric resection and reconstruction for gastric cancer from October 2007 to June 2008 at St. Mary's Hospital were prospectively enrolled in a fast-track critical pathway. The pathway included minimal preoperative procedures, optimal pain relief, proper fluid administration, early mobilization and early enteral nutrition at postoperative 1 day. The exclusion criteria were determined preoperatively, intraoperatively and postoperatively. Results: Of the 103 patients, 19 patients were excluded for preoperative (5), intraoperative (7) and postoperative (7) reasons. Eighty-four patients (81.6%) were included in the fast-track critical pathway. Sixty-eight (88.6%) of 84 patients were discharged at the planned 8 day after surgery during the initial period of the study, and the postoperative hospital stay was shortened up to 6 days during the more recent period. Postoperative complications occurred in 22 patients (26.2%), and these were gastrointestinal track-related complications in 6 cases (3 cases of ileus, 1 case of stasis and 2 cases of leakage) and infection-related complications in 8 cases. There was no statistical difference in the incidence of morbidity according to the clinic-operative features that included age, gender, stomach resection and lymphadenectomy. Conclusion: The fast-track critical pathway with using the available exclusion criteria was a valid option for patients who underwent gastric cancer surgery.

목적: 위암 수술 후 회복을 위한 입원기간은 지금까지 대개 1주일 이상이었다. 이러한 회복기간을 요구하는 가장 큰 이유는 수술 후 3~4일간의 금식기간의 필요성과 합병증 발생 여부에 대한 관찰 때문이다. 본 연구진은 이번 연구를 통하여 수술 후 환자를 빠른 시일 내에 일상으로 복귀시키기 위한 임상진료 지침서를 만들고 이를 환자들에게 적용하여, 그 유용성과 안정성을 평가 하고자 하였다. 대상 및 방법: 2007년 10월부터 2008년 6월까지 성모병원에서 연속적으로 수술을 받은 103명의 환자를 수술 후 조기회복을 위한 임상진료 지침서의 적용대상으로 하였다. 임상진료 지침서에는 수술 전 최소한의 시술, 수술 후 적절한 통증관리 및 수액공급, 수술 후 조기 보행과 조기경구영양공급 등을 포함하고 있다. 진료지침 제외 기준을 수술 전, 수술 중 그리고 수술 후에 따라 마련하였다. 결과: 103명의 환자들 중 모두 19명의 환자가 각각 수술 전 5명, 수술 중 7명 그리고 수술 직후 7명의 제외 기준에 따라 제외되었다. 제외되지 않은 84명(81.6%)에 대하여 진료지침 시행 초기엔 수술 8일 후 퇴원을 계획하였으며, 최근엔 6일 후 퇴원을 계획하고 있다. 이들 중 22명(26.2%)의 환자에서 수술 후 합병증이 발생하였으며, 위장관 관련 합병증은 6명, 감염 관련 합병증은 8명에서 발생하였다. 환자들의 임상적, 수술적 특징에 따라서 합병증 발생률의 차이를 나타내지 않았다. 결론: 위암 수술 후 조기회복을 위한 임상진료 지침서는 제외 기준을 적용 후 대상 환자를 선정하고 활용한 결과, 환자들에게 유용하고 안전하게 사용되었다.

Keywords

References

  1. Kim JP. Current status of surgical treatment of gastric cancer. J Surg Oncol 2002;79:79-80. https://doi.org/10.1002/jso.10050
  2. Pearson SD, Goulart-Fisher D, Lee TH. Critical pathways as a strategy for improving care: problems and potential. Ann Intern Med 1995;123:941-948. https://doi.org/10.7326/0003-4819-123-12-199512150-00008
  3. Anderson AD, McNaught CE, MacFie J, Tring I, Barker P, Mitchell CJ. Randomized clinical trial of multimodal optimization and standard perioperative surgical care. Br J Surg 2003;90:1497-1504. https://doi.org/10.1002/bjs.4371
  4. Basse L, Hjort Jakobsen D, Billesbolle P, Werner M, Kehlet H. A clinical pathway to accelerate recovery after colonic resection. Ann Surg 2000;232:51-57. https://doi.org/10.1097/00000658-200007000-00008
  5. Schwenk W, Neudecker J, Raue W, Haase O, Muller JM. "Fast-track" rehabilitation after rectal cancer resection. Int J Colorectal Dis 2006;21:547-553. https://doi.org/10.1007/s00384-005-0056-7
  6. Kehlet H, Dahl JB. Anaesthesia, surgery, and challenges in postoperative recovery. Lancet 2003;362:1921-1928. https://doi.org/10.1016/S0140-6736(03)14966-5
  7. Fearon KC, Luff R. The nutritional management of surgical patients: enhanced recovery after surgery. Proc Nutr Soc 2003;62:807-811. https://doi.org/10.1079/PNS2003299
  8. Lee IK, Lee SM, Kim SS, Lee YS, Koh WR, Kim HK, Oh ST, Jeon HM, Chang SK. Critical pathway for colorectal and gastric cancer. J Korean Soc Coloproctol 2007;23:80-85. https://doi.org/10.3393/jksc.2007.23.2.80
  9. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: a report by the American Society of Anesthesiologist Task Force on Preoperative Fasting. Anesthesiology 1999;90:896-905. https://doi.org/10.1097/00000542-199903000-00034
  10. Hausel J, Nygren J, Lagerkranser M, Hellstrom PM, Hammarqvist F, Almstrom C, Lindh A, Thorell A, Ljungqvist O. A carbohydrate-rich drink reduces preoperative discomfort in elective surgery patients. Anesth Analg 2001;93:1344-1350. https://doi.org/10.1097/00000539-200111000-00063
  11. Holte K, Nielsen KG, Madsen JL, Kehlet H. Physiologic effects of bowel preparation. Dis Colon Rectum 2004;47:1397-1402. https://doi.org/10.1007/s10350-004-0592-1
  12. Slim K, Vicaut E, Panis Y, Chipponi J. Meta-analysis of randomized clinical trials of colorectal surgery with or without mechanical bowel preparation. Br J Surg 2004;91:1125-1130. https://doi.org/10.1002/bjs.4651
  13. Carrere N, Seulin P, Julio CH, Bloom E, Gouzi JL, Pradere B. Is nasogastric or nasojejunal decompression necessary after gastrectomy? A prospective randomized trial. World J Surg 2007;31:122-127. https://doi.org/10.1007/s00268-006-0430-9
  14. Cunningham J, Temple WJ, Langevin JM, Kortbeek J. A prospective randomized trial of routine postoperative nasogastric decompression in patients with bowel anastomosis. Can J Surg 1992;35:629-632.
  15. Ballantyne JC, Carr DB, deFerranti S, Suarez T, Lau J, Chalmers TC, Angelillo IF, Mosteller F. The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analyses of randomized, controlled trials. Anesth Analg 1998;86:598-612. https://doi.org/10.1097/00000539-199803000-00032
  16. Hyllested M, Jones S, Pedersen JL, Kehlet H. Comparative effect of paracetamol, NSAIDs or their combination in postoperative pain management: a qualitative review. Br J Anaesth 2002;88:199-214. https://doi.org/10.1093/bja/88.2.199
  17. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999;20:250-278; quiz 279-280. https://doi.org/10.1086/501620
  18. Sumiyama Y, Kusachi S, Yoshida Y, Arima Y, Tanaka H, Nakamura Y, Nagao J, Saida Y, Watanabe M, Sato J. Questionnaire on perioperative antibiotic therapy in 2003: postoperative prophylaxis. Surg Today 2006;36:107-113. https://doi.org/10.1007/s00595-005-3112-6
  19. Lewis SJ, Egger M, Sylvester PA, Thomas S. Early enteral feeding versus "nil by mouth" after gastrointestinal surgery: systematic review and meta-analysis of controlled trials. Bmj 2001;323:773-776. https://doi.org/10.1136/bmj.323.7316.773
  20. Keele AM, Bray MJ, Emery PW, Duncan HD, Silk DB. Two phase randomised controlled clinical trial of postoperative oral dietary supplements in surgical patients. Gut 1997;40:393-399. https://doi.org/10.1136/gut.40.3.393
  21. Smedley F, Bowling T, James M, Stokes E, Goodger C, O'Connor O, Oldale C, Jones P, Silk D. Randomized clinical trial of the effects of preoperative and postoperative oral nutritional supplements on clinical course and cost of care. Br J Surg 2004;91:983-990. https://doi.org/10.1002/bjs.4578
  22. Suehiro T, Matsumata T, Shikada Y, Sugimachi K. Accelerated rehabilitation with early postoperative oral feeding following gastrectomy. Hepato-gastroenterology 2004;51:1852-1855.
  23. U.S. National Institutes of Health. 2008 Nov 30: URL:http://www.clinicaltrials.gov/ct2/show/NCT00606619.
  24. Park DJ, Lee HJ, Kim HH, Yang HK, Lee KU, Choe KJ. Predictors of operative morbidity and mortality in gastric cancer surgery. Br J Surg 2005;92:1099-1102. https://doi.org/10.1002/bjs.4952
  25. Calland JF, Tanaka K, Foley E, Bovbjerg VE, Mark DW, Blome S, Minasi JS, Hanks JB, Moore MM, Young JS, et al. Outpatient laparoscopic cholecystectomy: patient outcomes after implementation of a clinical pathway. Ann Surg 2001;233:704-715. https://doi.org/10.1097/00000658-200105000-00015