Journal of Gastrointestinal Surgery

, Volume 16, Issue 10, pp 1830–1839

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

Authors

  • Jin chen Hu
    • Department of Gastrointestinal SurgeryYantai Yuhuangding Hospital Affiliated to Medical College of Qingdao University
    • Department of Gastrointestinal SurgeryYantai Yuhuangding Hospital Affiliated to Medical College of Qingdao University
  • Li Cai
    • Department of PathologyYantai Yuhuangding Hospital Affiliated to Medical College of Qingdao University
  • Hai tao Zheng
    • Department of Gastrointestinal SurgeryYantai Yuhuangding Hospital Affiliated to Medical College of Qingdao University
  • San yuan Hu
    • Department of General SurgeryQilu Hospital, Shandong University
  • Hong bing Chen
    • Department of Gastrointestinal SurgeryYantai Yuhuangding Hospital Affiliated to Medical College of Qingdao University
  • Guo chang Wu
    • Department of Gastrointestinal SurgeryYantai Yuhuangding Hospital Affiliated to Medical College of Qingdao University
  • Yi fei Zhang
    • Department of Gastrointestinal SurgeryYantai Yuhuangding Hospital Affiliated to Medical College of Qingdao University
  • Zhong chuan Lv
    • Department of Gastrointestinal SurgeryYantai Yuhuangding Hospital Affiliated to Medical College of Qingdao University
Original Article

DOI: 10.1007/s11605-012-1969-4

Cite this article as:
chen Hu, J., xin Jiang, L., Cai, L. et al. J Gastrointest Surg (2012) 16: 1830. doi:10.1007/s11605-012-1969-4

Abstract

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.

Keywords

Fast-track surgeryLaparoscopy-assisted surgeryDistal gastrectomyNutritional statusGastric cancerPerioperative period

Introduction

With progress in diagnostic and therapeutic techniques, there is increased concern for faster and more comfortable recovery. In recent years, fast-track surgery (FTS), through application of multimodal rehabilitation for selective operations, has significantly relieved postoperative stress, reduced the morbidity associated with complications, and accelerated recovery. FTS requires multidisciplinary teamwork to reach an optimal outcome,1 and covers the whole perioperative period. FTS has been successfully applied to general,26 orthopedic,7,8 urological,9,10 gynecological,11 cardiovascular,1215 and thoracic16,17 surgery.

Laparoscopic surgery has definite advantages and has been used widely since its advent. Compared with traditional surgery, it can alleviate inflammation,18 immune inhibition,19 and interference with respiratory function.20 It can also accelerate postoperative recovery. In recent years, the advantages of laparoscopic surgery have been recognized in gastric cancer. Despite some continuing controversies about oncological safety, difficulties in performance, anastomosis, and lymph node dissection, laparoscopic surgery for gastric cancer is becoming more popular and more acceptable to patients.

To date, few studies have reported the application of FTS in laparoscopic radical gastrectomy for gastric cancer. The aim of the present study was to evaluate the safety and effectiveness of FTS combined with laparoscopy-assisted radical distal gastrectomy (LADG) in gastric cancer.

Patients and Methods Design

Study Design

This study is a prospective four-armed randomized controlled trial. The study was carried out in agreement with the Declaration of Helsinki (Tokyo, Venice, Hong Kong, Somerset West, and Edinburgh amendments). The study protocol was approved by the Ethics Committee of the affiliated Yantai Yuhuangding Hospital of Medical College of Qingdao University(Yantai, China). Patients with distal gastric cancer in Department of Gastrointestinal Surgery, Yantai Yuhuangding Hospital Affiliated to Medical College of Qingdao University were screened consecutively for enrollment into the study from January 2009 to May 2011 according to selection criteria. Informed consent was obtained from the patients and their families.

Selection Criteria

Patients who were eligible for the study met the following requirements: (1) age 25–75 years old, male or female; (2) diagnosis confirmed by endoscopic biopsy; (3) no lymph node or distant metastasis diagnosed by preoperative abdominal computed tomography; (4) no history of autoimmune or severe cardiopulmonary diseases; (5) no preoperative radiotherapy or chemotherapy; (6) no digestive obstruction, perioperative blood or albumin infusion, or combined intraoperative devisceration; and (7) acceptance by the patients and their families.

Patients and Groups

Eighty-eight eligible patients were randomly assigned into four groups comprising 22 patients each: (1) FTS + LADG, treated with LADG and FTS treatment; (2) LADG, treated with LADG and traditional treatment; (3) FTS + ODG, treated with ODG and FTS treatment; and (4) ODG, treated with ODG and traditional treatment. Three participants who withdrew their consent and two participants who lost to follow-up were excluded from the study (Fig. 1). A power analysis using historical data determined that 88 patients (22 in each group) would be needed to detect a 40 % differences in between the four groups with an alpha level of 0.05 and 80 % power for primary endpoints. The primary efficacy endpoints of the study were time of first flatus, postoperative hospital stay, medical cost, and postoperative complications. The general clinical characteristic, surgical parameters, and serum indices were documented as second endpoints.
https://static-content.springer.com/image/art%3A10.1007%2Fs11605-012-1969-4/MediaObjects/11605_2012_1969_Fig1_HTML.gif
Fig. 1

Flow diagram of the prospective four-armed randomized controlled trial. Three participants who withdrew their consent and two participants who lost to follow-up were excluded from the study

Methods

FTS included perioperative avoidance of mechanical bowel cleansing, no nasogastric tube decompression, restrictive intravenous fluids intraoperatively and postoperatively, and early ambulation and oral diet (Table 1).4,21 About 500–1,500 ml of oral nutritional supplements (e.g., enteral nutritional suspension; TPF) was given for 5–7 days preoperatively, if the patients met at least one of the following criteria: weight loss >10–15 % within 6 months; body mass index (BMI) <18.5 kg/m2; Subjective Global Assessment grade C; serum albumin <30 g/l22; and oral intake <60 % of recommended daily intake. A semi-fluid meal was administered until 6 h before surgery and a carbohydrate drink (commonly 250–500 ml 10 % glucose solution) until 2 h before surgery. Oral feeding was initiated at 6–8 h after surgery, following a stepwise program from warm clear water to a carbohydrate drink and TPF (temperature controlled at 38 °C), and finally to semi-fluid meals and normal food. Patients adhered to the rule of eating little and often. The amount and concentration of initial oral intake was adapted to the state of gastrointestinal function and individual tolerance. On the first day, the patients received about 500 ml liquid; on the second day, this was increased to about 1,000 ml; and on the third day, they received a total oral diet. During the first 1–2 days postoperatively, the oral diet could not meet daily physiological need. So, appropriate intravenous infusion of fat emulsion, amino acids, and glucose was administered according to daily physiological need and intake and output. Traditional perioperative treatments consisted of parenteral nutrition of fat emulsion, amino acids (17) and glucose (11 %) injection (about 2.5 l/day; Fresenius Kabi AB, Uppsala, Sweden), which was administered until flatus. At that time, the nasogastric tube was removed and the patient progressed from fluids to semi-fluids and then to normal food. The patients received nutritional support of 0.20 g/kg/day nitrogen and 25–30 kcal/kg/day calories. LADG was carried out in accordance with standardized procedures following the 13th edition of the Japanese Rules of Gastric Cancer Research23 by the same group of experienced surgeons.
Table 1

Perioperative program for FTS and traditional treatment

Perioperative period

Traditional treatment

FTS

Preoperative

Perioperative information

Schedule of surgery and informed consent

Health instruction, information, and discussion about FTS except for schedule of surgery and informed consent

Preparation of bowel

Mechanical bowel cleansing or oral laxative on the night before surgery

Not used as routine treatment

Nutritional support

None

Oral nutritional supplements (e.g., TPF) were given for 5–7 days to patients at severe nutritional risk

Diet

No meal for 12 h before surgery and no drink for 8 h before surgery

Feed semi-fluid meal until 6 h before surgery, and carbohydrate drink (commonly 250–500 ml 10 % glucose solution) until 2 h before surgery

Nasogastric decompression

Place the nasogastric tube on the day of surgery

If necessary, remove as early as possible after surgery

Intraoperative

Incision

Traditional laparotomy approach (epigastrium midline incision from the xiphoid to umbilicus or 1–2 cm below umbilicus)

Minimally invasive incision (epigastrium midline incision, ODG about 10–15 cm, not over umbilicus; LADG about 5–8 cm)

Abdominal cavity drainage tube

Yes

Not used as routine treatment. If necessary, remove as early as possible after surgery.

Restrictive fluid infusion regimen

No. Commonly Ringer's lactate 20 ml/kg in the first hour, then at the rate of 10–12 ml/kg/h.

Yes. Ringer's lactate 20 ml/kg in the first hour, then followed at the rate of 6 ml/kg/h.

Postoperation

Pain management

Opioid analgesic by intramuscular injection or patient-controlled analgesia (PCA)

Non-opioid analgesic by intramuscular injection or PCA, oral cyclooxygenase inhibitor

Nutrition and diet

Parenteral nutrition until flatus. Then, remove nasogastric tube and initiate oral diet from fluids to semi-fluids and normal food

Oral diet was initiated 6–8 h after surgery, following a stepwise program from warm clear water to carbohydrate drink to TPF, then to semi-fluids to normal food. Adhere to the premise of eating little and often. During first 1–2 days, the appropriate intravenous nutritional infusion was administered.

Urine catheter

Commonly for 24–48 h

For 6–24 h. Remove as early as possible.

Early ambulation

Mobilization out of bed until 24–48 h after surgery.

Encourage patient mobilization on bed after anesthesia recovery and out of bed 8–12 h after surgery.

Acceleration of enterocinesia

No

On first or second day after operation, accelerant was administered via anus.

In order to assure comparable treatment of patients, all surgeons and nurses who took part in this study were instructed on the study interventions, so that intra- and perioperative treatments were standardized. Patients were blinded for the study interventions. Blinding of the surgeons and nurses was not feasible. Therefore, two specially trained doctors blinded to patients' allocated treatment group were in charge for assessing postoperative outcomes and follow-up.

Measurement Indices and Discharge Criteria

The following clinical parameters were recorded: age, sex, BMI, body weight, anastomotic mode, pathological tumor stage, operation time, intraoperative blood loss, lymph node dissection number, time of first flatus (index of peristalsis recovery), postoperative hospital stay, medical cost, and postoperative complications. Blood samples were collected at 1 day before and 1, 4, and 7 days after surgery. Serum concentrations of albumin (ALB), blood urea nitrogen (BUN), and C-reactive protein (CRP) were determined using a commercially available ELISA kit (Siemens Healthcare Diagnostics Products GmbH, Jinan, China).

Four groups followed the same discharge criteria: (1) total oral diet without intravenous nutritional support; (2) no nausea or vomiting, and good flatus and/or defecation; (3) no pain, or well controlled with oral analgesics; (4) no drainage tubes or catheters; (5) able to carry out normal daily activities, and care for themselves; and (6) acceptance by the patients.

Follow-up

All the patients kept in touch with us by telephone after discharge so that we could learn about their condition and help with their rehabilitation. We also designed a telephone questionnaire to obtain detailed information about the patients' recovery. Follow-up was usually once weekly for 4 weeks. If necessary, they could contact us at any time. From the information received, we could decide whether to intervene, and plan further treatment.

Statistical Analysis

Measurement data are expressed as mean ± SD and were analyzed by Student's t test, whereas categorical data were analyzed by χ2 test. Statistical analysis was performed using SPSS version 12.0 software. P < 0.05 or 0.01 was considered to be significant.

Results

Patient Characteristics

The clinical characteristics are summarized in Table 2. The age ranged from 49 to71 years (median, 59 years) in the FTS + LADG group, 45–72 years (median, 62.5 years) in the LADG group,40–71 years (median, 64 years) in the FTS + ODG group, and49–75 years (median, 64.5 years) in the ODG group. The statistical analysis of age, sex, body weight, and BMI suggested similar characteristics in the four groups. There were no significant differences (all P > 0.05). As to anastomotic mode, Billroth I was adopted more often than Billroth II, but there were no differences between the four groups (P > 0.05). According to pathological tumor staging, most cases were found at stages II and III, and there were no differences between the four groups (P > 0.05).
Table 2

Comparison of characteristics of patients between the four groups

Group

FTS + LADG (n = 19)

LADG (n = 22)

FTS + ODG (n = 21)

ODG (n = 20)

Age (year)

59 (49–71)

62.5(45–72)

64 (40–71)

64.5 (49–75)

Median (range)

Sex (male/female)

10/9

10/12

9/12

12/8

BMI (kg/m2)

22.94 ± 2.23

22.99 ± 2.24

23.54 ± 2.59

23.47 ± 2.62

Body weight (kg)

68.00 ± 7.62

66.11 ± 6.71

69.67 ± 7.72

70.68 ± 8.63

Billroth I/II

13/6

14/8

16/5

14/6

pTNM stage

1/10/8/0

1/10/10/1

1/8/11/1

1/6/11/2

I/II/III/IV

p value: all > 0.05

Serum Parameters

Compared with the ODG group, the level of ALB in the other three groups was higher at 4 and 7 days after surgery (all P < 0.01), and perioperative variation was more moderate in the groups with FTS treatment than with traditional treatment, especially in the FTS + LADG group (Fig. 2). 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). There was no significant difference betweeen the four groups at different time points except the above compare (all P > 0. 05; Table 3). The level of BUN was similar at different time points between the four groups (all P > 0.05; Table 3).
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Fig. 2

Comparison of level of ALB in the four groups

Table 3

Comparison of levels of ALB and BUN between the four groups

 

FTS + LADG (n = 19)

LADG (n = 22)

FTS + ODG (n = 21)

ODG (n = 20)

p value

Albumin (g/l)

Preoperative

36.11 ± 3.93

36.06 ± 4.02

35.21 ± 3.87

35.30 ± 4.25

All > 0.05

Postoperative day 4

31.69 ± 3.72

29.22 ± 3.05

30.09 ± 3.30

26.02 ± 3.08

0.025a

0.000b

0.002c

0.000d

Postoperative day 7

34.33 ± 3.43

31.04 ± 3.29

32.9 ± 3.11

25.27 ± 3.04

0.003a

0.000b

0.000c

0.000d

BUN (mol/l)

Preoperative

4.45 ± 1.10

4.29 ± 1.06

4.30 ± 1.02

4.30 ± 1.35

All > 0.05

Postoperative day 4

4.77 ± 1.01

4.21 ± 1.03

4.28 ± 0.98

4.22 ± 1.25

All > 0.05

Postoperative day 7

4.84 ± 0.88

3.99 ± 0.97

4.49 ± 0.76

4.31 ± 1.30

All > 0.05

aFTS + LADG vs LADG

bFTS + LADG vs ODG

cLADG vs ODG

dFTS + ODG vs ODG

Compared with the ODG group, the level of CRP in the other three groups was lower after surgery (all P < 0.01), especially in the FTS + LADG group with smoother variation (Fig. 3). 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). There was no significant difference betweeen the FTS + LADG group and LADG group after surgery, as well as betweeen the LADG group and FTS + ODG group (all P > 0. 05; Table 4).
https://static-content.springer.com/image/art%3A10.1007%2Fs11605-012-1969-4/MediaObjects/11605_2012_1969_Fig3_HTML.gif
Fig. 3

Comparison of level of CRP in the four groups

Table 4

Comparison of levels of CRP between the four groups

 

FTS + LADG (n = 19)

LADG (n = 22)

FTS + ODG (n = 21)

ODG (n = 20)

p value

CRP (mg/l)

Preoperative

4.79 ± 1.55

4.86 ± 1.48

4.72 ± 1.58

5.15 ± 1.73

All > 0.05

Postoperative day 1

52.72 ± 17.85

53.65 ± 18.15

55.17 ± 14.96

76.61 ± 21.63

0.001a

0.001b

0.001c

Postoperative day 4

75.67 ± 22.88

90.76 ± 30.04

93.20 ± 21.76

133.42 ± 23.22

0.018d

0.000a

0.000b

0.000c

Postoperative day 7

36.09 ± 16.01

44.05 ± 18.68

45.23 ± 11.13

70.10 ± 17.57

0.041d

0.000a

0.000b

0.000c

aFTS + LADG vs ODG

bLADG vs ODG

cFTS + ODG vs ODG

dFTS + LADG vs FTS + ODG

Intraoperative Parameters and Postoperative Clinical Observation

The groups with LADG treatment had longer operation time and less intraoperative blood loss than the groups with ODG treatment (all P < 0.001; all P < 0.05), but between each groups, there was no significant difference (P > 0. 05, P > 0. 05; Table 5). There was no difference in lymph node dissection number between the four groups (all P > 0.05; Table 5).
Table 5

Comparison of operation time, intraoperative blood loss, lymph node dissection number, first flatus time, postoperative hospital stay, and medical costs between the four groups

 

FTS + LADG (n = 19)

LADG (n = 22)

FTS + ODG (n = 21)

ODG (n = 20)

p value

Operation time (min) (mean ± SD)

220.74 ± 28.87

218.27 ± 28.55

125.10 ± 30.17

123.25 ± 25.44

0.000a

0.000b

0.000c

0.000d

Intraoperative blood loss (ml) (mean ± SD)

75.26 ± 31.02

78.41 ± 32.27

110.48 ± 47.85

106.38 ± 39.04

0.010a

0.013b

0.006c

0.010d

Lymph node dissection number (mean ± SD)

17.58 ± 5.98

18.86 ± 6.68

19.14 ± 6.51

18.8 ± 6.26

all > 0.05

Time to first flatus (h) median (range)

58 (35–72)

65.5 (49–80)

64.5 (44–97)

76.5 (66–102)

0.014e

0.017a

0.000c

0.000d

0.000f

Postoperative hospital stay (days) median (range)

7 (5.5–10)

7.5 (6–11)

7.5 (6–11)

8.75 (7–14)

0.710e

0.690a

0.000c

0.040d

0.038f

Medical cost (RMB) (mean ± SD)

33,125.89 ± 2,297.69

35,858.27 ± 3,076.69

27,596.20 ± 2,957.03

28,972.29 ± 6,999.76

0.003e

0.000a

0.000b

0.001c

0.000d

0.002f

aFTS + LADG vs FTS + ODG

bLADG vs FTS + ODG

cFTS + LADG vs ODG

dLADG vs ODG

eFTS + LADG vs LADG

fFTS + ODG vs ODG

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. Except for the ODG group, the other three groups had similar postoperative hospital stay (all P > 0. 05; Table 5). First flatus in the FTS + LADG group was earlier than in the LADG group and FTS + ODG group (P < 0.05; P < 0.05), but between the LADG group and FTS + ODG group, there was no significant difference (P > 0. 05, P > 0. 05; Table 5).

The groups with LADG treatment had higher medical costs than the groups with ODG treatment (all P ≤ 0.001). In a comparison of the four groups, the FTS + ODG group had lowest medical costs and the LADG group had highest medical costs (all P < 0.01; all P < 0.01). Medical costs in the FTS + LADG group were second highest after the LADG group (Table 5).

After 4 weeks follow-up, the postoperative complications were classified according to the revised version of Clavien–Dindo classification system24,25 (Table 6). There were no differences in postoperative complications between the four groups (P > 0.05; Table 7). In more detail, anastomotic bleeding and acute urinary retention occurred in one patient each in the FTS + LADG group; gastroparesis, lung infection, abdominal liquid accumulation, and incision fat liquefaction occurred in one patient each in the LADG group; abdominal liquid accumulation, incision infection, and fat liquefaction occurred in one patient each in the FTS + ODG group; and lung infection, urinary tract infection, incision infection occurred in one patient each, and incision fat liquefaction in two patients in the ODG group. Anastomotic bleeding was cured by administration of thrombin and norepinephrine through a gastric tube, and intravenous injection of hemostatic agent. The abdominal liquid accumulation was diagnosed as a result of chyle leakage and was resolved after abdominocentesis and drainage under ultrasound guidance. There was no anastomotic leakage, intestinal obstruction, or deep vein thrombosis in both groups with FTS treatment. In addition, three patients in the FTS + LADG group and four in the FTS + ODG group had severe nausea, vomiting, or abdominal distension during early oral diet (mostly at 2–3 days after surgery). These symptoms disappeared through delaying oral diet, decreasing the concentration and volume of the oral nutritional supplements, and nasogastric decompression. All the patients with the complication were cured through conservative treatment.
Table 6

Classification of surgical complications adopted for gastric surgery according to the revised version of Clavien–Dindo classification system

Grade

Definition

I

Any deviation from the normal postoperative course without the need for intervention, or any non-life-threatening complication not requiring therapy. Physiotherapy and analgesics are the allowed therapeutic regimens. This grade also includes wound infections and fat liquefaction opened at the bedside

II

Requiring pharmacologic treatment with drugs other than ones allowed for grade I complications (including blood transfusions and total parenteral nutrition). Replacement of the nasogastric tube is included in this grade

III

Requiring surgical, endoscopic, or radiologic intervention

 IIIa

 Intervention not under general anesthesia

 IIIb

 Intervention under general anesthesia

IV

Life-threatening complications (including central nervous system complications) requiring intermedie care/ICU management:

 IVa

 Single-organ dysfunction (including dialysis)

 IVb

 Multiorgan dysfunction

V

Death of a patient

Table 7

Postoperative complications after 4 weeks follow-up

 

FTS + LADG (n = 19)

LADG (n = 22)

FTS + ODG (n = 21)

ODG (n = 20)

No complications

7 (36.8 %)

14 (63.64 %)

7 (33.3 %)

12 (60.0 %)

Grade I

7 (36.8 %)

4 (18.2 %)

9 (42.9 %)

5 (25.0 %)

Grade II

5 (26.3 %)

2 (9.1 %)

4 (19.0 %)

3 (15.0 %)

Grade III

IIIa

0 (0 %)

2 (9.1 %)

1 (4.8 %)

0 (0 %)

IIIb

0 (0 %)

0 (0 %)

0 (0 %)

0 (0 %)

Grade IV

IVa

0 (0 %)

0 (0 %)

0 (0 %)

0 (0 %)

IVb

0 (0 %)

0 (0 %)

0 (0 %)

0 (0 %)

Grade V

0 (0 %)

0 (0 %)

0 (0 %)

0 (0 %)

χ2

10.007

   

pa

0.286

   

aFisher's exact test

Discussion

FTS was first initiated by Professor Henrik Kehlet et al. in 2001,26,27 and it has been successfully used for treatment of many diseases. Some new techniques and ideas, especially laparoscopy and early enteral nutrition, have been gradually introduced in FTS. The traditional views about perioperative care of gastrointestinal surgery patients have been challenged by recent studies. FTS encompasses preoperative, intraoperative and postoperative treatment, and its successful implementation requires an effective commitment and a multidisciplinary approach. It has been shown that FTS in D2 gastrectomy is safe and efficient, and it can lessen postoperative stress, accelerate rehabilitation, shorten postoperative hospital stay, and hasten return of gut function,4,28 as was demonstrated in our present study. Laparoscopic techniques have been used in gastrointestinal surgery for many years. Their advantages in gastric cancer have been recognized widely, although some controversies about oncological safety, difficulties in performance, anastomosis, and lymph node dissection remain. Laparoscopic surgery can alleviate inflammation, immune inhibition, and interference with lung and gastrointestinal function, and accelerate postoperative recovery.2934 In the present study, FTS was used for LADG for gastric cancer. There was no difference in the postoperative complications between the four groups after 4 weeks follow-up. In the FTS + LADG group, except for faster recovery of peristalsis, there were no obvious advantages compared with the LADG and FTS + ODG groups. Furthermore, the FTS + LADG group had relatively high medical costs. The results suggested that FTS + LADG was safe, feasible, and efficient, but the advantages were limited. The FTS + ODG group had lowest medical costs, roughly same postoperative hospital stay, moderate recovery of peristalsis and favorable operation time and intraoperative blood loss. Therefore, FTS + ODG might be a more economic and feasible treatment for gastric cancer.

In the present study, most of the patients had advanced gastric cancer and malnutrition in view of progressive wasting before the radical treatment. Oral enteral nutritional supplements were administered before surgery in order to improve the nutritional status of the patients and create favorable conditions for surgery. Early postoperative oral diet, in addition to nutritional intake, can accelerate recovery of peristalsis, protect gut mucosal barrier function, and enhance portal circulation.35 A recent study in a rat model has indicated that early oral feeding after upper gastrointestinal surgery leads to prompt anastomotic healing.36 Early enteral nutrition with dietary fiber can alleviate intestinal barrier dysfunction and decrease incidence of bacterial translocation.37 Our study showed that postoperative serum albumin in patients with FTS remained higher and steadier than in those with traditional treatments. The postoperative level of serum albumin in the FTS + LADG group almost reached the preoperative level at 7 days after surgery. However, there were no differences in serum albumin between the FTS + LADG and FTS + ODG groups. We suggest that FTS and perioperative nutritional support for improving nutritional status are effective in patients with gastric cancer, and that LADG could contribute to this.

Previous studies have shown that the small intestine might return to normal enterocinesia 6 h after abdominal surgery, and that liquid in the small intestine can be reabsorbed at an early stage postoperatively.3840 Therefore, placement of a nasogastric tube is unnecessary in theory. However, in clinical practice, surgeons are primarily concerned that nausea, vomiting, or flatulence after early oral diet can result in anastomotic leakage, intestinal fistula, and other severe complications. A literature-based meta-analysis has shown that early enteral nutrition can reduce the risk of postoperative complications and mortality,41 although it increases the incidence of vomiting and flatulence. In the present study, most patients who underwent FTS tolerated early oral diet well. The clinical symptoms in the FTS + LADG group were similar to those in the FTS + ODG group. Although nausea, vomiting, or abdominal distension occurred in some patients, all the symptoms mostly occurred in the initial stage of oral diet and did not develop into severe complications. Therefore, we suggest that early oral diet in patients with LADG is safe and feasible.

Although surgery is considered as the most important method in tumor therapy, many studies have demonstrated that surgical stress has an inhibitory effect on immunity, which could have an adverse impact on prognosis. Recent studies have shown that laparoscopic surgery is associated with reduced surgical trauma, and therefore with a lesser acute-phase response compared with conventional surgery. CRP is one of the most frequently investigated markers that are involved in the acute-phase reaction. It correlates well with the extent of tissue injury induced by surgery.29 In the present study, the level of CRP in the FTS + LADG group was lower after surgery than in the other three groups with smoother variation. There was no significant difference betweeen the FTS + LADG group and LADG group after surgery, as well as betweeen the LADG group and FTS + ODG group. These findings suggested that FTS + LADG could further diminish surgical trauma and lessen postoperative stress. Laparoscopic surgery played an important role in it.

Conclusions

In conclusion, combination of FTS and LADG for 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, the advantages of FTS + LADG are limited to the short-term follow-up period. FTS + ODG might be a more economic, effective, and feasible treatment for gastric cancer. Nevertheless, a larger series with longer follow-up evaluation is necessary for definitive conclusions to be drawn.

Acknowledgments

We would like to thank Dr. Xue-Jun Gao for helpful advice, and Lei Chen for experimental and technical assistance.

Copyright information

© The Society for Surgery of the Alimentary Tract 2012