Enhanced Recovery Protocol for Subtotal Gastrectomy: A prospective cohort to assess whether post-operative recovery following subtotal gastrectomy can be enhanced by following a structured protocol

Nandu, Nair (2016) Enhanced Recovery Protocol for Subtotal Gastrectomy: A prospective cohort to assess whether post-operative recovery following subtotal gastrectomy can be enhanced by following a structured protocol. Masters thesis, Christian Medical College, Vellore.


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BACKGROUND: The concept of Enhanced Recovery After Surgery (ERAS) or Fast Track Protocol was pioneered by Bardram. Later popularised by Kehlet and Wilmore, ERAS consists of a protocol of interventions aimed at stimulating early recovery following surgery and reducing the stress response to surgery thereby reducing the morbidity following a major procedure. It was initially tried for elective colorectal surgeries. Due the promising results, this protocol has been tried in cardiovascular surgeries, urological procedures (radical cystectomy, nephrectomy) and is being tried in other specialties as well. Recently some studies have been done on the effectiveness of ERAS protocol in upper GI procedures. Although most of these studies show promising results by reduction in the duration of post-operative hospital stay and also a reduction in postoperative complications, some studies show no particular benefit. There is no consensus guideline for ERAS in upper GI surgery. Hence more studies and meta-analysis is required before the effectiveness can be conclusively proven. Also, no studies have been done to find out effectiveness of ERAS protocol among Indian population. AIM: To study effectiveness and feasibility of ERAS protocol in patients undergoing subtotal gastrectomy for carcinoma stomach in Surgery III unit, Christian Medical College, Vellore. OBJECTIVES: • To study whether ERAS protocol reduces the duration of post-operative hospital stay in patients undergoing subtotal gastrectomy in CMC during the period of November 2013 to July 2015 • To study the effect of ERAS on morbidity following subtotal gastrectomy. • To study the compliance of study population to ERAS protocol. METHODOLOGY: This study was a prospective observational cohort study includingadult patients with a confirmed tissue diagnosis of adenocarcinoma stomach, who underwentelective subtotal gastrectomy in the Surgery III unit at CMC hospital. All patients registered for the study followed the modified ERAS protocol which consisted of preoperative, intraoperative and postoperative interventions (Table 1). Patients and their caregivers were counselled about the components of the protocol and given a printed hand-out regarding the protocol. They were followed up daily after operation to record adherence to protocol. If any intervention in the protocol is not followed the reason for the same was recorded. These patients were discharged when they satisfied the predetermined criteria for discharge. These patients were kept under regular follow up for a period of one month to watch for any postoperative complications. Primary outcome wasduration of hospital stay and secondary outcomes studied included protocol compliance, postoperative complications (as per Clavien Dindo classification), day of passage of flatus and faeces following surgery, day of initiation of normal diet and any need for readmission. RESULTS: 44 patients were included in the ERAS group and were compared with historical controls. The median duration of hospital stay was less in patients following the ERAS protocol (6 days) as compared to the historical control group who received conventional postoperative care (7 days) however the difference was not statistically significant. Among the components of modified ERAS protocol used, early nasogastric tube removal was the intervention which had least adherence due to surgeon preference. ERAS following subtotal gastrectomy was not associated with any increase in rate of immediate postoperative complications or any increase in morbidity. CONCLUSIONS: 1. The duration of hospital stay following subtotal gastrectomy is reduced when ERAS protocol has been followed however the difference was not statistically significant. 2. Following an enhanced recovery protocol did not have any adverse effect on immediate postoperative morbidity or mortality. 3. Overall compliance to the ERAS protocol was good however more studies and randomised control trials among Indian population will be required to formulate a proper guideline for ERAS in gastrectomy.

Item Type: Thesis (Masters)
Uncontrolled Keywords: Enhanced Recovery Protocol ; Subtotal Gastrectomy.
Subjects: MEDICAL > General Surgery
Depositing User: Subramani R
Date Deposited: 12 Oct 2017 01:03
Last Modified: 12 Oct 2017 01:03
URI: http://repository-tnmgrmu.ac.in/id/eprint/3555

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