The Application Of Fast Track Surgery Combined With Laparoscopy-Assisted Distal Gastrectomy For Gastric Cancer

BackgroundFast 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, and covers the whole perioperative period. It has been successfully applied to general, orthopedic, urological, gynecological, cardiovascular and thoracic surgery.Laparoscopic surgery has definite advantages and has been used widely since its advent. Compared with traditional surgery, it can alleviate inflammation, immune inhibition, and interference with respiratory function. So 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. FTS combined with laparoscopy-assisted distal gastrectomy (LADG) might provide some clinical and theoretical support on exploring the better treatments for gastric cancer.ObjectiveThe aims of this study were (1) to evaluate the feasiblity and effectiveness of FTS combined with LADG for gastric cancer,(2) to explore more reasonable, safe, effective and feasible FTS procedure,(3) to observe postoperative nutritional status,(4) to observe the short-term oncological outcomes.MethodsEighty-two patients were admitted to Yantai Yuhuangding Hospital with distal gastric cancer from January2009to November2010, and were randomly divided into four groups:(1) FTS+LADG (n=19), treated with LADG and FTS treatments;(2) LADG (n=22), treated with LADG and traditional treatments;(3) FTS+ODG (n=21), treated with ODG and FTS treatments; and (4) ODG (n=20), treated with ODG and traditional treatments. FTS included preoperative avoidance of mechanical bowel cleansing, no nasogastric tube decompression, restrictive intravenous fluids intraoperatively and postoperatively, and early ambulation and oral diet. The following clinical parameters were recorded:age, sex, BMI, body weight, anastomotic mode, pathological tumor stage, operation time, intraoperative blood loss, number of lymph node dissection, time of first flatus (index of peristalsis recovery), postoperative hospital stay, medical cost, and postoperative complications. Blood samples were collected at1day before surgery (DO) and4(D4) and7(D7) days after surgery. Serum concentrations of ALB and BUN were determined. Follow-up was usually once weekly for4weeks.Results1. There were no differences statistically between the four groups at age, sex, BMI, body weight, anastomotic mode and pathological tumor stage (all P>0.05). 2. Compared with the ODG group, the level of ALB in the other three groups was higher at4and7days after surgery (all P<0.01), and perioperative variation was more moderate in the groups with FTS treatmen, especially in FTS+LADG group. The level of ALB was higher in FTS+LADG group than in LADG group at D4and D7(P<0.05, P<0.01). The variaiton of ALB from DO to D4was more significant in FTS+LADG group and FTS+ODG group than in LADG group (P<0.001,P<0.05).3. The groups with LADG treatment had longer operation time and less intraoperative blood loss than the groups with ODG treatment (all P<0.001).4. Compared with 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 FTS+LADG group. First flatus in FTS+LADG group was earlier than in LADG group and FTS+ODG group (P<0.05; P<0.05). The groups with LADG treatment had higher medical costs than the groups with ODG treatment (all P<0.001), and FTS+ODG group had lowest medical cost and LADG group had highest medical cost (all P<0.01; all P<0.01).5. As to postoperative complications, there were no differences between the four groups (all P>0.05).Conclusions4. The combination of FTS and LADG for gastric cancer is safe, feasible and effective.5. The combination of FTS and LADG can accelerate gastrointestinal peristalsis, reduce hospital stay, and accelerate rehabilitation postoperatively. But the advantages are limited compared with LADG and FTS+ODG.6. The FTS treatments for improving nutritional status are effective in patients with gastric cancer, and LADG can contribute to this. However, at present, FTS+ODG may be a more economic, effective and feasible treatment for gastric cancer.7. As to the short-term oncological outcomes, LADG combined with FTS was similar to the conventional surgery and treatments. It needs a larger series with longer follow-up evaluation for definitive conclusions. BackgroundAlthough surgery is considered as the most important means for cancer treatment, many studies have demonstrated that surgical stress has an inhibitory effect on immunity, which could have an adverse impact (e.g. infection) on prognosis. In addition, the immune function is correlated with development, progression, recurrence and prognosis of gastric cancer in the published literature. The better preserved immune function may restrain tumor nestling and distant metastases formation. In recent years, FTS and laparoscopic surgery have been applied in gastrointestinal surgery. And they both can lessen stress reaction and preserve immune function.ObjectiveThe aims of this study were (1) to observe the effect on humoral immune function and stress reaction of FTS combined with LADG for gastric cancer,(2) to observe perioperative variations of humoral immune function and stress reaction under different treatments (FTS, LADG or both together).MethodsEighty-two patients were admitted to Yantai Yuhuangding Hospital with distal gastric cancer from January2009to November2010, and were randomly divided into four groups:(1) FTS+LADG (n=19), treated with LADG and FTS treatments;(2) LADG (n=22), treated with LADG and traditional treatments;(3) FTS+ODG (open distal gastrectomy)(n=21), treated with ODG and FTS treatments; and (4) ODG (n=20), treated with ODG and traditional treatment. FTS includes perioperative avoidance of mechanical bowel cleansing, no nasogastric tube decompression, restrictive intravenous fluids intraoperatively and postoperatively, and early ambulation and oral diet. Blood samples were collected at1day before surgery (DO) and1day (D1),4(D4) and7(D7) days after surgery. Serum concentrations of C-reactive protein (CRP), C3, C4and immunoglobulin (G, A and M) were determined. Follow-up was usually once weekly for4weeks.Results1.Compared with ODG group, the levels of CRP in the other three groups after surgery were lower (all P≤0.001), especially more significantly in FTS+LADG group with smoother variation. The levels of CRP in FTS+LADG group were lower than in FTS+ODG group at D4and D7(P<0.05, P<0.05). The ampitude in FTS+LADG group was smaller than in FTS+ODG group from D1to D4(P<0.05) and from D4to D7(P=0.05).2.Compared with ODG group, the variations of C3and C4in the other three groups perioperatively were more smoother, especially in FTS+LADG group, and the levels of C3and C4in FTS+LADG group were higher at D1(P<0.05, P<0.05). As to the ampitude of variation about C3, FTS+LADG group, LADG group and FTS+ODG group were smaller than ODG group from DO to D1(P<0.001, P<0.05, P<0.001) and from D1to D4(P<0.001, P<0.05, P=0.005), and FTS+LADG group was smaller than FTS+ODG group from D1to D4(P<0.01). As to the ampitude of variation about C4, from DO to D1, FTS+LADG group and FTS+ODG group were smaller than ODG group (P<0.001, P<0.001) and FTS+LADG group was smaller than LADG group (P<0.05), and FTS+LADG group was smaller than ODG group from D4to D7(P<0.05).3.Compared with ODG group, the levels of IgG and IgA in the other three groups after surgery were higher with smoother variation. As to the ampitude of variation, compared with ODG group, FTS+LADG group, LADG group and FTS+ODG group at IgG and IgA were smaller from D1to D4(all P<0.001) and FTS+LADG group and LADG group were smaller at IgA from D4to D7(P<0.001, P<0.05). FTS+LADG group at IgM was smaller from D1to D4(P<0.001).Conclusions5. The traditional open gastrectomy and corresponding postoperative treatments can lead to more injury and more serious inflammatory response, whereas FTS treatments and laparoscopic surgery can reduce the inflammatory response perioperatively, and the combination of FTS and LADG can do it further but limited.6. As to lessening perioperativ stress response, FTS treatments applied in traditional open gastrectomy can reach the similar results to laparoscopic surgery for gastric cancer.7. The complement system is obviously suppressed postoperatively. FTS or laparoscopic surgery alone had neligible effects on lessening impact on complement system, and the combination of FTS and LADG has some advantages over the other two.8. The groups with FTS treatments or laparoscopic surgery have better postoperative early humoral immune status than those with traditional open surgery. This suggests the two treatments have definite protective effect on postoperative early humoral immune function, but the combineation of them has no significant improvement.