Patient-centered Issues Affect Surgical Outcomes

Patient-centered oncology is advancing care, reducing side effects, and improving cancer patients’ outcomes in ways never imagined. Recent years have seen increasing evidence that patient metabolism affects surgical outcomes. Current reviews recognize the hazards of the catabolic response to surgical stress and summarize the best available evidence for perioperative nutritional interventions to optimize patient homeostasis, postsurgical recovery, and related clinical outcomes. For example, avoiding traditional preoperative fasting and maintaining normal perioperative blood glucose have been shown to prevent insulin resistance and promote earlier recovery from major abdominal surgery.¹ Immunonutritional interventions are associated with decreased length of postoperative hospital stay, although insufficient evidence supports consistent effects on other surgical outcomes² to date. Ample research has revealed the use of live bacterial probiotics or synergistic synbiotics³ substantially reduces the likelihood of postoperative sepsis in patients undergoing elective general surgical procedures (P < 0.003) and length of postoperative antibiotic use (P = 0.03).⁴ The 2 studies described in this Evidence Corner highlight the importance of acknowledging and using patient variables to work with nature to guide practice decisions and improve surgical outcomes.^5,6 

Reference: Nakagawa H, Ohno K, Ikeda S, Muto M. The effect of preoperative subcutaneous fat thickness on surgical site infection risk in patients undergoing colorectal surgery: results of a multisite, prospective cohort study. Ostomy Wound Manage. 2016;62(8):14-20. 

Rationale: Individuals undergoing colorectal surgery experience a high likelihood of a surgical site infection (SSI), which is increased by stoma placement and by high body mass index (BMI). The thickness of subcutaneous fat (TSF), a more objective measure of BMI, has been independently reported as a risk factor for SSI.  

Objective: Conduct a prospective cohort study in acute care to determine the association of perioperative TSF with SSI development.

Methods: A prospective observational study was conducted in 17 consenting hospitals participating in the Japan Nosocomial Infection Surveillance or Japan Hospital Acquired Infection Surveillance programs. Wound ostomy continence nurses and infection control practitioners managed patient care throughout each hospital. The surveillance and prevention of SSI were standardized according to the Centers for Disease Control and Prevention (CDC) guidelines and World Health Organization Guidelines for Safe Surgery. Nutrition specialists evaluated all successive consenting patients (N = 155) for SSI risk on enrollment using a subjective global assessment (SGA) of nutritional status as “well nourished,” “moderate or suspected malnutrition,” or “severe malnutrition.” Abdominal TSF was obtained from each patient’s preoperative computed tomography scan used to confirm cancer diagnosis. Body mass index was recorded as: “underweight” < 18.5 kg/m²; “normal” = 18.5–25 kg/m²; “overweight” > 30 kg/m²). Other risk factors for SSI recorded were surgical duration > 75^th percentile of Japan’s national standards or wound CDC guideline SSI classification. Serum albumin and total protein were sampled on admission and weekly for 30 days after surgery. Appropriate tests determined statistical significance of preoperative differences between those who did or did not develop a postoperative SSI. Significant predictors were successively analyzed in a univariate analysis followed by a multivariate analysis to identify independent SSI predictors at a significance level of P < 0.05.

Results: Overall, 24 (15.5%) of the patients developed a SSI in a mean of 7.3 days after surgery. Nine of the 90 (10%) patients who underwent rectal surgery and 15 of the 65 patients (23%) who underwent colon surgery developed an SSI. The SSIs were more likely (N = 16; 67%) in individuals who underwent colostomy surgery, especially for those with an American Society of Anesthesiology score above 3. Patients who developed a SSI resumed oral intake a mean of 7.4 days after surgery compared to 4.6 days for those who remained SSI-free. Neither BMI nor SGA were significantly associated with SSI development, but baseline TSF > 15 mm was, as well as male gender, stoma construction, serum albumin < 3.5 g/dL 14 and 21 days after surgery. Total protein < 6.8 g/dL 7 days after surgery was significantly associated with SSI development.
Logistic regression identified TSF > 15 mm and serum albumen < 3.5 g/dL as independent SSI risk factors in the multivariate analysis.

Authors’ Conclusions:  Preoperative TSF > 15 mm and postoperative serum albumin < 3.5 g/dL were independent risk factors for SSIs in patients undergoing colorectal surgery. In addition, SSI development delayed resumption of oral food intake.

Reference: Liu G, Jian F, Wang X, Chen L. Fast-track surgery protocol in elderly patients undergoing laparoscopic radical gastrectomy for gastric cancer: a randomized controlled trial. Onco Targets Ther. 2016;9:3345–3351.

Rationale:  Fast-track surgery (FTS) procedures integrate standardized perioperative care practices to maintain physiological function, speeding recovery after a variety of surgeries in younger patients. There is limited evidence supporting their use in elderly patients undergoing laparoscopic surgery to remove gastric cancer.

Objective: Conduct a randomized, controlled trial comparing outcomes of standard or FTS perioperative procedures combined with either traditional open
distal gastrectomy or laparoscopic-assisted surgery when removing gastric cancer in patients 60–80 years of age.

Methods:  Surgically appropriate patients aged 60–80 years with gastric cancer confirmed by gastro-
scopic biopsy were randomly assigned (21/group) to receive open laparotomy or laparoscopic therapy in combination with conventional (C) or fast-track perioperative management. Fast-track surgery procedures included: 1) patient education; 2) fasting prior to surgery for 6 hours instead of the usual 12 hours, with water deprivation for 2 hours instead of the usual 4; 3) no routine bowel preparation compared to oral laxatives for usual care; 4) minimal use of nasogastric tubes instead of routine preoperative use; 5) intraoperative patient insulation and limiting transfusions to ≤ 1500 mL compared to none in usual care; 6) limiting incision size compared to no special emphasis on this in usual care; 7) routine nonsteroidal anti-inflammatory drugs compared to none for usual care; 8) urinary tube removal after 48 hours compared to 3–5 days for usual care; and 9) off-bed activity and oral diet required 1 day postsurgery, compared to awaiting normal function for usual care. These practices conformed to those published by the 2014 European FTS Association for the “Gastrectomy Fast Track Surgery Guideline.”⁷ Patients were evaluated for baseline and surgical variables including perioperative SSI risk factors. Observers blinded to the treatment group recorded postoperative outcome measures. These included SSI surveillance for 30 days, time to oral food intake, hospital costs, nutritional and stress markers, and length of hospital stay. Statistical differences among groups were tested at baseline and for outcome measures with significance at P ≤ 0.05.

Results:  The 4 groups were comparable at baseline and on all intraoperative variables except reduced blood loss and incision length for the 2 laparoscopic surgery groups. Among recovery indicators, days to first flatus, length of hospital stay, and hospital costs were reduced by laparoscopic surgery, more so in FTS subjects. There were no significant differences among groups on the incidence of SSI. Patients receiving laparoscopic surgery plus FTS experienced the lowest levels of postoperative stress responses including reduced interleukin-6 and C-reactive protein on days 1, 4, and 7 after surgery with increased serum albumin and pre-albumin 4 and 7 days postoperatively (P < 0.05). One complication, gastric retention, was observed more frequently in the FTS groups. 

Authors’ Conclusions:  When combined with laparoscopic surgery, using FTS protocols of perioperative care permits faster postoperative recovery and improved nutritional and stress responses compared to conventional care for elderly subjects undergoing gastrectomy surgery to remove gastric cancer.  

These studies suggest appreciating patient risk factors and addressing patient needs to preserve homeostasis are important aspects of performing surgery. Excess body weight is recognized as a risk factor for developing postoperative SSI, but as Nakagawa et al⁵ found, abdominal TSF > 15 mm offers a more consistent objective metric for alerting surgical professionals to the likelihood of a SSI. Their observation⁵ that subjects with higher serum albumin or total protein were less likely to develop a SSI cues wound care teams to assure adequate perioperative protein intake for all patients to the extent feasible. This supports the “fast track” shorter preoperative fast and patient-centered management, which Liu et al⁶ reported restores serum albumin and pre-albumin earlier than conventional care. Liu et al⁶ also found only 1 SSI in samples too small to test for significant effects of FTS on SSI. This parallels prior findings for absence of effects of FTS on low-SSI-risk cardiac surgery.⁸ However, effects of FTS remain to be tested on larger samples of patients undergoing colorectal surgery. The observation that patients developing a SSI experience delayed oral intake⁶ suggests that a SSI may add to a patient’s risk of postoperative nutritional deficits, alerting professional caregivers that individuals with a SSI have increased nutritional needs. We already know moisture-retentive dressings that preserve a physiological environment for wounds improve healing, pain, and infection outcomes.⁹ Why not extend that observation to patients? The works cited here suggest that the value of patient-centered surgery and perioperative practices preserving normal physiology are powerful tools to improve surgical outcomes.

Laura Bolton, PhD
Adjunct Associate Professor
Department of Surgery
Rutgers Robert Wood Johnson
Medical School
New Brunswick, NJ