Published online Dec 28, 2015. doi: 10.3748/wjg.v21.i48.13507
Revised: September 20, 2015
Accepted: November 24, 2015
Published online: December 28, 2015
Processing time: 168 Days and 15.1 Hours
AIM: To evaluate the implementation of a clinical pathway and identify clinical factors affecting the clinical pathway for laparoscopic gastrectomy.
METHODS: A standardized clinical pathway for gastric cancer (GC) patients was developed in 2001 by the GC surgery team at the Asan Medical Center. We reviewed the collected data of 4800 consecutive patients treated using the clinical pathway following laparoscopic gastrectomy with lymph node dissection for GC involving intracorporeal and extracorporeal anastomosis. The patients were treated between August 2004 and October 2013 in a single institution. To evaluate the rate of completion and risk factors affecting dropout from the clinical pathway, we used a multivariate logistic regression analysis.
RESULTS: The overall completion rate of the clinical pathway for laparoscopic gastrectomy was 84.1% (n = 4038). In the comparison between groups of intracorporeal anastomosis and extracorporeal anastomosis patients, the completion rates were 83.88% (n = 1740) and 84.36% (n = 2071), respectively, showing no statistically significant difference. The main reasons for dropping out were postoperative complications (n = 463, 9.7%) and the need for patient observation (n = 299, 6.2%). Among the discharged patients treated using the clinical pathway, the number of patients who were readmitted within 30 d due to postoperative complications was 54 (1.1%). In a multivariate analysis, the intraoperative events (OR = 2.558) were the most predictable risk factors for dropping out of the clinical pathway. Additionally, being male (OR = 1.459), advanced age (OR = 1.727), total gastrectomy (OR = 2.444), combined operation (OR = 1.731), and ASA score (OR = 1.889) were significant risk factors affecting the dropout rate from the clinical pathway.
CONCLUSION: Laparoscopic gastrectomy appears to be a good indication for the application of a clinical pathway. For successful application, patients with risk factors should be managed carefully.
Core tip: Laparoscopic gastrectomy has been proven to enhance postoperative recovery compared to open gastrectomy for gastric cancer (GC) patients. Therefore, laparoscopic gastrectomy is thought to be a suitable procedure for a clinical pathway. In this study, we retrospectively analyzed the outcomes of a clinical pathway application for laparoscopic gastrectomy and tried to investigate the clinical factors that may influence a clinical pathway in a high-volume center. Laparoscopic gastrectomy for GC appears to be a good indicator for the application of a clinical pathway. For successful application, patients with risk factors (male, advanced age, total gastrectomy, combined operation, intraoperative events, American Society of Anesthesiologists score) should be managed carefully.