Effects of integrated management on surgical outcomes and mental health of patients following endoscopic submucosal dissection

Abstract

BACKGROUND

Endoscopic submucosal dissection (ESD) is a less invasive local treatment for diseases throughout the gastrointestinal tract.

AIM

To develop an integrated management protocol and analyze its effects on surgical outcomes and mental health of patients after ESD.

METHODS

The study population consisted of patients undergoing ESD before implementation of integrated management and those undergoing ESD by the same pool of surgeons after implementation of integrated management.

RESULTS

The management group exhibited shortened fasting time and length of hospital stay compared to the control group (P < 0.05). The management group exhibited a higher incidence rate of postoperative complications than the control group (3 cases vs 11 cases; P = 0.043). The management group exhibited a lower uncertainty score for disease knowledge compared to the control group 12 h after surgery (P < 0.05). The management group gave more scores on the domains of patient familiarity to the responsible nurses, professional skills of responsible nurses, and general evaluation compared to the control group. The management group had a higher total score of patient satisfaction towards the responsible nurses in term of health care than the control group (P < 0.01). The management group exhibited lower Self-Rating Anxiety Scale and Self-Rating Depression Scale scores compared to the control group 12 h after surgery (P < 0.01).

CONCLUSION

The study demonstrates that integrated management could improve surgical outcomes and mental health of patients undergoing ESD.

Key Words: Endoscopic submucosal dissection, Gastrointestinal tract, Hospital stay, Outcome, Mental health

Core Tip: Technical difficulty results in a long time as well as many postoperative complications in the process of implementing endoscopic submucosal dissection (ESD). The integrated management protocol involving a multidisciplinary team, ESD guidelines and nursing pathway, health education model, and discharge criteria could improve surgical outcomes and mental health of patients undergoing ESD.

INTRODUCTION

The main therapeutic approach for large non-pedunculated colorectal polyps and early (T1) colorectal cancer is endoscopic submucosal dissection (ESD) in a number of East Asian countries[1]. ESD could promote R0-resection, improve histological assessment, and prevent disease recurrence, optimizing the endoscopic management of colorectal lesions[2]. This approach may contribute to the incidence of postoperative comorbidities, significantly affecting the quality of life of patients[3]. ESD is a challenging and risky operation, which suggests the crucial importance of case selection, especially in the colorectum[4]. Although ESD has the chance to overcome the limitations of endoscopic mucosal resection, it technically demands prolonged procedure times with more costs and carries a higher risk of complications, and has been restricted to lesions suspicious for high-grade dysplasia or early invasive cancer[5,6]. ESD was effective and safe in the treatment of colorectal laterally spreading tumors, but technical failure tends to occur in cases with positive non-lifting sign and tumor ≥ 20 mm or lesions resected by less-experienced endoscopists, creating a critical need for ESD procedure guidelines and expert endoscopic skills[7]. Improved peri-procedural preparation, profound understanding of endoscopic and maneuvers, and sufficient equipment knowledge all allow the feasibility of colorectal ESD[8].

During the traditional nursing management, nurses and physicians do not share the same views in the decision-making process of patients’ care, leading to absence of nurse-physician collaborations and a higher possibility of errors and omissions in patients’ care[9]. Nurse-physician collaborations are very important for team-based patient care in everyday practice and should be acknowledged by both nurses and physicians[10]. Interprofessional teamwork interventions should be developed and implemented to improve collaboration[11]. To improve nurse-physician communication and surgical recovery, an interdisciplinary team-based approach should be considered[12]. In this study, we developed an integrated management protocol to enhance nurse-physician communication and interdisciplinary team collaboration and analyzed its effects on surgical outcomes and mental health of patients after ESD.

MATERIALS AND METHODS

Patient selection

The study population consisted of patients undergoing ESD before implementation of integrated management from March 2021 to July 2021 and those after implementation of integrated management from March 2022 to July 2022. The inclusion criteria were: (1) Patients with adenomas > 20 mm that cannot be completely resected by ESD and early colorectal cancer that must be evaluated for resectability through lifting sign, endoscopy, or endoscopic ultrasound before surgery; (2) Patients with adenomas with non-lifting sign and early colorectal cancer; (3) Residual or recurrent lesions > 10 mm after ESD, and lesions that are difficult to resect by ESD; (4) Low rectal lesions that cannot be confirmed as cancer regardless of repeated biopsies; and (5) ESD was performed by the same pool of surgeons between the two periods. The exclusion criteria were: (1) Patients with tumors that have invaded into the deep submucosal layer; (2) Evidence of lymph node metastasis by preoperative examination; (3) Patients with familial adenomatous polyps and inflammatory bowel disease; and (4) Patients with coagulation dysfunction, hematological disorders, or taking anticoagulants, as well as those with severe cardiovascular and pulmonary diseases who cannot tolerate ESD. The patients undergoing ESD before implementation of integrated management were propensity-matched historical controls, severing as the control group. The patients agreed to participate in this study were asked to sign an informed consent form prior to ESD procedures after implementation of integrated management, severing as the management group. The study was approved by the Ethics Committee of Ningbo Yinzhou No. 2 Hospital.

Integrated management protocol

The integrated management protocol involved the following four aspects: A multidisciplinary team, ESD guidelines and nursing pathway, health education model, and discharge criteria. The multidisciplinary team included the Department of Gastroenterology Outpatient, Admission Preparation Center, 614 and 615 wards, Operating Room, and Endoscopy Center. The team members improved the instructions before admission and health education prescriptions which were distributed and educated by outpatient doctors and ward nurses, respectively. The Admission Preparation Center assisted in improving the preparation before admission. An assigned endoscopic surgery room was prepared. A WeChat message group was established and responsible for arrangement of regular meetings, summary of surgical procedures, and identification of existing problems. ESD guidelines and nursing pathway were updated. The health education model was updated. The instructions before admission and videos focusing on health education for intestinal ESD surgery were made. The intestinal ESD surgery education form was updated. A regular area for health education was assigned. The health education was promoted in diverse forms. The follow-up was refined and performed after discharge. When a patient was discharged, he/she should be informed of postoperative precautions and receive corresponding dietary plans. It is hoped that the patient can improve his/her self-protection awareness and develop good dietary and lifestyle habits after surgery. At the same time, the patient’s contact information was obtained to regularly guide them for follow-up visits via phone to better improve their quality of life.

Disease knowledge evaluation

Patient uncertainty for disease knowledge was evaluated at admission and 12 h after surgery. There are a total of 4 common factors covering 34 items, with a score range of 35-170. A higher score indicates a higher level of uncertainty of the disease.

Patient satisfaction

The patient satisfaction towards the responsible nurses was evaluated at admission and 12 h after surgery in term of health care involving 10 domains with a score ranging from 1 to 5 points representing the worst to best. The 10 domains include patient familiarity to the responsible nurses, service enthusiasm of the responsible nurse, health education from the responsible nurses, bed sheet replacement, timely assistance from the responsible nurses in case of requirement of help for life, timely infusion and withdrawal of needles by the responsible nurses, timely assistance from the responsible nurses in case of special difficulties confronted by the patients, active and rapid response from the responsible nurses during ward rounds, professional skills of responsible nurses, and general evaluation.

Depressive and anxiety symptoms

Depressive and anxiety symptoms were evaluated at admission and 12 h after surgery using the Chinese versions of the Zung’s Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS) that exhibit a Cronbach’s α coefficient of 0.827 and 0.898, respectively. The SAS and the SDS are 20-item self-report instruments designed to measure depressive and anxiety symptoms of each respondent for nearly 1 wk, each of which is scored 1 to 4 (never or very infrequently marked as 1, some of the time marked as 2, good part of the time marked as 3, and most or all of the time marked as 4). The raw scores range from 20 to 80 and are transformed to a standardized total score ranging from 25 to 100. Higher scores indicate more obvious anxiety and depression.

Statistical analysis

Demographic characteristics, disease-related characteristics, and outcome measures are summarized as the arithmetic mean with standard deviation for continuous variables, and frequencies and percentages for categorical variables. GraphPad prism 8.0 (GraphPad Software, San Diego, CA, United States) was employed to perform statistical tests including unpaired t-test and Fisher’s exact test, with P < 0.05 suggesting statistical significance.

RESULTS

Patient characteristics

The management group consisted of 60 prospective patients undergoing ESD after implementation of integrated management. There were 60 patients in the control group from which the propensity-matched cohort was pulled. As shown in Table 1, two cohorts were matched for age, gender distribution, body mass index, disease duration, and disease types (P > 0.05).

Table 1 Patient characteristics between the management group and control group.

Variable	Management group (n = 60)	Control group (n = 60)	P value
Age (yr, mean ± SD)	45.6 ± 3.5	44.3 ± 3.2	NS
Gender distribution, n (%)	32 (53.3)	30 (50.0)	NS
BMI (kg/m2, mean ± SD)	22.1 ± 2.1	21.8 ± 2.0	NS
Disease duration (month, mean ± SD)	4.7 ± 0.9	4.9 ± 0.9	NS
Disease type, n (%)			NS
Rectal leiomyoma	18 (30.0)	21 (35.0)	NS
Rectal adenoma	18 (30.0)	17 (28.3)	NS
Colorectal cancer	14 (23.3)	13 (21.7)	NS
Rectal stromal tumor	10 (16.7)	9 (15.0)	NS

BMI: Body mass index; NS: Not significant.

Effects of integrated management on surgical outcomes

The operation duration, fasting time, and length of hospital stay in the control group and management group are listed in Table 2. The two groups did not differ in the operation duration (P > 0.05). The management group exhibited shortened fasting time and length of hospital stay compared to the control group (P < 0.05). There were four cases of abdominal pain, three cases of bleeding, three cases of perforation, and one case of pulmonary infection in the control group. There were two cases of abdominal pain and one case of bleeding in the management group. The management group exhibited a higher incidence rate of postoperative complications than the control group (P = 0.043).

Table 2 Operation duration, fasting time, and length of hospital stay in the control group and management group.

Variable	Management group (n = 60)	Control group (n = 60)	P value
Operation duration (min, mean ± SD)	62.8 ± 9.7	65.4 ± 9.6	NS
Fasting time (d, mean ± SD)	1.6 ± 0.3	2.2 ± 0.4	< 0.01
Length of hospital stay (d, mean ± SD)	3.6 ± 0.5	4.8 ± 0.6	< 0.01
Postoperative complications, n (%)	3 (5.0)	11 (18.3)	0.043

NS: Not significant.

Effects of integrated management on patient knowledge about disease and patient satisfaction

The two groups did not differ in the uncertainty scores for disease knowledge at baseline (P > 0.05). The management group exhibited a lower uncertainty score for disease knowledge compared to the control group 12 h after surgery (P < 0.05). The management group gave more scores on the domains of patient familiarity to the responsible nurses, professional skills of responsible nurses, and general evaluation compared to the control group. The management group had a higher total score of patient satisfaction towards the responsible nurses in term of health care than the control group (P < 0.01, Table 3).

Table 3 Uncertainty scores for disease knowledge and patient satisfaction in the control group and management group.

Variable	Management group (n = 60)	Control group (n = 60)	P value
Uncertainty score for disease knowledge (mean ± SD)
Baseline	93.4 ± 7.8	92.8 ± 7.5	NS
12 h after surgery	69.3 ± 6.5	78.5 ± 7.0	< 0.01
Patient satisfaction (mean ± SD)	47.2 ± 2.1	44.6 ± 2.3	< 0.01

NS: Not significant.

Effects of integrated management on mental health of patients

The depressive and anxiety symptoms of patients in the control group and management group were evaluated by SDS and SAS scores which are listed in Table 4. The two groups did not differ in SDS and SAS scores at baseline (P > 0.05). The management group exhibited lower scores of SDS and SAS compared to the control group 12 h after surgery (P < 0.01).

Table 4 Self-Rating Depression Scale and Self-Rating Anxiety Scale scores in the control group and management group.

Variable	Management group (n = 60)	Control group (n = 60)	P value
SDS (mean ± SD)
Baseline	53.7 ± 6.2	54.1 ± 6.0	NS
12 h after surgery	38.6 ± 3.0	45.6 ± 3.5	< 0.01
SAS (mean ± SD)
Baseline	57.2 ± 5.1	58.0 ± 5.2	NS
12 h after surgery	44.6 ± 3.3	52.2 ± 4.8	< 0.01

SDS: Self-Rating Depression Scale; SAS: Self-Rating Anxiety Scale; NS: Not significant.

DISCUSSION

The ESD procedures could restore normal gastrointestinal function without impacting patient quality of life while removing the lesions for treating digestive tract diseases[13]. However, technical difficulty results in a long time as well as many postoperative complications in the process of implementing ESD[14]. The key for successful ESD procedures is an interdisciplinary cooperation between the operator and nurse so that the lesions can be safely resected, and complications can be reduced or avoided. To achieve better surgical outcomes after ESD procedures, our study developed an integrated management protocol and demonstrated its efficacy in improving surgical outcomes and mental health for patients undergoing ESD.

The results of this study showed that the implementation of integrated management could shorten the fasting time and reduce the length of hospital stay. For colorectal lesions larger than 10 cm, ESD is associated with higher technical difficulty and longer procedure times[15]. The implementation of integrated management allows patients receiving a continuum of health promotion, disease prevention and management, as well as rehabilitation based on their needs throughout the life course, thus significantly improving surgical recovery and reducing the length of hospital stay[16]. When patients were given ESD with the implementation of integrated management, they had higher scores on patient familiarity to the responsible nurses, professional skills of responsible nurses, and general evaluation. Like the integrated management developed in this study, the enhanced recovery after surgery protocol offers greater patient satisfaction after ESD[17]. A previous study showed that patient education via instagram is an effective way to increase disease-related knowledge and patient outcomes are thus improved[18]. In our integrated management, the WeChat group was the main method to increase patient education on disease-related knowledge and ESD guidelines. The implementation of integrated management run through the entire process of ESD procedures and further improved the quality of nursing[19]. Related studies have found that high-quality nursing to achieve better nurse-physician collaborations can effectively improve the clinical nursing quality of patients undergoing ESD surgery for early colorectal cancer, improve the nursing work environment, and ensure the postoperative quality of life of patients[20]. The integrated management affirmed and strengthened the leading role of nursing staff in team collaboration, mobilized their enthusiasm for work, enhanced their sense of achievement, promoted the effective nurse-physician collaborations, and ultimately improved patient outcomes[21]. Endoscopic treatment for early gastric cancer provides better patient quality of life, but stomach preservation might provoke cancer recurrence worries. To relieve a patient’s concern of cancer recurrence, endoscopists should address this issue during follow-up period after ESD[22]. As suggested by our results, when patients were given ESD with the implementation of integrated management, they exhibited lower scores of SDS and SAS compared to the control group 12 h after surgery.

The study limitations should be noted when the present data are interpreted. The first limitation was the small sample size in single center, which highlights the need for large-scale populations in multiple centers in future prospective randomized controlled studies. Additional limitation of the study was lack of follow-up data and hospitalization costs, which initiates the need of further studies investigating the long-term effects of integrated management developed in this study.

CONCLUSION

In conclusion, our study has developed an integrated management protocol and demonstrated that this nursing care pathway could significantly improve postoperative outcomes, enhance recovery, and achieve better patient satisfaction towards the responsible nurses in term of health care. These findings, if confirmed by large-scale population and widespread cancer types, will be more profound.