DISCUSSION

With the increasing development of the economy, science, and technology in China, the average life expectancy of the Chinese population is also increasing—as is the incidence of esophageal cancer (11). Although the prognosis of esophageal cancer treatment is relatively poor, most aged patients still choose surgery. Esophagectomy is associated with a high rate of postoperative complications, especially in aged patients. In recent years, the idea of fast-track surgery, which reduces surgical stress and enhances recovery of organ function, is gradually being applied to perioperative care of esophageal cancer patients. Adoption of fast-track protocols can reduce the surgical trauma and lighten the postoperative stress response to some extent (12,13). Aged patients, with their weaker bodies, usually experience more complications. They may also have poor postoperative recovery. We have modified our ERAS protocols in many aspects. We conducted this study to evaluate the safety and efficacy of mERAS protocols in aged patients who underwent esophagectomy by observing the postoperative clinical outcomes, QOL, and psychological status of the two groups during POWs 1–8.

The results of this study showed that the postoperative thoracic drainage time and hospital stay of the observation group were significantly shorter than those of the control group, similar to the results of Preston et al. and Munitiz et al. (13,14). In addition, the incidence of pulmonary infections and anastomotic leakage, and the frequency of sputum suctioning, were lower than in the control group. We believe that the main reason for these differences between the two groups was application of the mERAS protocol.


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Our reasoning is as follows: (I) shortening the preoperative food and drink fasting times greatly relieves patient discomfort (e.g., thirst, irritability, anxiety). It also reduces the adverse effects caused by prolonged fasting and reduces the stress response of patients to the operation; (II) we did not perform a cleansing enema for preoperative bowel preparation in the traditional way. The new bowel preparation could reduce the changes in the patients’ physiological environment, which can reduce intestinal damage, increase patient comfort, and reduce the stress response; (III) early postoperative extubation can promote early ambulation, thereby allowing early removal of drainage tubes and avoiding a variety of uncomfortable stimuli caused by the tubes; (IV) the use of a pneumatic pump and early ambulation postoperatively promotes lung function and tissue oxidation capacity and reduces venous stasis and thrombosis (15); (V) adequate early enteral nutrition after operation is a prerequisite for rapid rehabilitation. It is beneficial to the patient’s physiological state and could reduce the occurrence of anastomotic leakage and other complications (16). It also reduces the need for intravenous fluids, the volume of which may be associated with pulmonary and cardiac complications.

Our results showed significantly decreased incidence of anastomotic leakage in the mERAS intervention group, which was an outstanding result. We believed that the low incidence was the result of systematic project. It may associated with the preoperative mental nursing, evaluation of nutritional status, prevention of hyperthermia, protocols to prevent formation of thrombosis, early postoperative ambulation, early enteral nutrition support, prolonged fasting time, our modified surgical techniques and so on.

QOL has become an important concern regarding treatment options and long-term efficacy (17). This study shows that the QOL of the two groups had decreased significantly at POW 1 and gradually increased during POW 2, remaining relative steady during POWs 4–8, although it was still lower than that preoperatively. In addition, the QOL scores at POWs 1, 2, 4, and 8 were higher in the observation group than in the control group (P<0.05), which was largely related to the recovery status of the patient’s postoperative physical, psychological, and social conditions.

Psychological distress is a result of the patient’s emotional experiences brought on by a variety of factors. These emotional experiences could have an adverse effect on the cancer, physical symptoms, and the treatment (18). The psychological distress of the patients in the two groups in this study increased significantly at POW 1, then gradually decreased during POW 2, attaining a relatively steady state at POWs 4–8, although it was still higher than that preoperatively. The psychological distress of patients in the observation group was much lower than that of the controls at POWs 1, 2, 4, and 8 (P<0.05). The reason for this difference may be that, under normal circumstances, although patients often experience psychological distress because of the tumor itself and the side effects of the treatment (19), elderly patients with esophageal cancer who undergo surgery are more prone to fear and uneasiness because they do not have the relevant knowledge about the operation. In addition, the patient’s physical distress and discomfort at POW 1 are more serious because of their age and a more difficult physical recovery although their psychological fear and distress have gradually declined. In contrast, the patients in the observation group had a less severe postoperative stress reaction because of their preoperative education. In addition, the degree of their psychological distress was lower than that of those in the control group.

Application of mERAS protocols to perioperative nursing care in aged patients who undergo esophagectomy could reduce the incidence of postoperative complications. It could also relieve patients’ psychological distress and improve their QOL.

Authors would like to express our sincere appreciation to Dr. Yong Zhu for his valuable comments on our study. We thank Nancy Schatken, BS, MT (ASCP), from Liwen Bianji, Edanz Group China, for editing the English text of a draft of this manuscript.

Funding: This work was supported by the Science and Technology Key Project of Fujian Province, China (grant number: 2014Y0024) and Fujian Province Health Education Joint Plan Project (grant number: WKJ2016-2-09).

Footnote

Conflicts of Interest: The authors have no conflicts of interest to declare.

Ethical Statement: Our study was approved by the Ethics Committee of Fujian Medical University Union Hospital (No. 2015KY025), and all the participants agreed to participate in this study.

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Source: Journal of Thoracic Disease.
Originally published December 2017.