title: Use of a clinical pathway in laparoscopic gastrectomy for gastric cancer.
abstract: OBJECTIVE
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Hee Sung Kim, Byung Sik Kim, Department of Gastric Surgery, Asan Medical Center, Ulsan University School of Medicine, Seoul 138-736, South Korea.
authors.forename: Hee Sung
authors.initials: HS
authors.lastname: Kim
authors.affiliation: Hee Sung Kim, Byung Sik Kim, Department of Gastric Surgery, Asan Medical Center, Ulsan University School of Medicine, Seoul 138-736, South Korea.
authors.forename: Sun Oak
authors.initials: SO
authors.lastname: Kim
authors.affiliation: Hee Sung Kim, Byung Sik Kim, Department of Gastric Surgery, Asan Medical Center, Ulsan University School of Medicine, Seoul 138-736, South Korea.
authors.forename: Byung Sik
authors.initials: BS
authors.lastname: Kim
mesh_terms: D000368:Aged; D016009:Chi-Square Distribution; D019091:Critical Pathways; D003661:Decision Support Techniques; D005260:Female; D005743:Gastrectomy / Q000009:adverse effects / Q000379:methods*; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects; D016015:Logistic Models; D008197:Lymph Node Excision; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D010352:Patient Dropouts; D010359:Patient Readmission; D011183:Postoperative Complications / Q000628:therapy; D056910:Republic of Korea; D012189:Retrospective Studies; D012307:Risk Factors; D013274:Stomach Neoplasms / Q000473:pathology / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome
keywords: Clinical pathway; Extracorporeal anastomosis; Gastric cancer; Intracorporeal anastomosis; Laparoscopic gastrectomy