Effectiveness of nursing interventions in the postoperative recovery of gastric cancer patients : a systematic literature review

Context: Gastric cancer is a global health problem and surgery is the most common curative treatment. Objectives: To analyze and synthesize the nursing programs/interventions and their effectiveness in the postoperative recovery of gastric cancer patients. Review Method: Using a PICO guiding question, a literature review was conducted on articles exploring the effectiveness of nursing programs/interventions in the postoperative recovery of gastric cancer patients aged 18 years or more and published between 2005 and 2015. A search was performed in the CINAHL®, Cochrane Central Register of Controlled Trials, MedicLatina, and MEDLINE® databases. The methodological quality was assessed based on the recommendations of the Joanna Briggs Institute®. Interpretation of Results: Three studies were included, which support the effectiveness of nursing interventions in reducing patients’ functional and nutritional decline, and improving their cognitive function, knowledge, and ability to cope with the disease. Conclusion: The nursing programs/interventions contribute to the postoperative recovery of gastric cancer patients. Further studies should be conducted to consolidate these results.


Introduction
Gastric cancer is a global health problem, and it is one of the few malignant neoplasms with geographical differences in terms of incidence, pathology, treatment, and evolution.Although its incidence has been declining in the Western hemisphere, steady rates have been reported in Eastern countries, particularly South Korea and Japan (Yamamoto, Rashid, & Wong, 2015).The International Agency for Research on Cancer (International Agency for Research on Cancer, World Health Organization, 2014) estimates that, in 2012, approximately 1 million new cases of gastric cancer and 720,000 deaths occurred worldwide, with a higher incidence in Asia, Latin America, and Eastern Europe.
In 2012, about 734,000 of gastric cancer cases were attributable to Helicobacter pylori infection, which is the cause of 80% of cases of stomach cancer.For the American Cancer Society (2014), stomach cancer or gastric cancer is a cancer that starts in the stomach and tends to develop slowly over the years.Before a true cancer develops, pre-cancerous changes often occur in the inner lining of the stomach.There are currently four primary strategies available for cancer treatment: surgery, chemotherapy, radiotherapy, and biotherapy.According to Diaz-Nieto, Orti-Rodríguez, and Winslet (2013), Laporte, Weston, Paludo, Castria, and Kalil (2014), and Mello, Lucena, Echer, and Luzia (2010), surgery is the initial treatment choice because, given the advancement in surgical techniques, it is the only curative treatment of gastric cancer.However, it should be noted that survival rates are still low and, in order to improve these results, chemotherapy after surgery may be recommended.The surgical removal of the stomach is the most common curative treatment in gastric cancer patients; hence, Park and Park (2010) argue that it is important to develop guidelines for these patients' pre and postoperative care.Mello et al. (2010) also emphasize the importance of nurses' intervention in providing guidance/educating patients and their families and that this intervention should start in the preoperative period and continue throughout treatment, including the late postoperative period.Patients and their families need help for accepting the disease and deciding on treatment options, as well as information to promote the patient's recovery.

Systematic Review Method
The systematic review began with the formulation of the question based on the PICO strategy -Population, Intervention, Comparison, and Outcome (Joanna Briggs Institute, 2014).Inclusion criteria (Table 1) were defined to guide the search and select the relevant literature of interest to the intended outcomes and the formulated question.In addition to the criteria shown in Table 1, we also took into account the publication date: (January 2005 and June 2015 and the language (Portuguese, Spanish, or English).
of Pereira and Bachion (2006).A Relevance Test I (preliminary) was used with the purpose of refining the initial selection of articles (title and abstract reading).The studies selected in the Relevance Test I were again assessed in the Relevance Test II (full-text reading).

Assessment of the methodological quality of the studies
In this review, two reviewers assessed the methodological quality of the studies using the instruments recommended by the Joanna Briggs Institute (2011), adapted by Araújo (2014), namely the "Meta-Analysis of Statistics Assessment and Review Instrument (MAStARI) critical appraisal tools Comparable Cohort/Case Control Studies" and the "MAStARI critical appraisal tools Descriptive/Case Series Studies".The "MAStARI critical appraisal tools Randomized Control / Pseudo-randomized Trial" was also used.High or moderate quality studies (score higher than 7 or between 4 and 6, respectively) were included.Low quality studies were excluded.

Data extraction
Data were extracted and discussed by two independent reviewers to reach a consensus.Data extraction was based on the guidelines of the Joanna Briggs Institute (2014), adapted by Araújo (2014), taking into account the title, authors, year and place where the study was developed, methodological guidelines, objectives, participants, ethical aspects, intervention performed, statistical tests, outcomes, and conclusion of the articles.The items were compiled in a table with the purpose of proceeding to the narrative summary of the data.

Data synthesis
In this study, the narrative summary of quantitative data was performed since the included studies showed a great variability in terms of interventions and population.For this reason, they could not be grouped in order to meet the conditions necessary for the meta-analysis.

Presentation of results
Considering the methods described, the search results were refined depending on the criteria established until we reached the number of articles included in this review.Figure 1 shows the flow chart describing the steps taken until we reached the number of articles included.

Interpretation of the Results
Two studies were conducted in Asia (Thailand, Korea and Japan) and one in Europe (Germany); the scarce geographical variability puts into evidence the importance attributed by these countries to this issue.This finding is consistent with other studies, namely in Yamamoto et al. (2015), who mention that,

Reduction of postoperative complications
The organized and systematic implementation of nursing interventions in the pre-and postoperative period can be effective in improving surgical outcomes (S29), as well as in detecting and allowing the early intervention in possible postoperative complications, namely by providing help to perform activities of daily living, maintain the nutritional status, and improve the cognitive function (S23).When analyzing nursing interventions targeting gastric cancer patients in 14 centers, Ahn et al. (2011;S29) found similar interventions in the hospitals, except for the length of hospital stay.The authors emphasized that the information obtained can help set up protocols and consequently improve surgical outcomes.This study involved surgeons who described some interventions, including nursing interventions implemented in the pre and postoperative period such as the insertion/maintenance of a nasogastric tube, the patient's empowerment for pain selfmanagement, initiation of diet and corresponding education/support program, etc. Mental alterations, namely confusion, delirium, and agitation, are among the most common postoperative complications.Chen et al. (2011;S23) reported that the decline of cognitive function after surgery is common and may lead to increased mortality.This finding was also sustained by Ruiz-Neto, Moreira, and Furlaneto (2002), who report that delirium is a common complication in the postoperative period, being associated with increased postoperative mortality and morbidity.Therefore, with regard to cognitive function, the delivery of specific care, including therapeutic cognitive activities (orientating communication and cognitive stimulation activities, etc.) reduces postoperative delirium rates (S23).
In addition, in S23, Chen et al. (2011) found that care protocols reduced functional decline.Early mobilization and nutritional assistance contributed to a significantly lower decline in the patients' performance of activities of daily living and nutritional status.Sands (2007) shared this opinion, and emphasized that early mobilization after surgery is essential for the prevention of several complications because of the sharp decline in the self-care ability faced by gastric cancer patients.Sands (2007) also mentioned that these patients are at risk of having postoperative complications in the digestive system, including gastric reflux, dumping syndrome, among others.So, nurses play a key role in making the necessary changes to the patients' diet and providing education on eating strategies in order to minimize potential disorders and nutritional decline.
Similarly, Park and Park (2010) emphasized the importance of guidelines for the prevention, detection, and early intervention in possible postoperative complications such as bleeding, reflux gastritis, and dumping syndrome, as well as the reduction of disparities specific to nursing care delivery.

Promotion of self-management skills and quality of life improvement
Educating gastric cancer patients through interactive programs proved to be more effective in terms of the patient's disease-related knowledge in the short-(hospitalization) and long-term (6 and 12-month follow-up), such as coping with the disease in the short-term, when compared with an information-only program (Faller, Koch, Reusch, Pauli, & Allgayer, 2009;S27).Both programs were informative and had the same contents.The main difference was the amount of interaction allowed among patients and between patients and the educator.
In the interactive program (S27), patients were encouraged to ask questions and were in turn asked questions by the educator to promote a deeper understanding of the information presented.Patients were encouraged to link the information with their personal situations, thereby increasing their knowledge about their condition/disease and on how to cope with the illness, reinforcing the importance of the patients' interaction/participation in their care.Melo (2005) argues that informing and engaging patients, i.e. allowing interaction between the health professional and the patient, contributes to satisfy different needs, namely: "Facilitates coping with the disease, enhances the acceptance of the procedures, increases commitment and compliance, and leads to respect and dignity preservation" (p.58).In this line of thought, Wittmann et al. (2011) mention that providing adequate information improves the patients' psychological well-being and enables them to develop strategies to cope better with their condition and develop their ability to self-manage the disease and its implications.In S27, Faller et al. (2009), using the Gastrointestinal Life Quality Index (GLQI) which covers gastrointestinal symptoms, emotional well-being, physical function, social function, and medical treatment concluded that the group that received an interactive program reported a higher quality of life than the group that received the basic information program, in which no interaction was allowed between patient and educator.This difference in the results was only observed during hospitalization and not in the long term (6and 12-month follow-up).This may be due to the fact that the program was only implemented during hospitalization and not during the follow-up period.
Several authors corroborate the abovementioned data, including Santos and Fuly (2014), who argue for the need of a comprehensive patient care that includes not only hospital care, but also follow-up outside of the hospital (e.g., home visits), in order to ensure the patients' autonomy and quality of life.Malmstrom, Ivarsson, Johansson, and Klefsgard (2013) described cancer patients' experiences after surgical treatment in terms of their quality of life and ability to cope with their new situation.The results of the study showed that a supportive care program which encompasses care delivery is necessary to meet the patients' needs, particularly their physical, psychological, and social needs during diagnosis, treatment, and follow-up.Mello et al. (2010) believe that a multidisciplinary intervention, capable of addressing the patient as a whole, can improve postoperative outcomes and quality of life.

Conclusion
The With regard to the reduction of postoperative complications, we observed a lower functional decline in the performance of activities of daily living and in nutritional status, and the improvement of the cognitive function and surgical outcomes.As regards self-management skills, patients improved their level of knowledge about their condition/disease in the short-and long-term, as well as their ability to cope with the illness in the short-term.Patients' quality of life and well-being in the physical (improvement of gastrointestinal symptoms), emotional, and social domains improved during hospitalization.This SLR has some limitations and weaknesses.One of the limitations is the heterogeneity of the included studies, which made it impossible to conduct a meta-analysis and hindered the generalization of the results.Another limitation was the inclusion criterion related to the language of publication (only studies written in Portuguese, Spanish, and English were included), which may have contributed to the exclusion of potentially relevant studies.The fact that the search was performed based on title and abstract using keywords and a few synonyms, with no truncation in the search strategy, may have also contributed to the exclusion of potentially relevant studies.However, the expected objectives were achieved.The results obtained have implications for care delivery, particularly due to their contribution to the justification and redefinition of perioperative nursing interventions in gastric cancer patients undergoing surgery.Furthermore, they offer a valuable contribution to these patients' recovery, reducing complications and improving their disease self-management skills and quality of life.
In terms of research, it should be emphasized that further randomized studies are needed to enhance the current evidence on the topic under analysis, confirm/reinforce these results and/or explore the effectiveness of these interventions in other care dimensions with the purpose of improving health outcomes.

Figure 1 .
Figure 1.Flowchart of the search for the systematic literature review.Three studies were selected for assessment of the methodological quality: a pilot clinical trial (nonrandomized), a prospective study with a controlled clinical trial, and a descriptive and comparative study.With regard to the methodological quality, we found one high quality study and two moderate quality studies.None of the articles had low quality, and all of them passed in the methodological quality assessment test (Table2).

Table 1
Inclusion Criteria The studies were selected by two independent reviewers in two phases.Relevance tests were conducted in accordance with the recommendations

Table 2
Articles according to the JBI methodological quality score

Table 3
Summary of the data extracted after critical appraisal of the studies