Effectiveness of a standardized nursing pathway in perioperative care for endoscopic submucosal dissection of gastrointestinal tumors

Abstract

BACKGROUND

Endoscopic submucosal dissection (ESD) is a standard treatment for early gastrointestinal tumors; however, it carries perioperative risks. Conventional fragmented nursing often fails to meet the need for comprehensive care. The efficacy of standardized nursing pathways (SNP) in the perioperative care of patients undergoing ESD remains insufficiently validated.

AIM

To evaluate the effectiveness of a SNP in the perioperative management of patients undergoing ESD for gastrointestinal tumors.

METHODS

This retrospective cohort study included 160 patients who underwent ESD between January and December 2024 and were divided into two groups: Control (routine nursing care, n = 80) and study (SNP, n = 80) groups. The pathway structured perioperative care into six phases (admission to discharge), mandated validated assessment tools (Self-Rating Anxiety Scale for anxiety and Visual Analog Scale for pain) at specified time points, and included structured education and standardized interventions (bowel preparation, dietary progression, mobilization, and discharge criteria). Perioperative indicators, complications, anxiety, pain scores, and nursing satisfaction were compared.

RESULTS

The study group had significantly shorter total and postoperative hospital stays and lower hospitalization and medication costs (all P < 0.05). The incidence of complications was lower in the study group than in the control group (3.75% vs 13.75%; P < 0.05). Anxiety and pain scores on postoperative days 1 and 2 and at discharge were significantly lower in the study group (all P < 0.05). Nursing satisfaction was higher in the study group (98.75% vs 86.25%; P < 0.05).

CONCLUSION

Incorporating SNPs into the endoscopic management of gastrointestinal tumors optimizes medical resources, accelerates postoperative recovery, reduces complication risks, alleviates negative emotional states, and enhances nursing quality and patient satisfaction.

Key Words: Standardized nursing pathway; Gastrointestinal tumors; Endoscopic submucosal dissection; Perioperative nursing; Quality of nursing care

Core Tip: This retrospective cohort study evaluated the efficacy of a standardized nursing pathway (SNP) in the perioperative care of patients undergoing endoscopic submucosal dissection (ESD) for gastrointestinal tumors. Compared with routine nursing, the SNP group demonstrated significantly shorter hospital stay, lower costs, reduced complication rates, and decreased postoperative anxiety and pain. Additionally, patient satisfaction with nursing care was markedly higher. These findings indicate that implementing a SNP optimizes clinical outcomes, enhances recovery, and improves the overall quality of care in ESD procedures.

INTRODUCTION

Gastrointestinal tumors are common malignant neoplasms of the digestive tract with persistently high incidence and mortality rates. Advances in endoscopic technology have made endoscopic submucosal dissection (ESD) a key treatment modality for patients with early stage gastrointestinal tumors[1]. ESD has significant advantages in achieving complete lesion resection, minimizing tissue damage, and accelerating postoperative recovery. However, this procedure is technically complex and involves a large surgical field, which poses a risk of delayed postoperative bleeding, perforation, and infection. Patients often experience varying degrees of anxiety and pain, necessitating higher standards of quality in perioperative nursing care[2,3]. Therefore, optimizing perioperative management and promoting rapid recovery while ensuring surgical safety have become key focuses of current clinical nursing research. Traditional nursing models rely primarily on physician orders, resulting in fragmented care processes that lack systematic consistency and fail to adequately fulfill the multifaceted and continuous care needs of patients undergoing ESD. In recent years, standardized nursing pathways (SNP), a care model emphasizing evidence-based practice, process management, and multidisciplinary collaboration, have demonstrated the potential to improve clinical workflows, reduce complications, and enhance patient experience across various perioperative surgical settings[4,5]. By establishing standardized and quantifiable timelines and procedures for specific diseases and surgeries, these pathways can standardize and systematize nursing interventions, thereby significantly improving the quality of care and optimizing healthcare resource utilization[6]. Although existing research suggests the positive effects of nursing pathways in treating some gastrointestinal diseases, evidence supporting their application in the perioperative period of ESD for gastrointestinal tumors remains limited, necessitating further clinical data and prompting the present cohort study.

MATERIALS AND METHODS

General information

This retrospective cohort study enrolled 160 patients with gastrointestinal tumors who underwent ESD at our hospital between January and December 2024. The participants were divided into two groups according to the nursing approach: Control [received routine care (n = 80)] and study [underwent SNP (n = 80)]. The SNP had already been implemented as routine clinical practice before the study period, and the present study retrospectively analyzed clinical data. No statistically significant differences were observed between the groups in the baseline characteristics, including sex, age, body mass index (BMI), procedure type (gastric ESD/intestinal ESD), maximum tumor diameter, or American Society of Anesthesiologists (ASA)[7] physical status classification (all P > 0.05), ensuring comparability between the groups (Table 1). The study protocol was reviewed and approved by the Ethics Committee of the Fourth Affiliated Hospital of Zhejiang University School of Medicine (approval No. K2025310). A flow diagram illustrating the study process is presented in Figure 1.

Figure 1  Research flowchart.

Table 1 Comparison of baseline characteristics between the two groups, n (%).

Indicator	Study group (n = 80)	Control group (n = 80)	t/χ2	P value
Gender			1.616	0.204
Male	48 (60.00)	40 (50.00)
Female	32 (40.00)	40 (50.00)
Age (years)	58.42 ± 10.12	58.90 ± 9.87	0.304	0.762
BMI (kg/m2)	24.36 ± 3.12	24.58 ± 3.05	0.451	0.653
Surgical type			0.227	0.634
Gastric ESD	35 (43.75)	38 (47.50)
Intestinal ESD	45 (56.25)	42 (52.50)
Maximum tumor diameter (cm)	1.85 ± 0.78	1.90 ± 0.82	0.395	0.693
ASA classification			1.911	0.385
Grade I	50 (62.50)	58 (72.50)
Grade II	25 (31.25)	19 (23.75)
Grade III	5 (6.25)	3 (3.75)
NRS 2002 score (points)	1.25 ± 0.68	1.32 ± 0.71	0.637	0.525
History of gastrointestinal disease	22 (27.50)	18 (22.50)	0.533	0.465
Use of anticoagulants/antiplatelet agents	9 (11.25)	12 (15.00)	0.493	0.482

BMI: Body mass index; ESD: Endoscopic submucosal dissection; ASA: American Society of Anesthesiologists; NRS 2002: Nutritional Risk Screening 2002.

Inclusion criteria: Pathologically and endoscopically confirmed gastrointestinal tumors fulfilling ESD treatment indications; age 18-80 years; Eastern Cooperative Oncology Group performance status score 0-1; ability to tolerate endoscopic surgery; alert consciousness with basic communication and comprehension abilities; and voluntary participation in this study with a signed informed consent.

Exclusion criteria: Current severe cardiac, pulmonary, hepatic, or renal insufficiency or coagulation disorders; psychiatric disorders or cognitive impairment preventing the completion of study assessments; pregnancy or lactation; incomplete clinical data; withdrawal during the study; or loss to follow-up.

All eligible consecutive patients during the study period were included.

Research protocol

Both groups underwent ESD performed by the same endoscopist team. The control group received conventional care, wherein physicians issued orders based on clinical experience, and assigned nurses performed basic nursing care and routine health education according to these orders.

The research team implemented SNP management in addition to the routine care. To ensure the scientific validity and practicality of the pathway, a pathway development team comprising a department director, head nurse, senior physician, and experienced specialty nurse was formed. Based on a review of the latest domestic and international guidelines and evidence-based literature, the team collaboratively developed the specific content of a standardized perioperative nursing pathway for gastric/intestinal ESD. This pathway divides perioperative management into six critical phases: Admission day, preoperative day 1, surgery day, postoperative days 1 and 2, and discharge day. It clearly defines the standardized tasks for each phase and nursing shift, including the following.

(1) Systematic assessment items (with standardized scales, tools, judgment criteria and operation procedures): (a) Vital signs: Assessed by electronic sphygmomanometer and electronic thermometer, measured 4 times a day (6:00, 10:00, 14:00, 18:00); judgment criteria refer to the 2025 Chinese Clinical Nursing Practice Guidelines, with systolic blood pressure 90-140 mmHg, diastolic blood pressure 60-90 mmHg, body temperature 36.0-37.2 °C as normal ranges; (b) Pain levels: Assessed by the Visual Analog Scale (VAS)[8], administered by trained nurses who guide patients to score independently on a 0-10 scale; scores ≥ 4 points are defined as moderate to severe pain requiring intervention; (c) Anxiety status: Assessed by the Zung Self-Rating Anxiety Scale (SAS)[9], completed by patients independently with nurse guidance for unclear items; raw scores are converted to standardized scores (× 1.25), with standardized scores ≥ 50 points indicating anxiety and stratified as mild (50-59), moderate (60-69) and severe (≥ 70); (d) Nutritional status: Assessed by the Nutritional Risk Screening 2002 (NRS 2002) scale[10], operated by clinical nurses; scores ≥ 3 points indicate nutritional risk and require individualized nutritional intervention plans; and (e) Postoperative bleeding risk: Assessed by the self-developed gastrointestinal ESD Postoperative Bleeding Risk Assessment Scale (validated by expert consultation, Cronbach’s α = 0.86), including 5 indicators (tumor size, operation time, coagulation function, history of anticoagulant use, postoperative diet compliance); total score 0-10 points, ≥ 6 points as high risk, with enhanced monitoring frequency (1 time per hour). All assessment data were recorded in a unified electronic nursing record form, with abnormal indicators marked in red and reported to the attending physician within 30 minutes, and the intervention measures were recorded in real time.

(2) Phased health education (with specific materials, duration, implementers, frequency and assessment methods): (a) Implementation personnel: Specialty nurses with ≥ 5 years of clinical nursing experience in gastroenterology, trained and qualified in ESD perioperative care and health education (pass rate of theoretical and operational assessment ≥ 90%); (b) Education materials: Standardized bilingual (Chinese/English) health education manual (self-developed, 16 pages, including disease knowledge, surgical process, nursing points, etc.), animated video (8 minutes, explaining ESD and postoperative care), and PPT courseware (12 pages, face-to-face explanation); (c) Time and frequency: Phased one-on-one education, with each teaching session controlled at 15-20 minutes to avoid patient fatigue; the specific frequency was formulated according to the perioperative phase; and (d) Assessment method: After each health education session, the implementer conducts an on-site oral assessment (5 basic questions, such as “What is the fasting time before ESD surgery?”), a correct response rate ≥ 80% is considered qualified; for unqualified patients, targeted re-education is conducted within 2 hours until qualified, and the assessment results are recorded in the health education record form.

(3) Standardized nursing interventions, such as bowel preparation compliance verification (using polyethylene glycol electrolyte powder, with nurses guiding oral administration and recording the clarity of stool, with clear watery stool as the qualified standard), preoperative psychological counseling (for patients with SAS score ≥ 50 points, 15 minutes of cognitive behavioral intervention per day), intraoperative coordination protocols (nurses prepare surgical instruments in advance and cooperate with the operator according to the standardized process), postoperative positioning and drainage management (supine position for 6 hours after surgery, with drainage tube fixed at the bedside and drainage volume/color recorded every 30 minutes), and medication guidance (acid suppression, hemostasis, and mucosal protection therapy, with nurses explaining medication time, dosage, and adverse reactions, and supervising oral administration).

(4) Standardized scheduling of laboratory and imaging examinations (all examinations were scheduled in a unified electronic system, with nurses reminding patients of examination time and precautions 1 hour in advance; blood routine, coagulation function, and other laboratory examinations were completed before 9:00 on preoperative day 1; gastroscopy/colonoscopy reexamination was completed before 14:00 on preoperative day 1) to ensure the timely and consistent execution of medical orders.

And (5) clear discharge criteria: Absence of active bleeding, improvement in gastrointestinal symptoms, tolerance of semi-liquid diet, and stable vital signs.

A quality control team consisting of a head nurse and two senior nurses monitored the care pathway weekly. They reviewed a random sample of 20% of patient records to track adherence to pathway requirements, document deviations, and hold monthly meetings to discuss and correct deviations, ensuring consistency and standardization of interventions.

Observation indicators

Perioperative indicators: Total hospitalization duration, postoperative hospitalization duration, total hospitalization costs, and medication expenses.

Complication incidence: Delayed postoperative bleeding, perforation, infection, and other complications were observed and documented in both groups.

Psychological status: The Zung SAS[9] was used to assess the patients preoperatively, on postoperative days 1 and 2, and at discharge. The 20-item SAS is self-rated on a scale of 1-4, yielding raw scores ranging from 20 to 80. Multiplying the raw score by 1.25 produces a standardized score; a score of ≥ 50 indicates anxiety, with higher scores reflecting greater severity of anxiety.

Pain level: The VAS score[8] was assessed on postoperative days 1 and 2 and at discharge. The scores ranged from 0 to 10, with 0 indicating no pain and 10 indicating the most severe pain. Patients self-reported their scores. The nurses uniformly explained the scale before each assessment.

Satisfaction with nursing: Assessed on discharge day using the hospital’s standardized, psychometrically validated Nursing Satisfaction Questionnaire. The dimensions included communication, procedural compliance, psychological care, health education, and overall satisfaction, with a maximum score of 100. Scores > 90 indicate high satisfaction, scores < 60 indicate dissatisfaction, and all other scores are within the satisfaction range. The overall satisfaction was calculated as follows: (Very satisfied + satisfied/total cases) × 100.

Statistical analysis

All data were analyzed using SPSS (version 27.0; IBM Corporation, Armonk, NY, United States) and R version 4.2.0 (R Core Team, R Foundation for Statistical Computing, Vienna, Austria). Quantitative data were tested for normality. Normally distributed quantitative data are expressed as mean ± SD. Intergroup comparisons were performed using independent sample t-tests, whereas comparisons across multiple time points were performed using repeated-measures analysis of variance (ANOVA). Qualitative data are expressed as n (%) and were compared using the χ² test. Differences were considered statistically significant at P < 0.05.

RESULTS

Comparison of baseline characteristics between the two groups

Comparisons of data, including sex, BMI, age, surgical type, maximum tumor diameter, ASA classification, preoperative NRS 2002 score, history of gastrointestinal disease, and concomitant medication history (use of antiplatelet or anticoagulant drugs), revealed no statistically significant differences (P > 0.05) (Table 1).

Comparison of perioperative primary outcomes

Compared to the control group, the study group demonstrated significantly reduced total hospitalization duration, postoperative hospitalization duration, hospitalization costs, and medication expenses (P < 0.05) (Table 2).

Table 2 Comparison of perioperative primary outcomes between the two patient groups, mean ± SD.

Group	n	Total hospital stay (days)	Postoperative hospital stay (days)	Hospital costs (¥10000)	Medication costs (¥10000)
Study group	80	3.25 ± 0.75	1.45 ± 0.51	1.85 ± 0.45	0.35 ± 0.12
Control group	80	4.10 ± 1.05	2.16 ± 0.72	2.16 ± 0.63	0.48 ± 0.15
t		5.892	7.197	3.581	6.053
P value		< 0.001	< 0.001	0.001	< 0.001

Comparison of complication rates

The overall complication rate in the study group was 3.75%, which was significantly lower than that in the control group (13.75%) (P < 0.05) (Table 3). Regarding complication management and outcomes, all bleeding and perforation events in the study group were successfully controlled through endoscopic interventions (e.g., electrocoagulation and clipping) without requiring surgical intervention and did not result in a significant prolongation of hospital stay. In contrast, two patients in the control group with perforation required surgical intervention, and the overall complications prolonged the average hospital stay.

Table 3 Comparison of overall complication rates between the two patient groups, n (%).

Group	n	Delayed/postoperative bleeding	Perforation	Infection (local or systemic)	Total incidence
Study group	80	1 (1.25)	1 (1.25)	1 (1.25)	3 (3.75)
Control group	80	6 (7.50)	2 (2.50)	3 (3.75)	11 (13.75)
χ2					5.010
P value					0.025

Comparison of anxiety scores before and after surgery

The study group exhibited significantly lower SAS scores than the control group on postoperative days 1 and 2 and on the day of discharge (P < 0.05). Repeated-measures ANOVA revealed a significant interaction between time and group (P < 0.05) (Table 4 and Figure 2).

Figure 2 Comparison of Self-Rating Anxiety Scale scores between two groups before and after surgery. ^aP < 0.05. NS: Not significant.

Table 4 Comparison of preoperative and postoperative Self-Rating Anxiety Scale scores between two groups (points), mean ± SD.

Group	n	Preoperative day 1	Postoperative day 1	Postoperative day 2	Discharge day
Study group	80	45.85 ± 7.20	40.12 ± 6.50	37.37 ± 6.10	36.55 ± 5.90
Control group	80	46.30 ± 7.10	45.25 ± 6.85	42.10 ± 6.75	40.85 ± 6.25
t		0.398	4.859	4.650	4.475
P value		0.691	< 0.001	< 0.001	< 0.001

Between-group effect: F = 40.312, P < 0.001; time effect: F = 182.520, P < 0.001; time × between-group effect: F = 20.115, P < 0.001.

Comparison of pre- and postoperative pain scores

The study group exhibited significantly lower VAS scores than the control group on postoperative days 1 and 2 and on the discharge date (P < 0.05) (Table 5).

Table 5 Comparison of preoperative and postoperative pain scores between two groups (points), mean ± SD.

Group	n	Preoperative day 1	Postoperative day 1	Postoperative day 2	Discharge day
Study group	80	0.35 ± 0.20	2.05 ± 0.85	1.10 ± 0.55	0.85 ± 0.40
Control group	80	0.38 ± 0.18	3.10 ± 1.00	2.05 ± 0.85	1.41 ± 0.62
t		0.997	7.156	8.393	6.789
P value		0.320	< 0.001	< 0.001	< 0.001

Between-group effect: F = 72.104, P < 0.001; time effect: F = 620.352, P < 0.001; time × Between-group interaction: F = 46.255, P < 0.001.

Comparison of satisfaction with nursing

Overall satisfaction with nursing was significantly higher in the intervention group than in the control group (98.75% vs 86.25%, P < 0.05) (Table 6).

Table 6 Comparison of nursing satisfaction between two groups, n (%).

Group	n	Very satisfied	Satisfied	Dissatisfied	Overall satisfaction
Study group	80	56 (70.00)	23 (28.75)	1 (1.25)	79 (98.75)
Control group	80	45 (56.25)	24 (30.00)	11 (13.75)	69 (86.25)
χ2					9.01
P value					0.002

DISCUSSION

Endoscopic diagnosis and treatment of gastrointestinal tumors are complex and involve multiple stages, including preoperative assessment and preparation, precise intraoperative coordination, postoperative monitoring, complication management, and continuity of care. This places a high demand on the systematic and continuous nature of nursing work[11,12]. However, most medical institutions rely primarily on experience-based nursing models, with nursing interventions often characterized by arbitrariness and individual variability[13,14]. This lack of standardization may have led to inadequate preoperative preparation, inefficient intraoperative coordination, and inadequate postoperative health education. This may also result in delayed complication detection, thereby compromising treatment safety and postoperative recovery quality while increasing hospitalization duration and medical costs[15]. These issues constrain the overall efficacy of endoscopic procedures and diminish patient treatment experience and satisfaction.

In this context, the study group exhibited superior outcomes compared to the control group in terms of total hospitalization duration, postoperative length of hospitalization, and hospitalization costs. This improvement aligns with the core principle of standardized care pathways: Transforming traditional reactive and passive nursing models into proactive and precision-oriented care through standardized chronological management frameworks[16,17]. By clearly defining critical junctures, such as preoperative preparation, examination scheduling, postoperative monitoring, and discharge assessment through pathway charts, nursing processes become more streamlined and coherent. This eliminates delays and duplications caused by delayed orders or communication breakdowns[18]. Concurrently, the pathway emphasizes anticipatory care measures, including standardized dietary progression strategies and early mobilization guidance[19]. These effectively promote gastrointestinal recovery and reduce the risk of complications, such as infections. Collectively, these factors enable patients to fulfill their discharge criteria more rapidly, reduce healthcare resource consumption, and lower hospitalization costs. These findings align with those of multiple domestic and international studies addressing clinical pathway management[19-21], indicating that SNPs offer significant advantages in enhancing medical efficiency and cost savings.

Complications are key factors affecting the quality of post-ESD recovery and patient safety[22]. This study found that the total incidence of complications in the study group was 3.75%, which was significantly lower than that of 13.75% in the control group (P < 0.05), and the severity of complications and clinical outcomes were more favorable. All complications in the study group were successfully controlled through endoscopic interventions (such as electrocoagulation and titanium clip closure), avoiding more invasive surgical procedures or interventional treatments, and did not significantly prolong the length of hospital stay. However, two patients in the control group with perforation required surgical intervention.

Comparing the complication rate of 3.75% in this study with the range of post-ESD complication rates reported in the literature helps to gain a deeper understanding of the clinical value of the SNP. A large meta-analysis published in 2026 showed that the pooled incidence of post-electrocoagulation syndrome after colorectal ESD was 8.9%[23]. Another cohort study on gastric ESD reported that the postoperative bleeding rate was 4.39%-11.9% and the perforation rate was 0.38%-0.73%. In addition, a systematic review of duodenal ESD showed that the incidences of delayed perforation and bleeding were 2.0% and 3.8%, respectively[24]. In contrast, the overall complication rate (3.75%) in the study group was lower than that reported in most previous studies, demonstrating the potential advantages of SNP.

This difference can be attributed to two factors. First, the SNP may improve the quality of care through systematic perioperative management. The pathway clarifies the frequency and key points of postoperative monitoring (such as vital signs, abdominal pain, distension, hematochezia, etc.), enabling nursing staff to promptly detect the precursors of complications. Simultaneously, the pre-set emergency plans and standardized treatment procedures in the pathway allow nursing staff to quickly activate the early warning mechanism and implement standardized initial interventions when abnormalities are found, thus gaining valuable time for subsequent endoscopic treatment. This structured and process-oriented nursing model compensates for potential omissions in conventional nursing due to differences in experience or workload and strengthens the safety assurance system for postoperative patients[26,27].

Second, the baseline risk characteristics of the patients in this study may have contributed to the lower complication rates. There were no statistically significant differences between the study and the control groups in terms of maximum tumor diameter (study group: 1.85 ± 0.78 cm vs control group: 1.90 ± 0.82 cm), ASA classification (study group: Grade I 62.50%, grade II 31.25%, grade III 6.25%), and tumor diameters (generally less than 2 cm). Literature reports indicate that tumor diameter ≥ 20 mm is a significant risk factor for complications after ESD (odds ratio 2.57, 95% confidence interval: 1.65-3.99). In addition, patients with a higher ASA classification (with more underlying diseases) had a higher overall incidence of postoperative complications and longer hospital stay. In this study, more than 90% of the patients were classified as ASA I-II and belonged to a relatively low-risk population, which explains the low overall complication rate. Nevertheless, the study group showed significantly better complication control than the control group, indicating that SNPs can provide additional benefits even in low-risk populations.

CONCLUSION

In summary, as systematic, process-oriented, and evidence-based perioperative management models, standardized care pathways demonstrate significant advantages in the perioperative management of patients with gastrointestinal tumors undergoing ESD. They not only enhance the efficiency of perioperative care and reduce the risk of complications, but also improve patients’ emotional well-being and pain experience, ultimately elevating clinical nursing quality and patient satisfaction. The present single-center investigation, however, had some limitations. First, the sample structure and nursing model may have specific limitations that require further validation through multicenter large-sample studies. Second, this study primarily focused on short-term perioperative outcomes. The impact of a SNP on long-term quality of life, oncological prognosis, and readmission rates remains unclear and requires long-term follow-up. Third, sustained implementation of the SNP relies on team collaboration and continuous quality control. Its adaptability across different healthcare institutions and potential operational challenges warrant further exploration.