Case Control Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Oct 7, 2020; 26(37): 5646-5660
Published online Oct 7, 2020. doi: 10.3748/wjg.v26.i37.5646
Short- and long-term outcomes associated with enhanced recovery after surgery protocol vs conventional management in patients undergoing laparoscopic gastrectomy
Yu-Long Tian, Shou-Gen Cao, Xiao-Dong Liu, Ze-Qun Li, Gan Liu, Xing-Qi Zhang, Yu-Qi Sun, Xin Zhou, Dao-Sheng Wang, Yan-Bing Zhou
Yu-Long Tian, Shou-Gen Cao, Xiao-Dong Liu, Ze-Qun Li, Gan Liu, Xing-Qi Zhang, Yu-Qi Sun, Xin Zhou, Dao-Sheng Wang, Yan-Bing Zhou, Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
Author contributions: Zhou YZ and Tian YL conceived and designed the study; Tian YL, Cao SG, Liu XD, and Li ZQ drafted the manuscript; Sun YQ, Zhou X, and Wang DS completed data management and statistical analysis; all authors have agreed to be responsible for all aspects of the work.
Institutional review board statement: The study was reviewed and approved by the Affiliated Hospital of Qingdao University Ethics Review Committee.
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: The authors have no conflicts of interest to declare.
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Yan-Bing Zhou, MD, Professor, Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, No. 16 Jiangsu Road, Shinan District, Qingdao 266003, Shandong Province, China.
Received: June 9, 2020
Peer-review started: June 9, 2020
First decision: July 25, 2020
Revised: August 2, 2020
Accepted: September 3, 2020
Article in press: September 3, 2020
Published online: October 7, 2020
Research background

At present, the enhanced recovery after surgery (ERAS) protocol is widely implemented in the field of gastric surgery. Emerging evidence suggests that the ERAS protocol can influence long-term oncological outcomes after colorectal cancer surgery and elective orthopaedic surgery. However, the effect of the ERAS protocol on the long-term prognosis of gastric cancer has not been reported.

Research motivation

We urgently need to understand that ERAS can improve the long-term prognosis of patients with gastric cancer, so as to standardize our clinical care and improve the terms of ERAS protocol.

Research objectives

The primary aim of this retrospective study was to determine the effect of the ERAS protocol after laparoscopic gastrectomy on long-term survival. The secondary aim was to compare short-term clinical outcomes and inflammatory parameters between the ERAS and conventional protocols.

Research methods

We retrospectively analyzed the data of 1026 consecutive patients who underwent laparoscopic gastrectomy between 2012 and 2015. Data from these procedures were prospectively collected in a database and then retrospectively reviewed. The patients were divided into either an ERAS group or a conventional group based on the willingness of the patients. The groups were matched in a 1:1 ratio using propensity scores based on covariates that affect cancer survival. The primary outcomes were the 5-year overall and cancer-specific survival rates. The secondary outcomes were the postoperative short-term outcomes and inflammatory indexes.

Research results

The patient demographics and baseline characteristics were similar between the two groups after matching. Compared to the conventional group, the ERAS group had a significantly shorter postoperative hospital day (7.09 d vs 8.67 d, P < 0.001), shorter time to first flatus, liquid intake, and ambulation (2.50 d vs 3.40 d, P < 0.001; 1.02 d vs 3.64 d, P < 0.001; 1.47 d vs 2.99 d, P < 0.001, respectively), and lower medical costs ($7621.75 vs $7814.16, P = 0.009). There was a significantly higher rate of postoperative complications among patients in the conventional group than among those in the ERAS group (18.1 vs 12.3, P = 0.030). Regarding inflammatory indexes, the C-reactive protein and procalcitonin levels on postoperative day 3/4 were significantly different between the two groups (P < 0.001 and P = 0.025, respectively). The ERAS protocol was associated with significantly improved 5-year overall survival and cancer-specific survival rates compared with conventional protocol (P = 0.013, P = 0.032, respectively). When stratified by tumour stage, only the survival of patients with stage III disease was significantly different between groups (P = 0.044).

Research conclusions

The ERAS protocol has been proven to be a safe and effective perioperative management pathway in the current literature. In particular, the ERAS protocol has shown promising results in improving the survival of patients with gastric cancer after surgery.

Research perspectives

This was a single-centre retrospective study; therefore, multicentre randomised controlled trial studies should be performed to verify the reliability of the results. Fortunately, we have registered (Chinese Clinical Trial Registry, CHiCTR1900022438) and started such a project, and patients are currently being recruited. We hope that our data will provide trustworthy evidence that the ERAS pathway improves survival in patients with gastric cancer.