GastrointestinalEnhanced Recovery after Surgery in Elderly Gastric Cancer Patients Undergoing Laparoscopic Total Gastrectomy
Introduction
Gastric cancer is the fifth most frequently diagnosed cancer and the third leading cause of cancer-related deaths around the world,1 and the incidence of esophagogastric junction adenocarcinoma has distinctly increased in China and other countries over the past decades.2, 3, 4 Currently, R0 resection is still considered the primary treatment option for curable patients with esophagogastric junction adenocarcinoma. Given the advantages of less blood loss, reduced postoperative pain, and accelerated recovery, minimally invasive laparoscopic total gastrectomy becomes a feasible surgical strategy not only in eastern Asia but also in the Western world.5,6
Enhanced recovery after surgery (ERAS) is a multidisciplinary set of care interventions that optimize perioperative management and accelerate rehabilitation.7 Our previous study indicated that ERAS could lessen the stress reaction and accelerate the rehabilitation of patients with gastric cancer who undergo open gastrectomy.8 Moreover, several studies have demonstrated that the ERAS program could improve the short-term outcomes in patients undergoing laparoscopic colorectal cancer resection9,10 and in the patients undergoing laparoscopic subtotal or total gastrectomy.11, 12, 13 Notably, most of the existing trials focus mainly on the relatively younger and healthier patients rather than on the elderly patients who may present specific physical, metabolic, and socioenvironmental characteristics. To date, the feasibility and possible effects of ERAS remain an area of uncertainty and have not been specifically studied in elderly patients with gastric cancer who undergo laparoscopic total gastrectomy.
Thus, a prospective randomized controlled trial was performed to investigate whether elderly patients with gastric cancer undergoing laparoscopic total gastrectomy would benefit from the ERAS protocol. Meanwhile, the human leukocyte antigen (HLA)-DR expression on monocytes, C-reactive protein (CRP), and maximum pain scores indicated by the visual analog scale were analyzed to explore the underlying mechanisms of the ERAS protocol.
Section snippets
Patients, study design, and perioperative care program
This study was designed as a single-center, prospective, randomized controlled trial and approved by the ethics committee of the Affiliated Hospital of Qingdao University under the principles of the Declaration of Helsinki. Informed consent was obtained from each study patient. From January 2014 to December 2018, we screened 400 consecutive patients with gastric cancer. The inclusion criteria were as follows: (1) age from 65 to 85 y, (2) histologically confirmed primary gastric adenocarcinoma,
Demographic and surgical data
Among 350 patients screened, 171 eligible patients were included in the analysis: 85 in the ERAS group and 86 in the conventional group (Fig. 1). The main clinical characteristics and surgical data are given in Table 2. The statistical analysis of sex, age, BMI, current smoking, ASA classification, preoperative comorbidity, lymph node dissection, tumor node metastasis (TNM) stage, operation time, blood loss, number of retrieved lymph nodes, and open conversion showed no significant difference
Discussion
In this prospective and randomized trial, we investigated the effects of the ERAS program on the short-term postoperative outcomes in the elderly patients with gastric cancer who were undergoing laparoscopy-assisted total gastrectomy. Compared with the conventional care program, the ERAS program strikingly shortened the postoperative hospital stay. Although the ERAS program had no significant effects on mortality, overall postoperative morbidity, and ≥C-D grade II morbidity, it decreased the
Acknowledgment
The authors thank all the colleagues in the Department of Gastrointestinal Surgery in the Affiliated Hospital of Qingdao University for their assistance with implementing the ERAS protocol and taking excellent care of our patients.
Contribution: YB Zhou conceived and designed the study and obtained the funding; SG Cao and TH Zheng collected data; H Wang and ZJ Niu analyzed and interpreted the data; SG Cao drafted the manuscript; D Chen, Jian Zhang, and L Lv provided critical revisions; YB Zhou
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SG Cao and TH Zheng contributed equally to the article.
Conflict of interest: No author has financial interests to disclose.