Abstract
Background:
The purpose of this study was to investigate the effectiveness and feasibility of enhanced recovery after surgery (ERAS) in older gastric cancer (GC) patients by observing the changes in postoperative intestinal function recovery, nutritional indicators, and inflammatory markers following the surgery.
Methods:
A total of 61 older GC patients who underwent laparoscopic radical gastrectomy were selected as the subjects of this study. They were divided into an ERAS group (n = 28) and a conventional control group (n = 33) based on the different management modes during the perioperative period. General data, inflammatory response indicators, nutritional indicators, and perioperative indicators of the 2 groups were collected and compared. The changes in relevant indicators were analyzed, and the underlying reasons for these changes were explored.
Results:
There were no significant differences in general data and preoperative indicators between the 2 groups (P > .05). In the ERAS group, the inflammatory markers decreased more rapidly, and the nutritional indicators recovered more quickly after surgery. The differences between the 2 groups were statistically significant on the 5th and 7th postoperative days (P < .05). The ERAS group had significantly shorter postoperative hospital stay (10.07 ± 1.41 vs 13.04 ± 3.81), shorter time to first flatus (3.70 ± 0.72 vs 4.18 ± 1.17), shorter drainage tube retention time (8.96 ± 1.53 vs 10.93 ± 3.36), and shorter nasogastric tube retention time (3.36 ± 1.72 vs 6.14 ± 3.99) compared to the control group (P < .05).
Conclusion:
The application of the ERAS program in older GC patients is effective and feasible, and significantly contributes to faster postoperative recovery in older patients.
Keywords: enhanced recovery after surgery, gastric cancer, intestinal function, intestinal nutrition, older patients
1. Introduction
Gastric cancer (GC) is one of the common malignant tumors, with the incidence rate in males being approximately twice that of females.[1] The majority of cases occur in the older population aged over 60, making it crucial to focus on the treatment of GC in older patients. With the continuous aging of the world population, the number of GC cases and deaths is rapidly increasing.[2] Relevant studies have shown that older patients have relatively lower organ function and often present with multiple underlying diseases such as cardiovascular diseases, pulmonary diseases, and impaired liver and kidney function.[3,4] These diseases increase the surgical risks in GC patients, and due to their compromised immunity and compensatory abilities, older patients face greater difficulties in postoperative recovery.[5] These factors directly impact the prognosis of patients.
In recent years, enhanced recovery after surgery (ERAS) has optimized many aspects of traditional treatment, including preoperative antithrombotic drugs, optimization of routine bowel preparation, intraoperative multimodal analgesia, optimization of surgical modalities, early removal of drainage tubes after surgery, early feeding, and early mobility. Reducing fasting time can not only enhance intestinal activity, reduce related stress symptoms, but also reduce protein and energy consumption in elderly patients, and improve the nutritional status of patients. Therefore, after patients receive relevant ERAS measures, their own inflammatory factor levels will be significantly reduced, and the incidence of postoperative complications will be smaller, which plays an important role in promoting the recovery of intestinal function and early discharge of patients. Therefore, it is important to apply the ERAS concept to more elderly patients and promote better and faster recovery. Although the ERAS technique has been applied in many medical institutions, its application in GC patients, especially in older GC patients, is still in its early stages, is still in its early stage and lacks high-quality clinical summaries.[6,7] This study aims to analyze the postoperative recovery of the 2 groups of patients, explore the potential mechanism of ERAS to promote the postoperative recovery of elderly patients with GC, and confirm the safety and effectiveness of key technologies of ERAS in this population. This will provide evidence-based medicine and a theoretical basis for the application of ERAS technology in elderly patients with GC.
2. Data and methods
2.1. General information
The data collection for this study was conducted from August 2023 to February 2024. The study subjects were patients aged over 65 who underwent laparoscopic radical gastrectomy for GC at Jiangsu University Affiliated Hospital. At the time of admission, the patients were randomly divided into 2 groups by the admission preparation center, and 61 cases were selected according to the inclusion and exclusion criteria of the experiment. The ERAS group consisted of 28 patients who received a series of perioperative optimization measures, while the non-ERAS group consisted of 33 patients who received traditional perioperative management.
2.1.1. Declarations
The study was conducted in accordance with the Declaration of Helsinki, and approved by the Ethics Committee of the Clinical Research Center of the Affiliated Hospital of Jiangsu University (KY2022H1010-1,date of approval:2022.10.10).
The study protocol was approved Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
2.1.2. Randomization
For each elderly patient admitted for GC, a random number was obtained from the random number table at the time of admission, each random number was divided by the group number, and the remainder was taken. The subjects were divided into different groups according to the remainder value.
2.1.3. Inclusion and exclusion criteria
Inclusion criteria:
Patients aged over 65 years;
Patients with a definite diagnosis of gastric malignant tumor based on preoperative biopsy, in accordance with the diagnostic criteria of GC in the “Chinese Clinical Oncology Society Guidelines for Primary Gastric Cancer Treatment”;
Patients scheduled for radical gastrectomy for GC;
Patients voluntarily participating in this study, receiving relevant treatment measures based on the concept of ERAS, and signing informed consent form.
Exclusion criteria:
Patients with excessive body weight or severe nutritional disorders (body mass index [BMI] < 15 kg/m2 or BMI > 30 kg/m2);
Patients with complete gastrointestinal obstruction before surgery or severe organ dysfunction in the heart, lungs, liver, or kidneys who are unable to tolerate surgery;
Patients requiring palliative or emergency surgery due to their condition;
Patients with a history of gastrointestinal surgery or other major abdominal surgery;
Patients with poor compliance who refuse to accept measures related to enhanced recovery;
Patients with a history of previous abdominal tumor resection.
Exit criteria:(this experiment without exit)
The subjects withdrew from the trial by themselves: they felt that the efficacy was not good and they could not tolerate some events.
Subjects or their legal representatives (such as parents or legal guardians) withdraw informed consent;
The risk/benefit ratio was found to be unacceptable;
factors beyond our control significantly affected the course of the trial and/or the interpretation of the trial results;
The patients should be withdrawn from the trial if the adverse events occurred.
Discharge criteria:
complete restoration of oral diet;
no intravenous infusion;
Oral analgesics, no pain;
without any drainage or decompression catheter;
walking freely out of bed;
willing to go home for rehabilitation.
The same discharge criteria were implemented in the 2 groups.
The 2 groups of patients were comparable in terms of general information, including age, gender, body weight, BMI, and surgical method, with no statistically significant differences (P > .05) (Table 1).
Table 1.
Comparison of preoperative general conditions between the 2 groups.
| Patient data | ERAS | Control | Statistical value | P |
|---|---|---|---|---|
| Age | 70.43 ± 6.86 | 71.60 ± 6.65 | t = 0.623 | .538 |
| Gender | χ2 = 0.12 | .730 | ||
| Male | 19 | 21 | ||
| Female | 9 | 12 | ||
| BMI (kg/m2) | 23.92 ± 1.44 | 23.86 ± 1.51 | t = 0.395 | .694 |
| ASA | χ2 = 1.6 | .689 | ||
| II | 20 | 22 | ||
| III | 8 | 11 | ||
| NRS2002 | χ2 = 0.307 | .580 | ||
| <3 | 15 | 20 | ||
| ≥3 | 13 | 13 | ||
| Grip strength | χ2 = 0.062 | .803 | ||
| Low grip strength (male < 28.6 kg, female < 16.4 kg) | 4 | 4 | ||
| Normal grip strength | 24 | 29 | ||
| Gait speed | χ2 = 0.442 | .506 | ||
| Slow gait speed (<0.8 m/s) | 8 | 7 | ||
| Normal gait speed | 20 | 26 |
ASA = American Society of Anesthesiologists, BMI = body mass index, ERAS = enhanced recovery after surgery.
2.2. Methods
According to the concept of ERAS and the traditional concept of surgery, different nursing processes were carried out, which were recorded as the REAS group and the control group respectively. The specific management measures were as follows (Table 2).
Table 2.
Comparison of perioperative treatment measures between the 2 groups.
| ERAS | Control | |
|---|---|---|
| Preoperative education | The patients and their families were fully communicated with the advantages of ERAS measures, and psychological counseling was given to the patients | None |
| Preoperative evaluation | The nutritional assessment and preoperative psychological anxiety of patients were assessed, and patients with poor nutritional status were treated with nutritional support | Imperfect preoperative risk assessment was performed |
| Preoperative fasting | The patients were given a low-residue diet for 3 d before surgery, and were instructed to stop eating at 10 pm on the day before surgery and not to drink at 2 h before surgery. Carbohydrate preparation was taken on the day before surgery and on the morning of surgery | None |
| Preoperative bowel preparation | Preoperative low-residue diet. Avoid mechanical enema | Perform mechanical enema |
| Prevention of thrombotic risk | Preoperative examination of coagulation indicators, blood vessel B ultrasound of both lower limbs, lower limbs massage and wearing elastic stockings, and antithrombotic drugs were used as appropriate | None |
| Preoperative anesthesia evaluation | Abdominal B-ultrasonography was performed on the day before surgery and at the time of formal anesthesia. If gastric retention existed, gastric tube was inserted to reduce the risk of aspiration | None |
| Intraoperative anesthesia method | COX II underwent transversus abdominis fascia block + tracheal intubation-guided general anesthesia and epidural anesthesia. Long-acting sedation and opioids were avoided. The depth of anesthesia was monitored regularly during the operation | The endotracheal intubation anesthesia |
| Intraoperative fluid management | Reasonable control of intraoperative intravenous fluid volume and speed, monitoring patients’ fluid volume and urine volume balance | None |
| Temperature protection during operation | Monitor body temperature throughout the whole process, prepare the heater and insulation blanket | None |
| nasogastric tubes, drainage tubes, and urinary catheters | Early removal | It was placed for a long time after surgery |
| Postoperative analgesia | Short-acting drugs combined with multi-modality analgesia | Analgesic pump + opioid |
| Eating after surgery | Fluids were taken for 1–2 d after surgery. Eat small, frequent meals, transition from liquid to semi-liquid, and then to a normal diet. Eat more nutritious foods high in protein | Food was forbidden for a long time after surgery |
| Postoperative thrombosis prevention | Massage the lower limbs + raise the feet + wear elastic stockings + ambulate as soon as possible. Preventive use of antithrombotic drugs is recommended for patients with high risk of thrombosis | None |
ERAS = enhanced recovery after surgery.
2.3. Objective observations
2.3.1. Nutritional indicators
Albumin (ALB), lymphocyte count, and hemoglobin (HB) were measured and recorded in patients before surgery and on postoperative days 1, 3, 5, and 7. Prealbumin (PAB) levels were measured on postoperative days 1, 3, and 5.
2.3.2. Inflammatory markers
Peripheral blood C-reactive protein (CRP), white blood cell count (WBC), and absolute neutrophil count were measured and recorded in patients before surgery and on postoperative days 1, 3, 5, and 7.
2.3.3. Postoperative intestinal function recovery
The duration of abdominal drainage tube placement, nasoenteric tube placement, time to first bowel movement, length of hospital stay, and occurrence of postoperative complications were recorded and compared between the ERAS group and the control group.
2.4. Statistical methods
IBM SPSS Statistics 25.0 statistical software was used to analyze the recorded data in this study. Measurement data with normal distribution were represented as (x ± s), and comparison of measurement data between groups was analyzed using the independent sample t test. Categorical measurement data were analyzed by constituent ratio. Ordinal data were tested using non-parametric tests. The test level α = 0.05, P < .05 was considered statistically significant.
3. Results
3.1. Intraoperative data
There were no statistically significant differences (P > .05) between the ERAS group and the control group regarding the resection site, surgical duration, total number of lymph nodes removed, intraoperative blood loss, and tumor staging (Table 3).
Table 3.
Comparison of intraoperative general data of patients.
| Intraoperative data | ERAS | Control | Statistical value | P |
|---|---|---|---|---|
| Site of resection | χ2 = 1.007 | .604 | ||
| Whole stomach | 9 | 7 | ||
| Proximal stomach | 11 | 14 | ||
| Distal stomach | 8 | 12 | ||
| Time of operation | 4.00 ± 0.49 | 4.30 ± 0.70 | t = −1.796 | .08 |
| Intraoperative blood loss | 69.64 ± 7.86 | 80.36 ± 16.93 | t = −0.541 | .593 |
| Intraoperative lymph node dissection number | 20.50 ± 7.44 | 21.04 ± 5.67 | t = −0.335 | .704 |
| TNM | χ2 = 0.363 | .834 | ||
| I | 9 | 13 | ||
| II | 11 | 12 | ||
| III | 8 | 8 |
ERAS = enhanced recovery after surgery.
3.2. Comparison of nutritional indexes between ERAS group and control group
The results of this study showed that there was no significant difference in the levels of albumin, prealbumin, absolute lymphocyte count and HB on the first day before surgery between the 2 groups (P > .05), and the above indicators showed a trend of decreasing first and then increasing. The postoperative ALB, absolute lymphocyte count, prealbumin and HB in the ERAS group recovered faster. There were significant differences in ALB and lymphocyte count between the 2 groups on the 5th day and the 7th day, in prealbumin on the 3rd day and the 5th day, and in HB on the 3rd day and the 7th day (P < .05) (Table 4, Figs. 1–4).
Table 4.
Comparison of nutritional indicators between the 2 groups.
| ERAS | Control | t | P | |
|---|---|---|---|---|
| Albumin (g/L) | ||||
| 1 d before surgery | 38.59 ± 3.89 | 37.98 ± 5.74 | −1.114 | .275 |
| 1 d after surgery | 35.06 ± 3.63 | 34.36 ± 5.42 | −1.292 | .207 |
| 3 d after surgery | 33.51 ± 4.03 | 32.09 ± 3.48 | 1.321 | .198 |
| 5 d after surgery | 34.97 ± 3.45 | 32.20 ± 4.58 | 2.748 | .011 |
| 7 d after surgery | 37.80 ± 4.17 | 33.19 ± 4.76 | 4.002 | .001 |
| Prealbumin (g/L) | ||||
| 1 d before surgery | 199.32 ± 50.87 | 188.64 ± 52.99 | 0.774 | .446 |
| 1 d after surgery | 166.25 ± 48.00 | 149.04 ± 40.99 | 1.635 | .114 |
| 3 d after surgery | 151.46 ± 39.19 | 129.03 ± 37.82 | 2.522 | .018 |
| 5 d after surgery | 148.42 ± 46.46 | 128.03 ± 39.23 | 2.132 | .042 |
| lymphocytes (109/L) | ||||
| 1 d before surgery | 1.40 ± 0.45 | 1.39 ± 0.35 | −1.01 | .922 |
| 1 d after surgery | 1.00 ± 0.32 | 0.96 ± 0.33 | −1.005 | .301 |
| 3 d after surgery | 0.96 ± 0.24 | 0.90 ± 0.27 | −0.427 | .673 |
| 5 d after surgery | 1.09 ± 0.26 | 0.95 ± 0.25 | 2.556 | .017 |
| 57d after surgery | 1.22 ± 0.23 | 1.01 ± 0.23 | 3.667 | .001 |
| Hemoglobin (g/L) | ||||
| 1 d before surgery | 128.64 ± 15.39 | 125.94 ± 20.55 | 1.409 | .17 |
| 1 d after surgery | 121.54 ± 22.72 | 116.75 ± 15.49 | 0.762 | .453 |
| 3 d after surgery | 118.57 ± 15.59 | 108.57 ± 18.31 | 2.511 | .018 |
| 5 d after surgery | 118.05 ± 23.12 | 109.09 ± 19.26 | 1.884 | .070 |
| 7 d after surgery | 119.10 ± 22.78 | 108.42 ± 19.96 | 2.566 | .016 |
ERAS = enhanced recovery after surgery.
Figure 1.
Changes in albumin.
Figure 4.
Changes in hemoglobin.
Figure 2.
Changes in prealbumin.
Figure 3.
Changes in lymphocytes.
3.3. Comparison of preoperative and postoperative inflammatory indexes between ERAS group and control group
There was no significant difference in CRP WBS and absolute neutrophil count between the ERAS group and the control group (P > .05). The above indicators showed a trend of first increasing and then decreasing, and the increase of inflammatory indicators in ERAS group was smaller than that in control group and recovered faster. There were significant differences in CRP and absolute neutrophil count between the 2 groups on the 5th and 7th day after operation, and there were significant differences in WBS on the 3rd and 5th day after operation (P < .05) (Table 5, Figs. 5–7).
Table 5.
Comparison of inflammatory stress indexes before and after surgery between the 2 groups of older patients.
| ERAS | Control | t | P | |
|---|---|---|---|---|
| CRP (mg/L) | ||||
| 1 d before surgery | 2.61 ± 3.08 | 3.58 ± 6.22 | −0.058 | .954 |
| 1 d after surgery | 55.99 ± 32.77 | 55.77 ± 28.31 | 0.460 | .649 |
| 3 d after surgery | 46.60 ± 21.33 | 45.33 ± 29.16 | −0.225 | .823 |
| 5 d after surgery | 26.09 ± 20.86 | 29.63 ± 23.02 | −1.339 | .192 |
| 7 d after surgery | 6.75 ± 7.24 | 12.62 ± 16.70 | −2.182 | .038 |
| WBS (×109/L) | ||||
| 1 d before surgery | 5.59 ± 1.68 | 5.58 ± 1.02 | 0.025 | .980 |
| 1 d after surgery | 11.62 ± 2.73 | 12.37 ± 3.11 | −0.821 | .419 |
| 3 d after surgery | 8.98 ± 2.74 | 10.64 ± 2.34 | −2.338 | .027 |
| 5 d after surgery | 6.27 ± 1.91 | 8.26 ± 2.13 | −3.745 | .001 |
| 7 d after surgery | 6.24 ± 1.72 | 6.93 ± 2.01 | −1.528 | .138 |
| Neutrophils (109/L) | ||||
| 1 d before surgery | 3.62 ± 2.07 | 3.51 ± 1.28 | 0.262 | .795 |
| 1 d after surgery | 9.63 ± 2.09 | 10.65 ± 3.01 | −1.329 | .195 |
| 3 d after surgery | 6.84 ± 3.01 | 7.28 ± 2.77 | −0.591 | .559 |
| 5 d after surgery | 4.41 ± 1.59 | 5.82 ± 2.12 | −2.907 | .007 |
| 7 d after surgery | 4.13 ± 1.28 | 5.15 ± 1.89 | −2.338 | .027 |
CRP = C-reactive protein, ERAS = enhanced recovery after surgery, WBS = white blood cell.
P < .05 was considered statistically significant.
Figure 5.
Changes of CRP in the 2 groups. CRP = c-reactive protein.
Figure 7.
Changes in the neutrophil.
Figure 6.
Changes of WBS in the 2 groups. WBS = white blood cell.
3.4. Comparison of other perioperative indicators between the 2 groups
The first postoperative exhaust time, drainage tube indwelling time, nasointestinal tube indwelling time and postoperative hospital stay in the ERAS group were significantly shorter than those in the traditional group (P < .05). There was no significant difference in the total hospitalization cost between the 2 groups (P > .05) (Table 6). There were 6 cases of postoperative complications in ERAS group (5 cases of hypoalbuminemia and 1 case of pulmonary infection), with a complication rate of 21.4%. There were 9 cases of postoperative complications in the control group (6 cases of hypoalbuminemia, 2 cases of pulmonary infection, 1 case of anastomotic leakage, one of which pulmonary infection patient complicated with hypokalemia), with a complication rate of 27%. Therefore, the application of ERAS in the treatment of older patients with GC is safe and feasible.
Table 6.
Comparison of postoperative recovery and other comparative indicators between the 2 groups.
| ERAS | Control | t/χ2 | P | |
|---|---|---|---|---|
| Time to first flatus (d) | 3.70 ± 0.72 | 4.18 ± 1.17 | −2.309 | .024 |
| Drain indwelling time (d) | 8.96 ± 1.53 | 10.93 ± 3.36 | −2.867 | <.01 |
| Nasointestinal tube indwelling time (d) | 3.36 ± 1.72 | 6.14 ± 3.99 | −3.37 | <.01 |
| Postoperative hospital stays (d) | 10.07 ± 1.41 | 13.04 ± 3.81 | −3.764 | <.01 |
| Hospitalization expenses (thousand CNY) | 69.5 ± 0.95 | 68.0 ± 1.29 | 0.536 | .596 |
| Postoperative complications (Clavien-Dindo classification grade) | χ2 = 2.48 | .115 | ||
| ≤II | 6 (21%) | 8 (24%) | ||
| >II | 0 (0%) | 1 (3%) |
ERAS = enhanced recovery after surgery.
4. Discussion
The concept of ERAS is a medical concept of multi-mode cooperation.[8] It includes preoperative publicity and education, limited preoperative fasting, intraoperative multi-mode analgesia and anesthesia, and the application of minimally invasive techniques to greatly reduce surgical trauma and reduce the stress level of patients.[9] Early postoperative eating and activity, as well as the unconventional use of surgical drainage tubes and catheters are all aimed at alleviating the impaired intestinal function of patients and accelerating the postoperative recovery of patients.[10,11] It reduces the discomfort of patients as much as possible, greatly improves the satisfaction of patients during hospitalization and reduces the medical costs of patients.[12] According to the results of this study, compared with the traditional group, ERAS group does have smaller stress response, better nutritional status and faster intestinal function recovery, which is conducive to the rehabilitation of older patients with GC.
In this study, postoperative inflammatory factors in ERAS group were significantly lower than those in the traditional group. CRP and white blood cell count (WBC) were commonly used inflammatory markers. After surgery, the levels of CRP, WBC, and neutrophils in the serum of both groups of patients showed varying degrees of increase, indicating that the occurrence of stress response is an inevitable result when the body experiences certain external trauma. However, the difference between the 2 groups can be observed from the measurements of inflammatory markers on postoperative days 1, 3, 5, and 7. The increase in inflammatory markers was smaller and the time to return to normal was shorter in the ERAS group compared to the control group, indicating that the implementation of the ERAS concept can indeed alleviate patient stress responses. There was no significant difference in preoperative levels of ALB, total protein, and HB between the 2 groups (P > .05). However, the decrease in postoperative nutritional indicators was smaller and the recovery was faster in the ERAS group compared to the control group, indicating that patients in the control group generally had poorer nutritional status during the perioperative period compared to the ERAS group. The better nutritional performance of the ERAS group is an important reason why patients implementing ERAS measures can recover faster than those in the traditional group. At the same time, the ERAS group had a significant reduction in the time to first passage of gas after surgery, the duration of postoperative abdominal drainage tube placement, the duration of nasointestinal tube placement, and the length of hospital stay compared to the control group that did not receive ERAS treatment. This indicates that ERAS implementation can indeed reduce gastrointestinal stress response and accelerate the recovery of gastrointestinal function in older patients.
In this study, the nutritional status of patients with ERAS group, such as ALB and prealbumin, was also significantly superior to that of the traditional group. Because reducing fasting is an important part of the ERAS philosophy, while the traditional approach requires patients to maintain longer periods of fasting and abstaining from water, which can facilitate intraoperative procedures, avoid reflux of gastric residue into the lungs after anesthesia, and reduce the occurrence of postoperative complications.[13,14] However, this measure still has certain drawbacks, as prolonged fasting may lead to insulin resistance and stress-induced disturbances in patients’ endocrine and metabolic functions.[15,16] Many experts and scholars have conducted in-depth research on this issue,[17] and it has been found that administering a certain dose of carbohydrate preparation orally before surgery can effectively reduce patients’ level of hunger, while also preventing insulin resistance and reducing the incidence of stress-induced hyperglycemia after surgery. Research has also indicated that older patients, due to their poor nutritional status, often require nutrition supplementation 7 to 10 days before surgery, which can improve patient outcomes and reduce surgical complications.[18,19] Compared to the control group, early postoperative enteral feeding can enhance intestinal activity, alleviate related stress symptoms, reduce protein and energy depletion in older patients, improve nutritional status, and facilitate faster recovery in patients treated with the ERAS concept, resulting in shorter hospitalization stays.[20,21]
According to the study results, the postoperative intestinal recovery speed of patients in ERAS group is significantly superior to that in the traditional group, and the postoperative complications and symptoms in ERAS group are less severe than those in the control group. The reason is that traditional surgical approach often involves the placement of nasoenteric tubes for a longer period, which facilitates the drainage of gastrointestinal contents, reduces the burden on the gastrointestinal tract, and avoids excessive tension at the anastomotic site.[22] However, related reports have also pointed out that gastric and intestinal decompression can cause a foreign body sensation in patients’ throat, often leading to nausea, vomiting, and long-term decompression may also disrupt the patient water and electrolyte balance, as well as acid-base imbalance, and may eventually prolong the recovery time of gastrointestinal function in the postoperative period, leading to longer rectal gas passage time in patients in the traditional group compared to the ERAS group.[23,24] Early mobilization postoperatively also accelerates patient recovery, as early activity helps prevent pulmonary dysfunction, reduce muscle atrophy, and decrease the incidence of lower limb thromboembolism and intestinal obstruction, promoting faster recovery.[25,26] However, due to the poor nutritional status and physiological functions of older patients, early mobilization may require more support in terms of nursing care, health assistance, and physical therapy. Therefore, the ERAS concept should also be tailored to individual patient circumstances and develop relative appropriate plans.[27] In this study, the ERAS group had fewer and milder postoperative complications compared to the control group. Previous studies have also shown that applying the ERAS perioperative care model is more effective for older patients with gastrointestinal cancer compared to traditional approaches.[28] Since the subjects of this study were all older patients, they may have various underlying diseases before surgery, and their nutritional status and immune function are more fragile than younger individuals, making them more susceptible to the influence of surgical trauma and prone to stress responses. This results in a higher likelihood of postoperative complications in older patients.[29,30]
4.1. Study limitations
Of course, this study also has some limitations. First, the sample size of this study is small, and it was only carried out in one medical unit, so large-scale, multicenter studies should be conducted in the future. Second, due to the different specific conditions of patients and the shortage of medical personnel, the individualized treatment of ERAS model may be insufficient and more efforts should be made in the future. Third, ERAS treatment model has not been carried out in our hospital for a long time, and long-term follow-up results of patients with 5 years or more are still lacking.
5. Conclusion
In summary, according to the statistical analysis results of this study, the increase rate of inflammation indicators in ERAS group is smaller than that in control group, and they can recover faster. There were significant differences in CRP, neutrophil absolute value and WBS on the 5th or 7th day after operation compared with the control group (P < .05). In addition, the postoperative nutritional indexes such as ALB, absolute value of lymphocytes, prealbumin and HB recovered more quickly after surgery in ERAS group, and there were significant differences in the indexes on the 5th or 7th day after surgery compared with the control group (P < .05). The time of first postoperative exhaust, retention time of drainage tube, retention time of nasointestinal tube and postoperative hospital stay in patients treated with ERAS was significantly reduced compared with those in the traditional group (P < .05). The results of this study indicate that ERAS model has less stress response, lower inflammatory markers, better nutritional markers, and faster recovery of postoperative intestinal function than the traditional surgical model. It will not increase the incidence of postoperative complications in elderly patients, so that patients can recover faster and leave the hospital. Therefore, it is safe and feasible to apply the concept of accelerated rehabilitation surgery in elderly patients with GC.
Acknowledgments
We thank Dr Xin Fan for supporting the statistics of this study and we give thanks to all the patients in this study.
Author contributions
Investigation: Kuanxuan You.
Methodology: Kuanxuan You.
Project administration: He Han.
Resources: He Han.
Writing – original draft: Kuanxuan You.
Writing – review & editing: Kuanxuan You.
Abbreviations:
- ALB
- albumin
- BMI
- body mass index
- CRP
- C-reactive protein
- ERAS
- enhanced recovery after surgery
- GC
- gastric cancer
- HB
- hemoglobin
This study was supported by a multicenter study of enhanced recovery after surgery in older people with gastric cancer (grant no.LKZ2023012); Supported by Zhenjiang Key Laboratory of Cancer Clinical Medicine (grant no.SS2023011); Support of Jinshan Talents Flexible Team in 2022 (grant no.JSYCTD202202); Application of enhanced recovery after surgery in gastric cancer patients with type II diabetes mellitus (grant no.xjs2024201).
The study protocol was approved Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
The study was conducted in accordance with the Declaration of Hlsinki, and approved by the Ethics Committee of the Clinical Research Center of the Affiliated Hospital of Jiangsu University (KY2022H1010-1,date of approval:2022.10.10).
The authors have no conflicts of interest to disclose.
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
How to cite this article: You K, Han H. Application of ERAS in older patients with gastric cancer. Medicine 2024;103:22(e38409).
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