Enhanced recovery after surgery in laparoscopic gastric cancer surgery: Many questions, few answers

Disease does not spare even the surgeons who aim to treat it, as is evident by the little-known fact that gastric cancer victimised Robert Mcneill Love,[1] co-author of Bailey and Love's Short Practice of Surgery. Considered a disease predominantly of the Eastern world, gastric cancer is the third leading cause of cancer-related mortality in medium-developed countries.[2] India continues to have a low incidence, that is 9.1/100,000 in men, and even lower in women,[3] when compared to Japan, Eastern Europe, and South America.

Since the follow-up results of the landmark Dutch trial in 2010, D₂ spleen and pancreas-preserving gastrectomy has become the standard of care.[4] However, gastrectomy entails considerable morbidity in 23.6% patients, with a 30-day mortality of 4.1%, even today.[5] Our own data in 2006, perhaps the first series on D₂ gastrectomy from India, documented a morbidity and mortality of 4.4%, and 1.3%, respectively, at a time when we averaged 53 radical gastrectomies per year.[6] The 30-day mortality has been found to be significantly lower in centres operating more than 20 gastrectomies per year.[7]

Over the last two decades, there have been two indisputable developments in elective major abdominal surgery: The introduction of laparoscopic surgery and the implementation of enhanced recovery after surgery (ERAS) program, also referred to as fast track surgery; both focussing on reducing surgically induced trauma and accelerating post-operative recovery with resultant reduced hospital stay, as highlighted in the retrospective study by Sahoo et al. in this issue.[8]

After the rapidly gained popularity of ERAS in the field of elective colorectal surgery, propagated by Kehlet,[9] the world is eager to replicate its benefits and safety in many other surgeries. Sahoo et al. have shown that in patients undergoing laparoscopy-assisted total gastrectomy, the hospital stay (140 ± 28 h vs. 78 ± 26 h) and time-to passage of first flatus (74 ± 16 h vs. 37 ± 9 h) is almost double in the conventional-care group when compared to the ERAS group.[8]

Sahoo et al. have commendably envisioned the role of the ERAS protocol in laparoscopic upper gastrointestinal surgery, a frontier that has little level I evidence. Although we note that the authors have professed high skill levels in performance of gastrectomy with D₂ lymphadenectomy, sans complications,[8] certain thoughts merit deep introspection:

• It would have been interesting to know about the authors' negotiation of the learning curve and their rate of conversion, without which the realm of complex laparoscopic surgery stands incomplete.

• The inclusion of all resected gastric cancers, subtotal and total, open and laparoscopic, in this retrospective series would have given the interested reader a common denominator to accurately evaluate the influence of ERAS on short-term patient outcomes. The benefits of ERAS may have been camouflaged by laparoscopy, which itself hastens patient recovery and discharge. The 4-arm randomised controlled trial by Chen et al. in 2012, elegantly sub-stratified open and laparoscopic distal gastrectomies showing ERAS with laparoscopy to have shortest hospital stay, while ERAS with open surgery entailed lowest cost.[10]

• It is pertinent to note that in 2014 that the laparoscopic approach to locally-advanced-but-resectable gastric cancer is subject to intense debate and scrutiny.[11] In this context, one must bear in mind that in the Indian setting, the vast majority of gastric cancers present to the clinic in Stage III or beyond and not in early stages.[12] Interestingly, in the present article, only 42% of patients who underwent ERAS were Stage III suggesting that over 50% cases presenting to a government hospital were in Stages I and II.[8]

• Given the evolving concept of multidisciplinary approach to management of gastric cancer, the incorporation of data on neoadjuvant or adjuvant treatment would perhaps give us a comprehensive view of oncological outcomes, which should be at the centre of any study in oncology.[12]

• In this era of evidence-based medicine, it is striking to observe that in this study, <1 in four patients were mobilised on post-operative day (POD)-1,[8] while most centres of excellence would mobilise their patients on the first POD, even after open surgery. Does this bring out our age-old bias towards convention that unintentionally weaves itself into our day-to-day practice?

East-Asia has seen several RCTs and systematic reviews addressing the same issue. Wang et al.[13] studied the ERAS protocol in open surgery, while Kim et al.,[14] Chen et al.[10] and Yu et al.,[15] respectively, followed suit on the laparoscopic front. It was unanimously found that post-operative hospital stay and hospital costs were lower in the ERAS group, irrespective of the surgical approach. Occasionally, complication rates and re-admission rates have shown a favourable trend towards conventional perioperative care but this warrants further investigation.[16]

Pearsall et al., from Canada, recently studied the obstacles faced by ERAS, and reasoned why it is still under-implemented despite its apparent theoretical benefits.[17] The major barriers identified were the need for patient education, increased communication and collaboration, and better evidence for ERAS interventions.[17] In contrast, in a rapidly but yet-developing India, ensuring patient compliance despite thorough pre-operative counselling remains a definite challenge, not only due to sheer volume of patients per treating doctor, but also a lack of post-operative community-based nursing care and general physician support structure.

Enhanced recovery after surgery is not just a methodology, but a philosophy. It does away with the surgical dogmas of prolonged pre-operative starvation, bowel preparation, routine nasogastric and abdominal drainage, and late post-operative alimentation.[9] It attempts to make patients recover sooner, with least possible stress, bringing them back to their baseline pre-operative status as soon as possible. Decreased hospital stay and its offshoot of decreased costs are not the motives but purely consequences of superior medical management.

In summary, we first need to negotiate the learning curve of open D₂ gastrectomy and later standardise it as a procedure in India. Secondly, we need to improve our audits via better documentation and only then finally embark on negotiating the steep learning curve of laparoscopic D₂ gastrectomy. Once the aforementioned are achieved, it would make logical sense to proceed to the practice of ERAS, within a standardised protocol to avail of its believed synergistic advantage. This step-wise progression combats the famous Einstein belief, “perfection of means and confusion of goals seem to characterize our age.” The need of the hour is a multi-centric stratified randomised study to determine the future evolution of standard of care in gastric cancer surgery.