Background
Establish protocols to enhance the surgical management (ERAS) can improve outcomes, shortening hospital stay and save resources.
Several evidences have carried out for colorectal surgery, while a lack of studies for gastrectomy remains with only few reports.
This study aims to evaluate the impact in a large series of patients in adopting this strategy.
Methods
This project includes a meta-analysis and a propensity score-matched case-control study, comparing an ERAS group with a control group.
Primary outcomes: hospital stay, complications rate. Among the secondary outcomes, there are: POD of mobilization, POD of starting liquid diet and soft solid diet.
Hypothesis
An ERAS program can safely be established in referral centers for gastric cancer, enabling to significantly improve the main clinical outcomes.
The present study will evaluate the role of the ERAS program in the management of gastric cancer patients through a meta-analysis and a propensity score case matched analysis from the Imigastric database.
It is expected to demonstrate, as primary outcomes, a significant decrease in the length of hospital stay and in-hospital postoperative complications.
Important items in the ERAS protocol are early mobilization and feeding, which is especially facilitated by the absence of the NG tube and drainage, as well as an early removal of the urinary catheter. Smart showed that failure of early patient mobilization is associated with prolonged hospital stay.
Yamada in his study showed that the recovery of bowel function was significantly earlier in the ERAS group than in the conventional group.
In addition, Wang reported that the first day of flatulence after gastric surgery was a mean of one day earlier in patients who received fast-track surgery compared to those who received conventional care.
Some factors such as prolonged fasting and placement of the nasogastric tube appear to cause nausea and contribute to a delay of intestinal recovery.
In our study we want to overcome the limitations of studies in the current literature (retrospectives, single arms, small samples, most of studies regarding colorectal surgery) and demonstrate possible real advantages on the ERAS pathway by analyzing all steps of the patient's functional recovery.
The ERAS protocols require that the patient is not subjected to long periods of fasting.
Early postoperative nutrition reduces postoperative catabolism, accelerates the return of bowel function, and decreases the risk of complications. This was especially studied in colorectal surgery, but not for gastric cancer.
Moreover, Lewis et al. confirmed in their study that keeping patients in a fasting state is not beneficial.
Several studies have shown that early oral feeding is feasible and brings benefits in gastric surgery; however, this point remains controversial.
Even if an early postoperative oral feeding has been shown to speed up the recovery after various types of surgery, this approach after gastrectomy has always been seen with suspicion because of some concerns, not actually well demonstrated in the literature, that early food intake may cause anastomotic leakage or intestinal obstruction.
The adoption of a management based on the ERAS principles for gastric cancer can safely improve the patient's functional recovery, allowing an early discharge and a reduction of overall complications, but all these hypotheses need to be deepened.