Li JY, Ge MM, Pan HF, Wang G, Jiang ZW. Feasibility and safety of enhanced recovery after surgery in elderly patients with gastric cancer. World J Gastroenterol 2025; 31(47): 113331 [DOI: 10.3748/wjg.v31.i47.113331]
Corresponding Author of This Article
Gang Wang, MD, Associate Professor, Department of General Surgery, Affiliated Hospital of Nanjing University of Chinese Medicine, No. 155 Hanzhong Road, Qinhuai District, Nanjing 210023, Jiangsu Province, China. gangwang82@163.com
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Surgery
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Retrospective Study
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This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (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: http://creativecommons.org/licenses/by-nc/4.0/
Dec 21, 2025 (publication date) through Dec 19, 2025
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World Journal of Gastroenterology
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1007-9327
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Li JY, Ge MM, Pan HF, Wang G, Jiang ZW. Feasibility and safety of enhanced recovery after surgery in elderly patients with gastric cancer. World J Gastroenterol 2025; 31(47): 113331 [DOI: 10.3748/wjg.v31.i47.113331]
Jia-Yu Li, Miao-Miao Ge, Hua-Feng Pan, Gang Wang, Zhi-Wei Jiang, Department of General Surgery, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210023, Jiangsu Province, China
Co-corresponding authors: Hua-Feng Pan and Gang Wang.
Author contributions: Pan HF and Wang G contributed equally to this study as co-corresponding authors; Li JY was responsible for manuscript writing, data collection, data analysis, study conception, participated in the design of the study, data interpretation, and project coordination; Ge MM and Pan HF were responsible for data collection, data analysis, participated in study design and assisted in revising the manuscript; Wang G and Jiang ZW were responsible for project administration, data analysis, study conception, participated in the design of the study, supervision; and finalization of the draft.
Supported by The Medical Key Discipline Construction Project of Jiangsu Province, No. ZDXK202251; The Key project of Jiangsu Provincial Hospital Administration of Traditional Chinese Medicine, No. ZD201903; The Project of China Medical Education Association, No. 2022KTZ005; and National Natural Science Foundation of China, No. 81500417.
Institutional review board statement: The study protocol was approved by the Ethics Committee of Affiliated Hospital of Nanjing University of Chinese Medicine, approval No. 2022NL-129-02, and the study was performed in accordance with the Helsinki II declaration.
Informed consent statement: Informed consent was obtained from all the study subjects before enrollment.
Conflict-of-interest statement: The authors declare that they have no conflicts of interest.
Data sharing statement: Data is provided within the manuscript or Supplementary material.
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: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Gang Wang, MD, Associate Professor, Department of General Surgery, Affiliated Hospital of Nanjing University of Chinese Medicine, No. 155 Hanzhong Road, Qinhuai District, Nanjing 210023, Jiangsu Province, China. gangwang82@163.com
Received: August 22, 2025 Revised: September 22, 2025 Accepted: October 29, 2025 Published online: December 21, 2025 Processing time: 119 Days and 15.9 Hours
Abstract
BACKGROUND
The enhanced recovery after surgery (ERAS) perioperative management framework has been well-documented to improve surgical outcomes and alleviate financial burdens for patients. Against the backdrop of a rapidly aging global population, the incidence of gastric cancer (GC) among elderly individuals continues to increase.
AIM
To validate the feasibility and safety of the ERAS protocol in elderly GC patients, thereby enhancing its evidence-based medical foundation.
METHODS
A retrospective analysis of 161 GC patients who underwent ERAS between January 2022 and January 2024 was conducted. The subjects included 79 young patients (< 65 years) and 82 elderly patients (≥ 65 years). The rates of ERAS compliance, postoperative ventilation time, postoperative hospital stay, reoperation rate, mortality rate, postoperative inflammatory markers C-reactive protein (CRP), white blood cells (WBCs), IL-2, IL-6, and the rate of postoperative complications (anastomotic leakage, incision infection, pulmonary infection) were compared between these two groups.
RESULTS
The incidence of complications in the elderly group was significantly higher than that in the young group, and included hypertension (P = 0.002), diabetes (P = 0.005), respiratory disease (P = 0.034), and heart disease (P = 0.016). In terms of American Society of Anesthesiologists (ASA) grading indicators, the overall ASA grade in the elderly group was biased toward grade II, which was significantly higher than that in the young group (P < 0.001). There was no significant difference in sex, body mass index, preoperative albumin, preoperative WBCs, TNM classification, differentiation, number of lymph node metastasis, and preoperative IL-6 between the two groups. There were no significant differences between the two groups in terms of operative method, surgical approach, conversion to open surgery, operation time, intraoperative bleeding volume, and number of lymph nodes dissected (all P values > 0.05). There were no significant differences between the two groups in ERAS completion rate, reoperation, postoperative first ventilation time, postoperative hospital stays, postoperative anastomotic leakage, postoperative incision infection, postoperative pulmonary infection, and serum inflammatory markers (WBCs, CRP and IL-6) on postoperative day 1 and 3 (all P values > 0.05). No patients in either group died within 30 days after surgery.
CONCLUSION
The application of ERAS protocols in elderly patients is feasible and safe, and its management measures are universally applicable to patients of different ages.
Core Tip: This retrospective analysis of 161 gastric cancer patients confirms both the feasibility and safety of implementing enhanced recovery after surgery (ERAS) protocols for elderly individuals undergoing gastrectomy. Our findings contribute substantively to the evidence base for clinical adoption of ERAS. Furthermore, we describe and analyze key implementation insights regarding perioperative pathway execution in routine practice.
Citation: Li JY, Ge MM, Pan HF, Wang G, Jiang ZW. Feasibility and safety of enhanced recovery after surgery in elderly patients with gastric cancer. World J Gastroenterol 2025; 31(47): 113331
Gastric cancer (GC) is one of the most common malignant tumors of the digestive system. New annual cases of GC in China account for approximately 40% of all GC cases worldwide. The overall 5-year survival rate of GC is less than 50%, which seriously threatens human health and social as well as economic development. Currently, the overall treatment strategy for GC is still based on comprehensive treatment with surgery[1,2]. Enhanced recovery after surgery (ERAS) is a management concept based on evidence-based medicine to optimize perioperative management, which has been proven to effectively reduce perioperative stress response and accelerate patient recovery[3]. Since the first paper on the clinical application of ERAS in GC was published in China in 2007 around the world, and the expert consensus on enhanced recovery after gastrectomy for GC was released in 2016[4,5], ERAS has been widely used in the field of GC surgery. With the aging of population, the number of elderly patients with GC is increasing rapidly. Different from young patients, elderly patients have lower cardiopulmonary endurance, more underlying diseases, a decline in physiological function, and a relatively higher incidence of postoperative complications and mortality[6]. Therefore, the application of ERAS in elderly patients with GC is still in the exploratory stage and has not yet formed a standard. This study retrospectively analyzed the clinical data of elderly patients with GC, aiming to provide a reference for the normalization and standardized application of ERAS in elderly patients with GC.
MATERIALS AND METHODS
General information
A total of 161 patients with GC who underwent surgery and implemented ERAS program from January 2022 to January 2024 were retrospectively analyzed. They were divided into the young group (79 cases, aged 18-65 years) and the elderly group (82 cases, aged ≥ 65). According to the general data, surgical data and perioperative data of the patients, an analysis database was established.
The inclusion criteria were as follows: (1) GC confirmed by pathological diagnosis; (2) Elective radical resection of GC; and (3) Voluntarily participated in this study and signed the informed consent. The exclusion criteria were: (1) Patients with GC not confirmed by pathological diagnosis; (2) Those who underwent emergency surgery; (3) Only abdominal exploration was performed; and (4) Those who refused to accept ERAS perioperative management measures.
Treatment methods
Surgery and anesthesia were performed by surgeons and anesthesiologists trained in ERAS. Implementation of the perioperative ERAS program was based on the expert consensus on enhanced recovery after gastrectomy for GC (2016 edition)[5]. The specific perioperative interventions were as follows.
Preoperative measures: (1) Inform patients of the relevant contents of ERAS in detail and careful communication to relieve preoperative anxiety; (2) Preoperative nutritional status was assessed and nutritional support was given when necessary; (3) For those with a smoking history, they were encouraged to quit smoking before surgery and improve cardiopulmonary function with strengthening exercises; (4) No routine mechanical bowel preparation before surgery; (5) Fasting for 6h and water deprivation for 2 hours before surgery; (6) 10 hours preoperative, orally ingest 500 mL of 5% glucose solution; 2 hours preoperative, ingest 250 mL of 5% glucose solution; (7) Lactulose administration on the eve of surgery and in the early postoperative period to promote gastrointestinal peristalsis; and (8) Antibiotic prophylaxis 30 minutes before skin incision.
Intraoperative measures: (1) During surgery, the abdominal cavity was washed with warm water and covered with a thermal insulation blanket; (2) If the operation time exceeded 3 h, an additional dose of antibiotics was given during the operation; (3) A nasogastric tube was not routinely placed during surgery and appropriate placement of an abdominal drainage tube was performed; and (4) Intraoperative and postoperative controlled fluid infusion to prevent excessive fluid overload.
Postoperative interventions: (1) Multimodal analgesia; (2) Patients were encouraged to take fluids orally on postoperative day (POD) 1, and the amount was gradually increased according to gastrointestinal tolerance; (3) Early removal of urinary catheter and drainage tube after surgery; and (4) Encourage patients to get out of bed as soon as possible on the first POD, and increase the amount of daily activity.
Observation indicators
ERAS compliance rate, first postoperative ventilation time, postoperative hospital stays, reoperation rate, postoperative 30-day mortality, the level of postoperative inflammatory markers [C-reactive protein (CRP), white blood cells (WBCs), IL-2, and IL-6], incidence of postoperative complications (anastomotic leakage, incision infection, and pulmonary infection) were observed. This study implemented ERAS perioperative management according to established guidelines, incorporating a total of 16 predefined interventions. ERAS compliance was defined as completion of ≥ 87.5% of perioperative measures (i.e., ≥ 14 implemented items). ERAS adherence rate was calculated as the proportion of patients managed under this compliance threshold (Table 1).
Table 1 Enhanced recovery after surgery bundle implementation metrics.
Variables
Young group (n = 79; not completed)
Elderly group (n = 82; not completed)
Preoperative measures
Patient education on ERAS
0
0
Nutritional assessment
0
0
Cardiopulmonary exercise training
2
1
Avoidance of routine mechanical bowel preparation
0
1
Reduced preoperative fasting duration
0
0
Take carbohydrates orally
3
5
Standard surgical antibiotic prophylaxis
0
0
Intraoperative measures
Minimal access surgery
1
2
Temperature management
0
0
Intraoperative antibiotic redosing as indicated
0
0
Avoidance of routine nasogastric tube placement
5
3
Selective surgical drainage
0
0
Goal-directed fluid therapy
0
0
Postoperative interventions
Multimodal analgesia
3
2
Lactulose administration
0
3
Clear liquid diet initiation on POD1
9
7
Early removal of urinary catheters and surgical drains
IBM SPSS26.0 software was used for statistical analysis. The measurement data were expressed as mean ± SD if the distribution was normal or approximately normal, and skewed distribution data are presented as median and interquartile range. Count data are expressed as frequency and constituent ratio. The χ2 test was used to compare the unordered categorical variables, and rank-sum test (Mann-Whitney U test) was used to compare the ordered categorical variables. The Student’s t-test was used if the measurement data conformed to the normal distribution, and the rank-sum test (Mann-Whitney U test) was used if the measurement data did not conform to the normal distribution. P < 0.05 was considered statistically significant.
RESULTS
Clinicopathological features
There were no significant differences in sex, body mass index (BMI), preoperative albumin, preoperative WBCs and preoperative IL-6 between the two groups. The incidence of preoperative comorbidities in the elderly group was significantly higher than that in the young group, including hypertension (P = 0.002), diabetes (P = 0.005), respiratory disease (P = 0.034), and heart disease (P = 0.016). In terms of American Society of Anesthesiologists (ASA) grading indicators, the overall ASA grade in the elderly group was biased toward grade II, which was significantly higher than that in the young group (P < 0.001). In addition, there were no significant differences in TNM classification, differentiation and number of lymph node metastasis between the two groups (all P values > 0.05; Table 2).
Table 2 Main clinicopathological features of patients in two groups.
There were no significant differences between the two groups in terms of operative method, surgical approach, conversion to open surgery, operation time, intraoperative bleeding volume, and number of lymph nodes dissected (all P values > 0.05; Table 3).
There were no significant differences between the two groups in ERAS completion rate, reoperation, postoperative first ventilation time, postoperative hospital stays, postoperative anastomotic leakage, postoperative incision infection, postoperative pulmonary infection, and serum inflammatory markers (WBCs, CRP and IL-6) on POD1 and POD3 (all P values > 0.05; Table 4). No patients in either group died within 30 days after surgery.
Table 4 Short-term outcomes after surgery in two groups.
Since publication of the ERAS guidelines for Gastrectomy by the European Society for ERAS in 2014[7], many international gastrointestinal surgery centers have begun to explore the application of ERAS in GC surgery. The application of ERAS in the perioperative management of GC has been repeatedly proved to be safe and feasible, and can shorten the length of hospital stay, reduce the incidence of complications and mortality, reduce hospitalization costs and improve patient quality of life[8-11]. Elderly patients with GC have many complications. It is still unclear whether implementation of the ERAS program can be carried out completely in accordance with the guidelines, and there are few relevant studies. Xiao et al[12] showed in a prospective randomized controlled study involving 100 elderly patients with GC surgery that ERAS was safe and reliable, and could shorten the length of hospital stay. Cao et al[13] divided 171 subjects into the ERAS group and the conventional group, and the results showed that the application of ERAS in the perioperative period in elderly patients with GC was feasible and effective, and the main role of ERAS was to inhibit the inflammatory response and reduce the degree of immune function damage. Consistent with our findings, Jeong et al[14] demonstrated comparable recovery outcomes when applying identical ERAS protocols to GC patients above and below the 70-year age threshold, with no statistically significant differences in postoperative rehabilitation efficacy between the cohorts - a conclusion that directly parallels our observations. Although the results of the above studies can be used as relevant evidence for the safety of ERAS perioperative management in elderly patients with GC, further research is still needed to evaluate the need to develop a special rehabilitation pathway for elderly patients.
According to the Chinese guidelines for perioperative nutritional support for adults, nutritional status and nutritional risk are independent prognostic factors for hospitalized patients, and nutritional status assessment and risk screening are the primary conditions for the formulation of perioperative nutritional intervention programs[15]. It is necessary to use Nutritional risk screening 2002 (NRS2002) for comprehensive nutritional risk assessment before surgery[16]. A large number of clinical studies have shown that patients with malnutrition have an increased incidence of postoperative complications (including infection, anastomotic leakage, etc.), prolonged intensive care unit observation time and hospital stay, and increased medical costs, which affect the clinical outcome and quality of life of patients[17].
In the present study, the proportion of patients in the young group with BMI < 18.5 kg/m2 was 1.3%, and the proportion of patients with preoperative albumin < 30 g/L was 10.1%. In the elderly group, the proportion of patients with BMI < 18.5 kg/m2 and preoperative albumin < 30 g/L was 7.3% and 12.2%, respectively, which were lower than those reported in the literature. Preoperative malnourished patients were corrected with oral nutritional supplements, which played a role in reducing the incidence of postoperative complications.
Jung et al[10] showed that the compliance of patients with GC surgery to the ERAS protocol was significantly correlated with the clinical outcomes of patients. This study showed that the number of elderly patients with hypertension, diabetes, respiratory diseases and cardiovascular diseases was much higher than that of young patients, but there was no significant difference in the compliance or completion of the ERAS protocol between the two groups. The compliance rate of elderly patients was 85.4%, and that of young patients was 86.1%. Both groups had a high degree of acceptance of ERAS and completed it well. The ERAS management protocol used in this study was formulated according to the expert consensus on ERAS for GC (2016 edition). At the time of this study, there were concerns about the implementation of some of these programs; however, there were gains after implementation. (1) Consistent with our clinical experience implementing ERAS protocols, multiple cross-disciplinary studies have demonstrated that preoperative oral carbohydrate loading not only alleviates preoperative fasting burden but also reduces postoperative insulin resistance[18,19]. Notably, this approach remains effective even in surgical patients with comorbid diabetes[18,20]; (2) The use of general anesthesia + epidural anesthesia, reduces the dosage of general anesthetics, is conducive to reducing the stress response and postoperative ileus, and is conducive to rapid postoperative recovery and intestinal function recovery; (3) Before removing the abdominal drainage tube, on the premise of the flow of less than 100 mL, the color, odor and character of the drainage fluid should be comprehensively considered, and the drainage fluid is removed only when the color of the drainage fluid is light blood, clear with no peculiar smell. When the drainage fluid color is dark or even bloody, flocculent or has a peculiar smell, timely relevant examinations should be performed. Bleeding and anastomotic leakage should be excluded; and (4) The catheter was removed in the morning of the first day after surgery. None of the patients in the young group had acute urinary retention. Two patients in the elderly group had urinary retention, and both were complicated with prostatic hyperplasia, and the catheter was successfully removed on the second day after surgery. In this study, urinary retention was classified as a general complication, which will have a certain impact on the completion rate of the ERAS protocol, but its impact on safety was small.
Patients with TNM stage IV were present in both groups of patients in this study. ERAS is a multidisciplinary collaborative and comprehensive management concept of surgery, anesthesia, nursing and nutrition, so the inclusion and exclusion criteria of this study are relatively broad, and tumor staging was not used as an exclusion criterion, so that more patients could benefit from ERAS. Therefore, the ERAS protocol was implemented without differentiation in this study. Statistics showed that there was no significant difference in the compliance rate and complication rate between these stage IV patients and stage I-III patients. Therefore, our team believes that regardless of the clinical or pathological stage of stage IV patients, if the condition permits, the ERAS program can be implemented.
Shevchenko et al[21] identified serum inflammatory biomarkers as noninvasive tools for postoperative risk assessment in colorectal cancer patients. Shi et al[22] demonstrated that CRP was a reliable predictor of inflammatory complications following gastric surgery. Analysis of our data revealed a characteristic postoperative biomarker pattern: Both WBCs and IL-6 levels peaked on POD1 and declined by POD3, in contrast to CRP levels which maintained an upward trajectory through POD3. This distinct profile objectively reflects surgical recovery progression. Critically, persistent elevations across all three biomarkers beyond POD3 signify exacerbated inflammatory responses and potentially heralds increased complication rates.
The results of this study demonstrated no statistically significant differences between the two groups in terms of postoperative ventilation duration, length of hospital stay, postoperative inflammatory marker levels, reoperation rates, or incidence of postoperative complications (including anastomotic leakage, pulmonary infections, and surgical site infections). Given that the elderly group had a higher proportion of patients with preoperative comorbidities compared to the younger cohort, we performed Cochran-Mantel-Haenszel Statistics using preoperative comorbidities as the stratification variable, which confirmed that preoperative comorbidities did not constitute confounding factors in this study, with adjusted results remaining consistent with the initial statistical analysis (specific results are presented in the Supplementary Tables 1-22). Regarding postoperative complications, the occurrence of pulmonary infections in both groups underscores the critical importance of ERAS principles—specifically early ambulation and respiratory function training—which effectively prevent pulmonary embolism and pneumonia. Additionally, postoperative fluid restriction and early enteral nutrition implementation demonstrate preventive effects against cardiac insufficiency development.
This study used age as the sole grouping criterion to evaluate the safety and feasibility of standardized ERAS protocols in elderly patients, introducing the following inherent methodological constraints: (1) The retrospective design may have overlooked unmeasured confounding factors such as socioeconomic status; and (2) Generalizability may be limited by the single-center setting and high ERAS compliance rates, potentially reducing applicability to broader clinical practice. Given the absence of internationally standardized age criteria for distinguishing elderly vs younger patients, this study considered "elderly" as aged ≥ 65 years, consistent with predominant thresholds reported in clinical studies involving geriatric surgical populations with gastric, colorectal, and pancreatic cancers[13,23-30].
CONCLUSION
In summary, although elderly patients were significantly worse than young patients in terms of underlying diseases such as hypertension, diabetes, respiratory system diseases and cardiovascular system diseases, there were no significant differences in the ERAS protocol compliance rate, anastomotic leakage rate, incision infection rate, pulmonary infection rate, reoperation rate and postoperative mortality. These results indicate that the application of ERAS protocols in elderly patients is feasible and safe, its management measures are universally applicable to patients of different ages, and separate ERAS management pathways for elderly patients are not required.
Footnotes
Provenance and peer review: Unsolicited article; Externally peer reviewed.
Peer-review model: Single blind
Corresponding Author's Membership in Professional Societies: The Young Committee of the Accelerated Recovery Surgery Specialty of the Chinese Medical Doctor Association Surgery Branch; The Robotic Surgery Physicians Committee of the Chinese Medical Doctor Association's Surgical Sciences Branch; The Young Committee of the Colorectal Cancer Specialized Committee of the Chinese Medical Doctor Association; The Accelerated Rehabilitation Surgery Specialized Committee of the Chinese Medical Education Association; The Young Committee of the Gastrointestinal Stromal Tumor Diagnosis and Treatment Professional Committee of the Chinese Medical Doctor Association's Surgical Sciences Branch.
Specialty type: Surgery
Country of origin: China
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P-Reviewer: Sun GY, PhD, Associate Research Scientist, China; Wan HJ, MD, PhD, Vice Director, China S-Editor: Lin C L-Editor: Filipodia P-Editor: Xu J
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