Fast-track surgery could improve postoperative recovery in radical total gastrectomy patients

Table 1 Comparison of fast-track surgery and conventional perioperative intervention protocols

Perioperative intervention	Conventional	Fast-track surgery
Diet before surgery	No intake of food and drink after supper the day before surgery	Intake of 1000 mL 14% carbohydrate drink 12 h before and 350 mL 14% carbohydrate drink 3 h before surgery.
Anesthesia	Tracheal intubation and general anesthesia	Tracheal intubation and general anesthesia
Thermal insulation during operation	No thermal insulation, room temperature was maintained at 22  °C	Thermal insulation of the body and extremities, body temperature was maintained at 36  °C
Operation procedure	Standard laparotomy approach	Standard laparotomy approach
Placement of abdominal drainage	Use of abdominal drainage tube	No routine use of abdominal drainage tube
Analgesia after operation	Standard use of patient-controlled analgesic pump	Infiltration of surgical wounds with ropivacaine at the end of surgery and 24 h after surgery. Oral intake of 200 mg celecoxib twice daily
Mobilization after operation	Mobilize out of bed on patients’ own request	Encourage patients to mobilize out of bed
Diet after operation	Oral intake initiated after flatus (following a stepwise plan from water to other liquids to semi-fluids to normal food)	Oral intake of 500-1000 mL glucose saline on the day of surgery. Intake of 2000-3000 mL liquid food containing 1000 kcal to 1200 kcal per day from the 1st day after surgery
Intravenous nutrition after operation	Infusion of glucose saline and amino acid injection iv on the day of surgery. Infusion of parenteral nutrition (25 kcal/kg of body weight) iv before oral intake. Appropriate level of iv fluid intake based on the volume of liquid intake and output, and physiological need	Infusion of parenteral nutrition iv if oral intake is not adequate. Appropriate level of iv fluid intake based on the volume of liquid intake and output, and physiological need
Removal of nasogastric tube	Removal of nasogastric tube after flatus	Removal of nasogastric tube within 24 h after surgery
Removal of urine catheter	Removal of urine catheter on the 3rd or 4th day after surgery	Removal of urine catheter within 24 h after surgery
Antibiotics	Standard use of antibiotics for 3 d after surgery	Standard use of antibiotics before and once after surgery

Table 2 Comparison of baseline characteristics of the two groups (mean ± SD)

Characteristics	Conventional	Fast-track surgery	P value
Age, yr	55.79 ± 10.06	54.98 ± 11.35	0.682
Sex			0.689
Male/female	44/16	41/18
BMI	21.01 ± 1.78	22.44 ± 3.51	0.061
NRS 2002 score	0.81 ± 1.10	1.08 ± 1.41	0.424
ASA score			0.364
I/II	1/59	3/56
Differentiation status			0.857
Well differentiated	6	4
Moderately differentiated	20	17
Poorly differentiated	34	38
TNM classification			0.324
I/II/III	8/31/2021	14/12/33
White blood cell	6.20 ± 1.74	6.05 ± 2.08	0.671
Hemoglobin, g/L	133.36 ± 22.03	130.65 ± 22.41	0.52
Albumin, g/L	44.42 ± 4.89	42.83 ± 4.65	0.082
ALT	17.91 ± 11.35	21.29 ± 15.55	0.195
AST	21.84 ± 11.46	25.83 ± 17.00	0.151
Operation time, min	242.38 ± 72.89	226.11 ± 65.87	0.214
Blood loss, mL	221.17 ± 122.55	230.55 ± 171.82	0.735

BMI: Body mass index; ASA: American Society of Anesthesiologists; NRS: Nutritional risk screening; TNM: Tumor node metastases; ALT: Alanine aminotransferase; AST: Aspartate aminotransferase.

Table 3 Comparison postoperative pain intensity and white blood cell count between the two groups (mean ± SD)

Time	Conventional	Fast-track surgery	P value
Postoperative pain intensity
POD 1	5.41 ± 1.45	4.32 ± 1.65	0.000
POD 2	4.43 ± 1.54	3.39 ± 1.65	0.001
POD 3	3.63 ± 1.48	2.76 ± 1.36	0.002
POD 4	3.02 ± 1.45	2.51 ± 1.87	0.119
POD 5	2.21 ± 1.39	2.30 ± 1.56	0.789
White blood cell count
POD 1	14.81 ± 5.34	14.55 ± 5.04	0.793
POD 2	15.36 ± 5.36	12.26 ± 4.78	0.002
POD 3	11.80 ± 4.80	9.35 ± 3.83	0.005
POD 4	8.56 ± 3.70	7.52 ± 3.57	0.223
POD 5	6.37 ± 2.34	6.91 ± 3.34	0.684

POD: Postoperative day.

Table 4 Comparison clinical outcomes and postoperative complications between the two groups

	Conventional	Fast-track surgery	P value
Clinical outcomes
First flatus, h	79.03 ± 20.26	60.97 ± 24.40	0.000
First defecation, h	93.03 ± 27.95	68.00 ± 25.42	0.000
Postoperative stay, d	7.10 ± 2.13	5.68 ± 1.22	0.000
Cost of hospitalization, RMB	43783.25 ± 8102.36	39597.62 ± 7529.98	0.005
Postoperative complications
Total cases	17	6	0.019
Pneumonia	10	5	0.269
Incision infection	3	1	0.619
Urinary infection	1	0	1.000
Abdominal infection	1	0	1.000
Gastric retention	0	0
Anastomotic leak	0	0
Deep-vein thrombosis	0	0
Ileus	1	0	1.000
Reoperation	1	0	1.000
Readmission	0	0
Mortality	0	0