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©The Author(s) 2020.
World J Gastroenterol. Oct 7, 2020; 26(37): 5646-5660
Published online Oct 7, 2020. doi: 10.3748/wjg.v26.i37.5646
Published online Oct 7, 2020. doi: 10.3748/wjg.v26.i37.5646
Table 1 Compliance with the enhanced recovery after surgery protocol in enhanced recovery after surgery group
| ERAS variable | Compliance (%), n = 365 |
| Health education, exercise advice, dietary guidance | 365 (100) |
| Organ function evaluation, pre-rehabilitation treatment | 312 (85.5) |
| Fasting for 6 h and drinking for 2 h before operation | 332 (91.0) |
| No indwelling nasogastric tube | 310 (84.9) |
| Intraoperative safety check (WHO check list) | 365 (100) |
| Precision surgery scheme | 365 (100) |
| Goal-directed therapy | 306 (83.8) |
| Epidural anesthesia/analgesia | 299 (81.9) |
| Intraoperative heat preservation | 349 (95.6) |
| Small midline (< 8 cm) incision of upper abdomen | 358 (98.1) |
| Incision infiltration anesthesia | 310 (93.2) |
| Multimodal analgesia | 358 (98.1) |
| Prevention of deep venous thrombosis | 348 (95.3) |
| Mobilization on the first postoperative day | 320 (87.7) |
| Oral diet on the first postoperative day | 311 (85.2) |
| Early removal of catheter (< 24 h) | 339 (92.9) |
| Early extraction of abdominal drainage tube (< 48 h) | 304 (83.3) |
Table 2 Patient demographics and baseline characteristics
| Entire cohort | Propensity score matched cohort | |||||
| Conventional group (n = 433) | ERAS group (n = 394) | P value | Conventional group (n = 365) | ERAS group (n = 365) | P value | |
| Age, yr (mean ± SD) | 59.4 ± 10.2 | 59.6 ± 10.3 | 0.105 | 59.4 ± 10.3 | 59.5 ± 10.3 | 0.881 |
| Gender | 0.534 | 0.810 | ||||
| Male, n (%) | 298 (68.8) | 279 (70.8) | 253 (69.3) | 256 (70.1) | ||
| Female, n (%) | 135 (31.2) | 115 (29.2) | 112 (30.7) | 109 (29.9) | ||
| BMI, kg/m2 (mean ± SD) | 23.7 ± 3.0 | 24.0 ± 3.1 | 0.287 | 23.8 ± 3.2 | 24.0 ± 3.1 | 0.379 |
| ASA score | 0.594 | 0.833 | ||||
| I, n (%) | 226 (52.2) | 210 (53.3) | 190 (52.1) | 196 (53.7) | ||
| II, n (%) | 179 (41.3) | 165 (41.9) | 153 (41.9) | 152 (41.6) | ||
| III, n (%) | 28 (6.5) | 19 (4.9) | 22 (6.0) | 17 (4.7) | ||
| NRS 2002 | 0.784 | 0.767 | ||||
| < 3 | 197 (45.5) | 183 (46.4) | 165 (45.2) | 169 (46.3) | ||
| ≥ 3 | 236 (54.5) | 211 (53.6) | 200 (54.8) | 196 (53.7) | ||
| Comorbidity | ||||||
| Diabetes, n (%) | 52 (12.0) | 36 (9.1) | 0.181 | 35 (9.6) | 32 (8.8) | 0.700 |
| Cardiovascular, n (%) | 80 (18.5) | 52 (13.2) | 0.038 | 49 (13.4) | 40 (11.0) | 0.309 |
| Hypertension, n (%) | 115 (26.6) | 110 (27.9) | 0.660 | 98 (26.8) | 105 (28.8) | 0.563 |
| Pulmonary, n (%) | 45 (10.4) | 38 (9.6) | 0.720 | 33 (9.0) | 32 (8.8) | 0.896 |
| Hepatic, n (%) | 17 (3.9) | 20 (5.1) | 0.424 | 17 (4.7) | 19 (5.2) | 0.528 |
| Renal, n (%) | 3 (0.7) | 4 (1.0) | 0.614 | 3 (0.8) | 4 (1.1) | 0.614 |
| Tumor location | 0.892 | 0.962 | ||||
| Upper, n (%) | 59 (13.6) | 56 (14.2) | 55 (15.1) | 54 (14.8) | ||
| Middle, n (%) | 88 (20.3) | 84 (21.3) | 75 (20.5) | 78 (21.4) | ||
| Lower, n (%) | 286 (66.1) | 254 (64.5) | 235 (64.4) | 233 (63.8) | ||
| Histologic type | 0.651 | 0.829 | ||||
| Well, n (%) | 42 (9.7) | 31 (7.9) | 31 (8.5) | 31 (8.5) | ||
| Moderate, n (%) | 101 (23.3) | 94 (23.9) | 93 (25.5) | 86 (23.6) | ||
| Poor, n (%) | 290 (67.0) | 269 (68.3) | 241 (66.0) | 248 (67.9) | ||
| Pathological T stage | 0.254 | 0.350 | ||||
| T1, n (%) | 56 (12.9) | 42 (10.7) | 48 (13.2) | 38 (10.4) | ||
| T2, n (%) | 89 (20.6) | 91 (23.1) | 72 (19.7) | 82 (22.5) | ||
| T3, n (%) | 99 (22.9) | 107 (27.2) | 85 (23.3) | 98 (26.8) | ||
| T4, n (%) | 189 (43.6) | 154 (39.1) | 160 (43.8) | 147 (40.3) | ||
| Pathological N stage | 0.091 | 0.417 | ||||
| N0, n (%) | 95 (21.9) | 97 (24.6) | 86 (23.6) | 91 (24.9) | ||
| N1, n (%) | 89 (20.6) | 104 (26.4) | 79 (21.6) | 95 (26.0) | ||
| N2, n (%) | 92 (21.2) | 70 (17.8) | 74 (20.3) | 64 (17.5) | ||
| N3, n (%) | 157 (36.3) | 123 (31.2) | 126 (34.5) | 115 (31.5) | ||
| pTNM stage | 0.502 | 0.819 | ||||
| IA, n (%) | 45 (10.4) | 48 (12.2) | 40 (11.0) | 46 (12.6) | ||
| IB, n (%) | 69 (15.9) | 70 (17.8) | 62 (17.0) | 64 (17.5) | ||
| IIA, n (%) | 66 (15.2) | 64 (16.2) | 56 (15.3) | 62 (17.0) | ||
| IIB, n (%) | 72 (16.6) | 63 (16.0) | 60 (16.4) | 58 (15.9) | ||
| IIIA, n (%) | 47 (10.9) | 52 (13.2) | 42 (11.5) | 48 (13.2) | ||
| IIIB, n (%) | 66 (15.2) | 51 (12.9) | 54 (14.8) | 46 (12.6) | ||
| IIIC, n (%) | 68 (15.7) | 46 (11.7) | 51 (14.0) | 41 (11.2) | ||
| Operation date | 0.049 | 0.573 | ||||
| 2012, n (%) | 91 (21.0) | 65 (16.5) | 71 (19.5) | 60 (16.4) | ||
| 2013, n (%) | 98 (22.6) | 78 (19.8) | 70 (19.2) | 69 (18.9) | ||
| 2014, n (%) | 118 (27.3) | 102 (25.9) | 102 (27.9) | 98 (26.8) | ||
| 2015, n (%) | 126 (29.1) | 179 (45.4) | 122 (33.4) | 138 (37.8) | ||
| Adjuvant chemotherapy, n (%) | 282 (65.1) | 261 (66.2) | 0.736 | 233 (63.8) | 245 (67.1) | 0.351 |
Table 3 Surgical results for enhanced recovery after surgery and conventional groups
| Variable | Conventional group (n = 365) | ERAS group (n = 365) | P value |
| Extent of resection | 0.716 | ||
| Proximal gastrectomy, n (%) | 9 (2.5) | 6 (1.6) | |
| Total gastrectomy, n (%) | 90 (24.7) | 88 (24.1) | |
| Distal gastrectomy, n (%) | 266 (72.9) | 271 (74.2) | |
| Reconstruction | 0.520 | ||
| Esophagogastrostomy, n (%) | 7 (1.9) | 6 (1.6) | |
| Billroth-I, n (%) | 11 (3.0) | 7 (1.9) | |
| Billroth-II, n (%) | 21 (5.8) | 29 (7.9) | |
| Roux-en-Y, n (%) | 326 (89.3) | 323 (88.5) | |
| Retrieved LN number (mean ± SD) | 33.02 ± 13.14 | 32.72 ± 14.05 | 0.763 |
| Operation time, min (mean ± SD) | 198.35 ± 40.07 | 195.26 ± 42.94 | 0.315 |
| Estimated blood loss, mL (mean ± SD) | 72.49 ± 34.24 | 69.91 ± 34.22 | 0.308 |
| Intraoperative transfusion, n (%) | 23 (6.3) | 16 (4.4) | 0.249 |
| Length of incision, cm (mean ± SD) | 7.58 ± 1.54 | 7.47 ± 1.39 | 0.315 |
| Time to first flatus, d (mean ± SD) | 3.40 ± 1.21 | 2.50 ± 0.81 | < 0.001 |
| Time to first liquid intake, d (mean ± SD) | 3.64 ± 1.20 | 1.02 ± 0.57 | < 0.001 |
| Time to ambulation, d (mean ± SD) | 2.99 ± 1.51 | 1.47 ± 062 | < 0.001 |
| Postoperative hospital stay, d (mean ± SD) | 8.67 ± 2.38 | 7.09 ± 1.76 | < 0.001 |
| 30-d reoperation, n (%) | 7 (1.9) | 5 (1.4) | 0.560 |
| 30-d readmission, n (%) | 17 (4.7) | 15 (4.1) | 0.717 |
| Medical cost, $ (mean ± SD) | 7814.16 ± 1024.19 | 7621.75 ± 949.73 | 0.009 |
Table 4 Postoperative morbidity and mortality
| Variable | Conventional group (n = 365) | ERAS group (n = 365) | P value |
| Intraoperative complications, n (%) | 15 (4.1) | 16 (4.4) | 0.854 |
| Postoperative complications, n (%) | 66 (18.1) | 45 (12.3) | 0.030 |
| Wound infection, n (%) | 7 (1.9) | 4 (1.1) | 0.546 |
| Pulmonary, n (%) | 20 (5.5) | 13 (3.6) | 0.212 |
| Gastroparesis, n (%) | 6 (1.6) | 6 (1.6) | 1.000 |
| Anastomotic leakage, n (%) | 9 (2.5) | 7 (1.9) | 0.613 |
| Lymphatic leakage, n (%) | 4 (1.1) | 2 (0.5) | 0.686 |
| Pancreatic fistula, n (%) | 2 (0.5) | 1 (0.3) | 1.000 |
| Intra-abdominal bleeding, n (%) | 2 (0.5) | 0 (0) | 0.499 |
| Intraluminal bleeding, n (%) | 5 (1.4) | 5 (1.4) | 1.000 |
| Intra-abdominal abscess, n (%) | 2 (0.5) | 1 (0.3) | 1.000 |
| Deep vein thrombosis, n (%) | 2 (0.5) | 0 (0) | 0.499 |
| Ileus, n (%) | 3 (0.8) | 2 (0.5) | 1.000 |
| Cerebrovascular, n (%) | 0 (0) | 0 (0) | 1.000 |
| Cardiac, n (%) | 2 (0.5) | 1 (0.3) | 1.000 |
| Cholecystitis, n (%) | 0 (0) | 1 (0.3) | 1.000 |
| Hepatic, n (%) | 1 (0.3) | 1 (0.3) | 1.000 |
| Renal, n (%) | 1 (0.3) | 1 (0.3) | 1.000 |
| Mortality, n (%) | 0 (0) | 0 (0) | 1.000 |
| Clavien-Dindo classification | |||
| I, n (%) | 6 (1.6) | 4 (1.1) | 0.752 |
| II, n (%) | 50 (13.7) | 35 (9.6) | 0.083 |
| IIIa, n (%) | 4 (1.1) | 4 (1.1) | 1.000 |
| IIIb, n (%) | 3 (0.8) | 1 (0.3) | 0.624 |
| IV, n (%) | 3 (0.8) | 1 (0.3) | 0.624 |
- Citation: Tian YL, Cao SG, Liu XD, Li ZQ, Liu G, Zhang XQ, Sun YQ, Zhou X, Wang DS, Zhou YB. Short- and long-term outcomes associated with enhanced recovery after surgery protocol vs conventional management in patients undergoing laparoscopic gastrectomy. World J Gastroenterol 2020; 26(37): 5646-5660
- URL: https://www.wjgnet.com/1007-9327/full/v26/i37/5646.htm
- DOI: https://dx.doi.org/10.3748/wjg.v26.i37.5646