Letter to the Editor: Rethinking geriatric onco-surgery: A paradigm shift validates enhanced recovery after surgery for elderly gastric cancer patients

Abstract

The rising incidence of gastric cancer in an aging population poses a significant surgical challenge, as elderly patients often present with greater comorbidities, leading to concerns about their ability to tolerate standardized enhanced recovery after surgery (ERAS) protocols. The groundbreaking retrospective study by Li et al, directly addresses this critical evidence gap. Their study demonstrates 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. 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. We argue that the work of Li et al catalyzes a paradigm shift, advocating for the universal application of evidence-based ERAS protocols across all age groups. This mandates a reevaluation of clinical practice and guidelines to ensure that elderly patients are not inadvertently deprived of the proven benefits of standardized ERAS pathways, thereby promoting equitable and optimal surgical outcomes for the growing geriatric oncological population.

Key Words: Enhanced recovery after surgery; Gastric cancer; Elderly patients; Geriatric oncology; Surgical outcomes; Postoperative complications; Feasibility

Core Tip: Against the backdrop of the escalating global health burden of gastric cancer in older adults, refining postoperative rehabilitation strategies is crucial for enhancing prognosis and improving quality of life in this population. A retrospective study conducted by Li et al on 161 older gastric cancer patients who underwent Enhanced recovery after surgery (ERAS) provided robust evidence supporting the clinical adoption of ERAS protocols. Additionally, the study offered critical implementation insights into perioperative pathway execution in routine practice. However, the study is constrained by its retrospective, single-center design; future investigations should prioritize multicenter, prospective cohorts to elevate the level of evidence and accelerate clinical translation. Equally important, real-world adherence to ERAS protocols must be rigorously evaluated.

TO THE EDITOR

Gastric cancer (GC) remains a major global health burden[1]. In older patients, the rising incidence of GC together with a higher prevalence of comorbidities poses an even greater surgical challenge[2]. Enhanced recovery after surgery (ERAS) optimizes perioperative care to attenuate surgical stress and improve patient outcomes[3]. However, the application of ERAS in older patients with multiple comorbidities and diminished physiological reserve remains exploratory. We read with great interest the retrospective study by Li et al[4]. Their analysis of reoperation, postoperative complications, and mortality in 161 GC patients managed within an ERAS protocol provides solid evidence supporting clinical adoption of ERAS, especially in older adults.

STUDY OVERVIEW AND DISCUSSION

Li et al[4] retrospectively collected single-center data on 161 GC patients who received ERAS, including ERAS compliance rate, duration of postoperative ventilation, postoperative hospital stays, reoperation rate, mortality, postoperative inflammatory markers C-reactive protein, white blood cells, interleukin (IL)-2, IL-6, and the incidence of postoperative complications such as anastomotic leakage, incisional infection, and pulmonary infection. The results showed that older patients had more comorbidities; however, there were no significant differences between the two groups in ERAS completion rate, reoperation, time to first postoperative ventilation, postoperative hospital stay, postoperative anastomotic leakage, postoperative incision infection, postoperative pulmonary infection, or serum inflammatory markers (white blood cells, C-reactive protein, and IL-6) on postoperative day one and three. The authors address a critical clinical question: Whether ERAS is both feasible and safe in older GC patients. The work of Li et al[4] catalyzes a paradigm shift by demonstrating that ERAS is feasible and safe in older patients, and that its management measures are generally applicable across age groups without the need for a separate ERAS pathway tailored specifically to the elderly. This is consistent with the findings reported by Iniesta et al[5]. Given the rising number of frails, older patients with multiple comorbidities undergoing gastric resection, a scenario further complicated by procedure- and patient-specific risk factors, rigorous evaluation of the feasibility and clinical benefit of perioperative interventions such as ERAS is imperative[6]. After reviewing the study by Li et al[4], we compiled a table summarizing recent ERAS research in gastric-cancer patients and created a graphical abstract of Li et al[4] findings to provide an integrated overview (Figure 1, Table 1)[7-9].

Figure 1 Graphical abstract. ERAS: Enhanced recovery after surgery; RCT: Randomized controlled trial.

Table 1 Summary of three clinical studies on enhanced recovery after surgery in gastric-cancer patients.

Ref.	Study design	Patient characteristics	Sample sizes	Key ERAS protocol elements	Primary outcome measures	Conclusions
Xiao et al[7]	Prospective study	Elderly gastric-cancer patients (age ≥ 70 years) undergoing gastrectomy	n = 100 (50 ERAS vs 50 conventional)	Preoperative carbohydrate loading, no nasogastric tube, early oral intake, early mobilization, etc.	Postoperative complications, length of stay, hospitalization costs, readmission rate	ERAS protocols can be safely applied to elderly gastric-cancer patients, significantly shortening post-operative length of stay without increasing complication risk
Cao et al[8]	RCT	Elderly gastric-cancer patients (age ≥ 65 years) undergoing laparoscopic total gastrectomy	n = 171 (85 ERAS vs 86 conventional)	Preoperative counselling, carbohydrate loading, no nasogastric tube, goal-directed fluid therapy, early feeding (starting POD 1), epidural analgesia, etc.	Length of stay, complications (Clavien-Dindo classification), immune marker (HLA-DR expression), inflammatory marker (CRP level)	ERAS is feasible and effective in elderly patients undergoing laparoscopic total gastrectomy; the benefits are linked to improved immune function and suppressed inflammatory response
Jeong et al[9]	Before-after propensity-score-matched study	Gastric-cancer patients undergoing gastrectomy (both distal and total procedures)	Pre-matching: 424 pre-ERAS vs 565 ERAS; post-matching: n = 219 each	18-item protocol: Preoperative carbohydrate loading, no drains, early oral intake (POD 1), restricted intravenous fluids, active mobilization, etc.	Length of stay, complications, readmission rate, re-operation rate	In real-world clinical practice, ERAS reduces hospital stay by approximately 3 days without raising readmission rates, confirming its tangible benefits

RCT: Randomized controlled trial; ERAS: Enhanced recovery after surgery; POD 1: Postoperative day 1; HLA: Human leukocyte antigen; CRP: C-reactive protein.

STRENGTHS AND LIMITATIONS

Li et al’s study[4] design strictly adhered to the ERAS trial design recommendations outlined in EClinicalMedicine[6]. The study exemplifies methodological rigor through stringent inclusion and exclusion criteria, precise perioperative intervention protocols, and clearly defined endpoints, strategies that collectively mitigate the bias inherent in retrospective analyses. This study provides an innovative assessment of the feasibility and safety of ERAS in older GC patients, addressing concerns that diminished physiological reserve might impose additional health burdens and limit survival benefit when ERAS is implemented in this population. In recent years, ERAS protocols have attracted substantial research interest, and a growing body of work has subjected these protocols to rigorous scientific scrutiny[10-12]. Nevertheless, baseline physiological heterogeneity between older and younger patients continues to impede their widespread application[13]. In frail, older adults with hip fracture, the capacity of multidisciplinary teams to make integrated decisions within an enhanced recovery framework has been shown to serve as a reliable touchstone for both early and long-term clinical outcomes, indicating that individualized care is advisable for this population[13]. In older patients with colorectal cancer, Pirrera et al[11] demonstrated that ERAS did not significantly differ from younger patients in morbidity, ninety day mortality, length of stay, or readmission rate, findings that align with the present results. Therefore, the present study, together with the work of Li et al[4], supports that implementation of ERAS is both safe and feasible in older adults undergoing gastrointestinal oncological resection.

A foremost concern is adherence to enhanced recovery protocols. A nationwide Spanish study across 21 centers reported a median protocol adherence of 68.2% among colorectal cancer patients, with an overall adherence rate of 63.6% in the entire cohort[14,15]. However, the ERAS adherence rate in this study reached 85% to 86%; such unusually high compliance may introduce bias and compromise the validity and generalizability of the findings. The unusually high adherence rate reported in this study may reflect measurement bias in how compliance was assessed. In routine practice, factors such as delayed postoperative mobilization or prolonged catheter use could distort the studied cohort. A retrospective analysis of 908 patients undergoing elective colon resection demonstrated that such deviations, particularly postponed ambulation among older adults, obscure the true effect of the protocol[16]. Another investigation has indicated that protocol deviations after surgery stemming from atypical team composition and intersurgeon variability also serve as sources of bias in ERAS research[17]. Therefore, the study should explicitly describe the detailed ERAS assessment protocol and provide a robust strategy for minimizing bias.

Furthermore, the age criterion used to define older adults in Li et al’s study[4] has prompted wide discussion. Previous ERAS investigations have typically set the threshold at 70 years or above, whereas the present study adopted 65 years as the cut off[18,19]. The World Health Organization sets 60 years as the general threshold for older age, yet it recommends 75 years for research purposes, because physiological decline, chronic disease management, and health maintenance become markedly more relevant beyond that point[20,21]. This study observed that GC patients managed with ERAS showed significantly different complication profiles between those aged 60-65 years and those aged 65-70 years, prompting Li et al[4] to choose 65 years as the cut-off. The definition of young, middle-aged, and older patients has long been debated. We therefore advocate disease- and intervention-specific age thresholds. Selecting optimal cut-offs for prognostic and diagnostic risk in distinct clinical contexts, for example by restricted cubic spline analysis, offers greater practical value.

FUTURE RESEARCH DIRECTIONS

To address these limitations and advance the field, we propose a comprehensive research agenda. First, multiple retrospective and prospective studies have indicated that older patients receiving ERAS interventions may achieve benefits comparable to those of younger patients[22]. Therefore, a randomized controlled trial is fully justified. As the study design that provides the highest level of clinical evidence, a randomized controlled trial can definitively clarify the feasibility and safety of ERAS in older patients[23]. Second, standardizing the ERAS bundle is essential. The protocol comprises preoperative shortening of fasting duration, intraoperative use of minimally invasive techniques combined with optimized anesthesia, and postoperative early oral intake plus mobilization[24-27]. Using propensity score matching to select patients can mitigate the bias introduced by ERAS interventions, and employing strict inclusion criteria is also important for reducing selection bias. Third, constructing forest plots to analyses risk factors in GC patients managed with ERAS offers high clinical and scientific value. Identifying variables such as diabetes, hematological indices of inflammation, and tumor markers can alert clinicians to provide additional interventions or closer surveillance for high-risk individuals, while also guiding future molecular and translational research. Finally, because the present analysis centers on age and the cut-off for “older” remains contentious, future work should re-define age thresholds in relation to the outcomes reported here. Comparing these new cut-offs with those used in previous studies and with World Health Organization benchmarks will clarify risk gradients across age subgroups and yield more precise clinical guidance.

CONCLUSION

The seminal work by Li et al[4] provides compelling data that validate the feasibility and safety of standardized ERAS protocols in elderly patients undergoing GC surgery. Crucially, this study offers a paradigm-shifting insight by demonstrating that even patients with stage IV GC can successfully benefit from ERAS, provided their general condition permits surgical intervention. This expands the potential application of ERAS to a broader, more vulnerable patient population.

However, the universal applicability of a single ERAS pathway should not be interpreted as a one-size-fits-all solution. Successful implementation in elderly or advanced-stage patients requires individualized planning, including proactive management of comorbidities, careful monitoring of age-related vulnerabilities, and adjustment for the increased physiological stress and potential nutritional deficits associated with extensive surgery. These promising findings need validation in large-scale, prospective, multicenter studies to ensure reproducibility, minimize bias, and provide a robust evidence base for the development of refined ERAS guidelines that optimize surgical outcomes across geriatric GC populations.