This study was reviewed and approved by the Chinese People’s Liberation Army General Hospital Research Ethics Committee. From January 2017 to December 2018, consecutive patients in ERAS settings and those in conventional perioperative management who underwent 3D laparoscopy-assisted gastrectomy performed by L.C. and C.L were enrolled. All patients provided written informed consent. The patients’ data were recorded in a prospectively maintained database.
A tailored ERAS protocol was established based on knowledge-to-action cycle . The ERAS development team consisted of surgeons, anesthesiologists, nurses, dietitians, and administrator. Each provided their unique expertise and perspective regarding various points in the patients’ care. The ERAS protocol is summarized in Table 1. Before admission, the patients received orally presented preoperative education and counseling at the outpatient clinic. Abdominal computed tomography, chest radiography, gastroscopy, electrocardiography, blood testing, and respiratory function testing were performed for diagnosis and preoperative assessment. The patients were encouraged to quit smoking for >2 weeks. Frail and deconditioned patients underwent a prehabilitation program that addressed their physical, metabolic, nutritional, and mental status to increase their functional reserve. On the day of admission, the preoperative education was further enhanced by written material. The patients were informed of the approximate length of stay (generally 5–7 days after gastrectomy), preoperative fasting time, surgical strategy, pain control, and time of catheter removal. Their nutritional status was evaluated according to the Nutrition Risk Screening 2002. Mechanical bowl preparation was not performed, and the patients were fasted up to 6 h before surgery. No preanesthetic medication was administered.
On the day of surgery, the patients underwent anesthetic induction with propofol and a short-acting opioid in the operating room. A short-acting non-depolarizing muscle relaxant was used to facilitate intubation and ventilation. Full monitoring and internal jugular vein access were established. Short-acting anesthetic drugs were used for maintenance of anesthesia, and short-acting muscle relaxants were used for surgical exposure during the laparoscopic procedures. The depth of anesthesia was controlled by maintaining the bispectral index (BIS) at 40 to 60 or the end-tidal concentration at 0.7 to 1.3 using monitored anesthesia care, and too-deep anesthesia (BIS of <45) was avoided in patients of advanced age. A nasogastric tube and urinary catheter were inserted after anesthesia. Antibiotics were administered within 1 h before skin incision, and a further dose was administered when the operative time lasted more than 3 h. The air conditioner in the operating room was set at 25ºC to 28ºC. A Bair Hugger Warming Unit (3M, Maplewood, MN, USA) was used to keep the patients’ temperature at >36ºC when necessary. During the surgery, an individualized goal-directed fluid management strategy and protective-ventilation strategy were adopted. To relieve postoperative pain, ropivacaine (0.5%) was administered regionally near the abdominal incision and flurbiprofen axetil (50 mg) was administered intravenously when suturing the abdominal skin. Patient-controlled analgesia was utilized. Ondansetron (4 mg) was administered to prevent postoperative nausea and vomiting. Upon completion of the surgery, the nasogastric tube was removed; an abdominal drainage tube was not placed.
On postoperative day (POD) 1 and 2, the patients were encouraged to walk around the ward with increasing frequency, and oral intake began with water and clear nutritional liquid (six spoonfuls of Ensure® Powder in 200 ml if water three times daily; 750 kcal/d). The urinary catheter was removed. Ondansetron (4 mg) was intravenously administered each day as needed for nausea and vomiting. On POD 3 to 5, a liquid diet was started if tolerated. On POD 5 to 7, a soft blended meal was started if tolerated. Discharge to perioperative surgical home was encouraged if the patients had normal laboratory test results and no discomfort.
Conventional perioperative care
Patients in the conventional group received primary nursing care. A solid diet was allowed until the day before surgery and clear fluid was allowed until 22:00. Bowel preparation (polyethylene glycol electrolyte) was administered on the day before surgery. During surgery, drainage tubes were regularly placed. After surgery, additional analgesics were administered when the patient reported pain. Nasogastric tube was removed on POD 1 or POD 2. Clear fluid was allowed when patients had a flatus, and soft blended food was allowed after two-to-three days of clear fluid without abnormity. Removal of urinary tube was generally on POD 1 if patients had no difficulty in urination. Abdominal drainage was removed when drainage fluid was clear and was less than 20 ml. Patients were usually discharged on POD 8 to 14 if the blood test was normal and patients had no complaint.
Based on the preoperative examination and intraoperative exploration, the patients underwent either total or subtotal 3D laparoscopy-assisted gastrectomy (Aesculap EinsteinVision® 3D camera system; B. Braun, Melsungen, Germany). Gastrectomy and lymph node dissection were performed to the extent previously described [17-19]. Digestive reconstruction was performed extracorporeally. Gastroduodenostomy, gastrojejunostomy, Roux-en-Y anastomosis, or esophagogastric anastomosis was performed according to the intraoperative exploration findings and surgeon’s preference.
The patients’ clinic-pathological data were collected, including sex, age, comorbidities, nutritional risk, operative time, intraoperative blood loss, pathological stage, and other variables. Postoperative complications were recorded according to the Clavien–Dindo grading system . Postoperative mortality and readmission rate within 30 days was documented. The following items were documented to calculate protocol compliance: no placement of nasogastric tube postoperatively, removal of urinary catheter on POD 1 to 2, no placement of abdominal drainage tube, ambulation on POD 1, oral intake of clear nutritional liquid on POD 1, oral intake of a liquid diet on POD 3 to 5, postoperative analgesia, and prevention of postoperative nausea and vomiting.
Continuous variables are presented as mean ± standard deviation or median with interquartile range (IQR). The Mann–Whitney test or independent-samples t test was used to compare continuous variables, and the χ2 test was used to compare categorical variables. Univariate and multivariate logistic regression were performed to investigate the factors influencing delayed discharge [postoperative hospital stay (PHS) of >7 days]. Pearson’s correlation analysis was applied to investigate the relationship between the compliance rate and PHS. SPSS software version 17.0 (SPSS, Inc., Chicago, IL, USA) was used for the statistical analysis. A two-sided P value of <0.05 was considered statistically significant.