the enhanced recovery after surgery ( eras ) concept of multimodal perioperative care was proposed by henrik kehlet almost 2 decades ago and continues to gain support among surgeons from all over the world .
in addition to appropriate analgesia , early postoperative oral feeding and mobilization allow for a shortened hospital stay while decreasing the number of complications .
the eras protocol is well documented in colorectal surgery by several randomized controlled trials , which confirmed its effectiveness .
recently , the first reports on benefits from this kind of perioperative care in patients undergoing gastric surgery have appeared . in the past years
, there has been an increase in the number of laparoscopic surgeries performed due to gastrointestinal ( gi ) neoplasms . in comparison with open surgery
, laparoscopy is associated with less postoperative pain , quicker recovery , and better quality of life early after the procedure [ 4 , 5 ] . as in other operations , it is associated with better postoperative outcomes when compared with the classical approach .
this is especially important to patients with gastric neoplasms , particularly cancer , who are usually in poor general condition  commonly undernourished and burdened by neoadjuvant chemotherapy and comorbidities .
it seems that a maximal reduction of unfavorable surgery - induced trauma in this particular group of patients via the enhanced recovery program combined with minimally invasive techniques can result in improved outcomes .
the aim of this study was to analyze patient outcomes after minimally invasive surgery for gastric cancer and the application of perioperative care according to the eras protocol .
the analysis covered all patients who underwent laparoscopic gastric resection due to malignancy between august 2009 and november 2013 .
inclusion criteria were surgery due to gastric malignancy , performed with the intention to cure ; use of the laparoscopic approach ; and the patient s consent to perioperative care according to eras principles .
mean age was 64 years ( range : 3986 years ) , and mean body mass index was 27.4  kg / m ( range : 16.139.1  kg / m ) .
table 1demographic characteristics of the studied groupsexnumber of patients ( n)mean age ( years)age range ( years)mean body mass index ( kg / m)female1867.9398627.3male1063.4417727.6overall2864.0398627.4 demographic characteristics of the studied group indications for surgery were malignant gastric tumors : gi stromal tumors ( gist ) in 17 patients , adenocarcinoma in 10 , and multiple neuroendocrine tumors in 1 . in total , 18 gastric wedge resections and 10 gastrectomies with d2 lymphadenectomy were performed ( table  2 ) .
surgical procedureindication 
 n 
 local excision ( n  =  18)gastrointestinal stromal tumor17adenocarcinoma1d2 gastrectomy ( n  =  10)adenocarcinoma9multiple neuroendocrine tumor1 preoperative staging ( computed tomography , endoscopic ultrasound ) excluded distant metastases . in all patients , histological verification of the tumor was achieved preoperatively . in patients with gist , the average tumor size was 3.5  cm ( 1.56  cm ) .
five of nine patients with gastric adenocarcinoma received preoperative chemotherapy ( ecf protocol  three cycles of epirubicin , cisplatin , and 5-fluorouracil ) .
patients were eligible for neoadjuvant treatment if their world health organization performance status was 0 or 1 and the histologically proven adenocarcinoma of the stomach was considered to be stage ii or higher , with no evidence of distant metastases , or if they had locally advanced disease .
of the four patients who had not undergone preoperative chemotherapy , two were not submitted to neoadjuvant treatment due to the early stage of the disease , and in the case of two others , chemotherapy was contraindicated due to their poor general health .
after the creation of pneumoperitoneum and introduction of four trocars , intraoperative gastroscopy was performed to precisely locate the tumor . in case of smaller tumors , wedge resection was performed using an echelon stapler ( green color )
larger lesions were resected with a harmonic scalpel , and the defect in the stomach was closed with two layers of running suture . none of the patients had intraoperative tumor perforation .
specimens were placed in a plastic bag and removed through minilaparotomy in the epigastrium . in four patients , small tumor size allowed for extraction of the specimen through the mouth with the assistance of gastroscopy ( natural orifice specimen extraction ) . at the end of the surgery , the anastomosis patency test was performed via insufflation by gastroscope .
side - to - side esophagoenterostomy with a roux limb was then performed using a linear stapling device , and the anterior wall was closed by two absorbable running stitches .
subsequently , entero - enteral side - to - side anastomosis was performed with a similar technique .
the specimen was placed in a plastic bag and then removed through minilaparatomy , additionally protected with a wound protector .
a blue dye leakage test of the esophagoenteric anastomosis was performed at the end of surgery . in some patients , after hemostasis , a drain was left in the area of the duodenal stump . in one patient with cardiac infiltration involving 6  cm of distal esophagus , it was necessary to dissect the larger part of the esophagus to allow for an adequate proximal resection margin . in another patient with multiple neuroendocrine tumors also involving the duodenal bulb , the margins of the distal resection
two hours before the surgery , all patients received 400  ml of a carbohydrate - rich drink .
operations were performed with the laparoscopic technique . in 20 patients , minilaparotomy and trocar placement sites
were postoperatively injected with 0.25  % bupivacaine solution ( incisions 10  mm and greater in size were injected with 10  ml of bupivacaine , while smaller incisions with 5  ml of bupivacaine solution ) . in the remaining eight patients , transversus abdominis plane block ( tap block ) under ultrasound guidance
was used at the end of the surgery ( 20  ml of 0.25  % bupivacaine solution on each side ) .
intraoperatively , the fluid therapy was restricted , and natrium - rich crystaloids were partially replaced by colloids .
all patients received prophylaxis for postoperative nausea and vomiting through the administration of 8  mg of intravenous dexamethasone and 8  mg of ondansetron prior to the end of surgery , and supplemental oxygen was administered postoperatively .
drains were used only in selected cases ( not routinely ) . as patients returned to the ward ,
a single shot of antibiotic was administered for a second time on the first postoperative day ( cefazoline 2  g ) .
analgesia was based on paracetamol and nonsteroidal anti - inflammatory drugs ( nsaids ) . in the early postoperative hours
, morphine could be administered in minimal doses on patient s demand ( patient - controlled anesthesia ) .
upper gi contrast x - ray series with water - soluble contrast were performed for esophagojejunostomy leakage test on the first postoperative day .
afterward , the diet was expanded gradually to a full hospital diet with additional supplementation of protein - rich drinks .
after the creation of pneumoperitoneum and introduction of four trocars , intraoperative gastroscopy was performed to precisely locate the tumor . in case of smaller tumors ,
larger lesions were resected with a harmonic scalpel , and the defect in the stomach was closed with two layers of running suture .
specimens were placed in a plastic bag and removed through minilaparotomy in the epigastrium . in four patients , small tumor size allowed for extraction of the specimen through the mouth with the assistance of gastroscopy ( natural orifice specimen extraction ) . at the end of the surgery , the anastomosis patency test was performed via insufflation by gastroscope .
side - to - side esophagoenterostomy with a roux limb was then performed using a linear stapling device , and the anterior wall was closed by two absorbable running stitches .
subsequently , entero - enteral side - to - side anastomosis was performed with a similar technique .
the specimen was placed in a plastic bag and then removed through minilaparatomy , additionally protected with a wound protector .
a blue dye leakage test of the esophagoenteric anastomosis was performed at the end of surgery . in some patients , after hemostasis , a drain was left in the area of the duodenal stump . in one patient with cardiac infiltration involving 6  cm of distal esophagus , it was necessary to dissect the larger part of the esophagus to allow for an adequate proximal resection margin . in another patient with multiple neuroendocrine tumors also involving the duodenal bulb ,
two hours before the surgery , all patients received 400  ml of a carbohydrate - rich drink .
operations were performed with the laparoscopic technique . in 20 patients , minilaparotomy and trocar placement sites
were postoperatively injected with 0.25  % bupivacaine solution ( incisions 10  mm and greater in size were injected with 10  ml of bupivacaine , while smaller incisions with 5  ml of bupivacaine solution ) . in the remaining eight patients , transversus abdominis plane block ( tap block ) under ultrasound guidance
was used at the end of the surgery ( 20  ml of 0.25  % bupivacaine solution on each side ) .
intraoperatively , the fluid therapy was restricted , and natrium - rich crystaloids were partially replaced by colloids .
all patients received prophylaxis for postoperative nausea and vomiting through the administration of 8  mg of intravenous dexamethasone and 8  mg of ondansetron prior to the end of surgery , and supplemental oxygen was administered postoperatively .
drains were used only in selected cases ( not routinely ) . as patients returned to the ward ,
a single shot of antibiotic was administered for a second time on the first postoperative day ( cefazoline 2  g ) .
analgesia was based on paracetamol and nonsteroidal anti - inflammatory drugs ( nsaids ) . in the early postoperative hours
, morphine could be administered in minimal doses on patient s demand ( patient - controlled anesthesia ) .
upper gi contrast x - ray series with water - soluble contrast were performed for esophagojejunostomy leakage test on the first postoperative day .
afterward , the diet was expanded gradually to a full hospital diet with additional supplementation of protein - rich drinks .
after the creation of pneumoperitoneum and introduction of four trocars , intraoperative gastroscopy was performed to precisely locate the tumor . in case of smaller tumors ,
larger lesions were resected with a harmonic scalpel , and the defect in the stomach was closed with two layers of running suture .
specimens were placed in a plastic bag and removed through minilaparotomy in the epigastrium . in four patients , small tumor size allowed for extraction of the specimen through the mouth with the assistance of gastroscopy ( natural orifice specimen extraction ) . at the end of the surgery , the anastomosis patency test was performed via insufflation by gastroscope .
the stomach was dissected according to all oncological principles to obtain appropriate lymphadenectomy . side - to - side esophagoenterostomy with a roux limb
was then performed using a linear stapling device , and the anterior wall was closed by two absorbable running stitches .
subsequently , entero - enteral side - to - side anastomosis was performed with a similar technique .
the specimen was placed in a plastic bag and then removed through minilaparatomy , additionally protected with a wound protector .
a blue dye leakage test of the esophagoenteric anastomosis was performed at the end of surgery . in some patients , after hemostasis , a drain was left in the area of the duodenal stump . in one patient with cardiac infiltration involving 6  cm of distal esophagus , it was necessary to dissect the larger part of the esophagus to allow for an adequate proximal resection margin . in another patient with multiple neuroendocrine tumors also involving the duodenal bulb ,
two hours before the surgery , all patients received 400  ml of a carbohydrate - rich drink .
operations were performed with the laparoscopic technique . in 20 patients , minilaparotomy and trocar placement sites
were postoperatively injected with 0.25  % bupivacaine solution ( incisions 10  mm and greater in size were injected with 10  ml of bupivacaine , while smaller incisions with 5  ml of bupivacaine solution ) . in the remaining eight patients , transversus abdominis plane block ( tap block ) under ultrasound guidance
was used at the end of the surgery ( 20  ml of 0.25  % bupivacaine solution on each side ) .
intraoperatively , the fluid therapy was restricted , and natrium - rich crystaloids were partially replaced by colloids .
all patients received prophylaxis for postoperative nausea and vomiting through the administration of 8  mg of intravenous dexamethasone and 8  mg of ondansetron prior to the end of surgery , and supplemental oxygen was administered postoperatively .
drains were used only in selected cases ( not routinely ) . as patients returned to the ward , oral fluid intake was introduced .
a single shot of antibiotic was administered for a second time on the first postoperative day ( cefazoline 2  g ) .
analgesia was based on paracetamol and nonsteroidal anti - inflammatory drugs ( nsaids ) . in the early postoperative hours
, morphine could be administered in minimal doses on patient s demand ( patient - controlled anesthesia ) .
upper gi contrast x - ray series with water - soluble contrast were performed for esophagojejunostomy leakage test on the first postoperative day .
afterward , the diet was expanded gradually to a full hospital diet with additional supplementation of protein - rich drinks .
conversion was necessary in one case because the infiltration of the tumor could not be assessed . in that particular case , total gastrectomy with splenectomy and resection of the transverse colon
an accidental splenic artery injury occurred during dissection of neighboring tissues by a ligasure vessel sealer .
the vessel was successfully sutured , but due to the suturing delay and signs of thrombosis in the vessel , splenectomy had to be performed .
mean time of gastrectomy was 233  min ( 160420  min ) , and wedge resection , 75  min ( 35140  min ) .
the mean number of harvested lymph nodes was 29.2 ( 2236 ) , and to our knowledge , it is comparable with results from open surgery in our center .
postoperative complications occurred in one patient in whom reoperation was required after gastric wedge resection , due to problems with the passage of gastric contents resulting from stenosis at the suture line .
oral fluids were introduced on day 0 and were well tolerated in 26 ( 92.8  % ) patients .
intravenous fluids were stopped within the first 24  h in 23 ( 82.1  % ) patients .
a full hospital diet was started on day 2 in all patients ; however , it was well tolerated in only 18 ( 64.0  % ) of them  in 5 from the gastrectomy group and 13 from the local excision group .
all patients were mobilized ( including the patient after conversion ) within the first 24  h after surgery .
only five patients required postoperative doses of morphine during the first day after surgery ( total dose not exceeding 20  mg ) .
urinary catheters were removed on the day of surgery in the afternoon in all but the one converted patient .
drains in the peritoneal cavity were left in five patients after gastrectomy  we removed them on the first postoperative day in three cases , while for the remaining two patients , the drains were left in because the intraoperative blue dye leakage test indicated a need for anastomosis reinforcement with an additional layer of sutures ; these drains were removed on the second postoperative day .
the length of the hospital stay in patients after gastrectomy and gastric wedge resection was 4.6 ( 26 ) days and 3.3 ( 26 ) days , respectively .
the most recent data confirm that the oncological quality of laparoscopic resection of gists is comparable with open surgery and provides better postoperative outcomes and a lower risk of complications .
thus , many experts agree that minimally invasive techniques should be the first - choice treatment option in patients with gist [ 79 ] .
we also know that laparoscopy is a safe alternative for patients with gastric adenocarcinoma undergoing gastrectomy .
a comparison of laparoscopic surgery and open operations shows that the number of harvested lymph nodes is similar regardless of the chosen technique [ 1113 ] . in our study , perioperative care was based on the guidelines of the eras protocol .
it is well known that perioperative care of this kind benefits patients after colonic resections .
eras is widely used in bariatric surgery and allows for shortening hospital stays after surgical procedures , even down to 1 day .
they are commonly burdened by neoadjuvant systemic chemotherapy , have numerous comorbidities , and are frequently undernourished .
all these factors can increase the risk of early postoperative complications that can postpone adjuvant therapy and worsen overall treatment outcomes .
we can reasonably expect a decrease in unfavorable surgery - induced trauma through implementation of the eras protocol .
currently , only a few publications report improved postoperative outcomes in laparoscopic gastric surgery as a result of enhanced recovery programs .
these publications unambiguously emphasize the shorter hospital stays that result from using the protocol , though only a few of them report an accompanying lower rate of complications .
although fasting even up to 12  h prior to surgery has been a standard practice intended to prevent pulmonary aspiration in elective surgery , recent studies have found no scientific support for its effectiveness .
a review of available studies and clinical observations provided robust evidence that reducing preoperative fasting for clear fluids to 2  h and solid foods to 6  h does not lead to an increase in complication rates .
additionally , administration of carbohydrate - rich fluids 23  h prior to surgery reduces the fasting time , which decreases catabolic reaction and reduces insulin resistance in the organism , has an overall positive influence on the nitrogen balance , and also allows for earlier postoperative return of gi function [ 17 , 18 ] .
it is also proven to be safe in patients with uncomplicated diabetes mellitus type 2 . in the postoperative period ,
fluid intake can be started on the day of the surgery so that on the second postoperative day , patients receive a full semi - liquid diet . in many centers
, postoperative oral intake tends to be restricted ; however , there is strong evidence that early postoperative enteral feeding ( on the day of surgery ) reduces postoperative catabolism , hastens the return of intestinal function , and decreases the risk of complications ( as well as reduces the risk of anastomotic leakage ) .
there are far fewer publications available on similar topics in the case of upper gi tract surgery . according to lassen et al . , who performed a multicenter randomized control trial on upper gi surgery patients , the early introduction of a full diet on the first postoperative day was not associated with a higher complication rate and allowed for a reduction in the hospital stay . to sum up
, it seems that early oral intake , starting with a small amount of mixed food or protein - rich drinks , results in faster return of gi tract function and reduces the length of the hospital stay .
additionally , early enteral feeding allows for the reduction of postoperative intravenous fluid administration , which has positive effect on the return of bowel function and lowers the complication rate [ 2325 ] .
the presented group of patients was allowed to drink up to 800  ml of fluids on the day of the surgery , which partially eliminated the need of infusions .
it did not decrease anastomotic dehiscence risk , the number of pulmonary complications , or the mortality rate .
a meta - analysis by yang et al .   including more than 700 patients after gastrectomy has shown that leaving of esophageoenteric tube prolongs postoperative ileus and the time of the first passage of flatus .
evidence also shows no benefit in the use of drains in the case of colorectal surgery , or surgery of the pancreas , appendix , or gallbladder [ 27 , 28 ] .
no publications on this topic were found with regard to upper gi surgery . the advantage of minimally invasive techniques can be that relaparoscopy in the case of suspected bleeding or anastomotic dehiscence
is associated with lower complication risk than relaparotomy . in the described group of patients ,
although we left them in the first few cases , we tend not to use them anymore in any uncomplicated surgery .
epidural anesthesia is particularly important in the case of classical operations , but its use in laparoscopy is limited .
increasingly common is the use of trocar placement sites for infiltration with local anesthetic drugs or tap block .
evidence has shown that analgesia based on nsaids is generally sufficient in the case of laparoscopic surgeries [ 30 , 31 ] . in our opinion , nsaids together with paracetamol and local anesthesia ( especially tap block ) can provide full pain control in the first few days after surgery . when needed , analgesia can be enhanced with small doses of opioids ( patient controlled analgesia ) . an important element of the eras protocol is early mobilization .
its importance is well documented in the study by smart et al . , which showed that failure of early mobilization is one of the most common causes of deviation from the eras protocol and is associated with prolonged hospital stays
. early effective postoperative mobilization of patients is possible mainly due to adequate pain control .
similarly , restriction of intravenous fluid administration , early removal of the urinary catheter , and peritoneal drains improve postoperative patients comfort , leading to earlier postoperative mobilization .
in our opinion , the clinical implementation of the eras protocol in combination with laparoscopy for patients operated on due to malignant gastric tumors can result in improved postoperative care quality , shortened hospital stays , and a faster return to normal activity in the postoperative period .
micha pdziwiatr , maciej matok , mikhail kisialeuski , marcin migaczewski , piotr major , marek winiarski , piotr budzynski , anna zub - pokrowiecka , and andrzej budzynski have no conflicts of interest to declare .
all procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation ( institutional and national ) and with the helsinki declaration of 1975 , as revised in 2008 .
this article is distributed under the terms of the creative commons attribution noncommercial license which permits any noncommercial use , distribution , and reproduction in any medium , provided the original author(s ) and the source are credited .
micha pdziwiatr , maciej matok , mikhail kisialeuski , marcin migaczewski , piotr major , marek winiarski , piotr budzynski , anna zub - pokrowiecka , and andrzej budzynski have no conflicts of interest to declare .
all procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation ( institutional and national ) and with the helsinki declaration of 1975 , as revised in 2008 .
this article is distributed under the terms of the creative commons attribution noncommercial license which permits any noncommercial use , distribution , and reproduction in any medium , provided the original author(s ) and the source are credited .
 summaryintroductionrecently , first reports on benefits from enhanced recovery after surgery ( eras ) pathway in patients undergoing gastric surgery have appeared . 
 it seems that maximal reduction of unfavorable surgery - induced trauma in patients with gastric malignancy via eras protocol combined with minimally invasive techniques can improve outcomes.objectivethe aim of this study was to determine the influence of laparoscopic surgery and eras protocol in oncological gastric surgery on early outcomes.materials and methodsprospective analysis involved 28 patients ( 18 female and 10 male ) with gastric malignancy who underwent laparoscopic gastric resection between 2009 and 2013 . gastric tumors ( gastrointestinal stromal tumors or adenocarcinoma ) were the indication for the surgery . 
 a total of 17 patients underwent laparoscopic local excision , and 11 patients with adenocarcinoma or multiple neuroendocrine tumors underwent laparoscopic d2 total gastrectomy . 
 perioperative care was based on eras principles . 
 length of hospital stay , postoperative course , perioperative complications , and readmission rates were analyzed.resultsthere was one conversion in the gastrectomy group . 
 all patients were mobilized on the day of surgery . 
 oral fluids were introduced on day 0 and were well tolerated . full hospital diet 
 was started on day 2 in all patients , but was well tolerated in only 18 of them . 
 one postoperative complication requiring reoperation was noted . 
 the length of stay after gastrectomy and gastric wedge resection was 4.6 ( 26 ) and 3.3 ( 26 ) days , respectively . 
 no readmissions were noted in the entire group.conclusionsthe implementation of eras protocol to clinical practice in combination with laparoscopy in patients with gastric tumors can result in improved postoperative care quality , shortening of hospital stay , and quicker return to normal activity . 
Introduction
Aim
Materials and methods
Operative technique
Gastric wedge resection
Gastrectomy
Perioperative care
Results
Discussion
Conclusions
Consent
Conflict of interest
Open Access