This document discusses Enhanced Recovery After Surgery (ERAS) for gastric cancer (ERAS-GC). It outlines the components of ERAS-GC, which include general guidelines like early mobilization and feeding as well as procedure-specific guidelines. The document then describes how ERAS-GC was introduced at the author's hospital, including the protocol and discharge criteria. Finally, it presents two case examples comparing outcomes for patients who received ERAS-GC versus traditional care, finding improved short-term outcomes like faster recovery of bowel function and shorter hospital stay with ERAS-GC.

1. Enhanced Recovery After Surgery for gastric
cancer (ERAS-GC)
Presented by
Mugemana Henri Paterne

2. Outline
Introduction
ERAS-GC components
ERAS-GC introduced in our hospital
Cases presentation
References

3. Introduction
● ERAS is a multidisciplinary protocol of care with aim of maintaining normal
physiology and hence facilitating post-op recovery
● Routinely used in colorectal and pancreatic cancer surgeries
○ Significantly reducing surgical morbidity & Mortality Rate, duration of hospital stay, cost of
hospitalization and improving post-op recovery
● Despite its clinical benefits, the implementation has been slow in gastric
cancer surgeries
○ Reasons being among others; lack of convincing data and limitations in institutional
experience

4. Components of ERAS-GC
https://bjssjournals.onlinelibrary.wiley.com/doi/10.1002/bjs.9582
➔ General (not procedure-specific) enhanced recovery guidelines
➔ Procedure-specific guidelines

5. Components of ERAS-GC
➔ General (not procedure-specific) enhanced recovery guidelines

6. Components of ERAS-GC: General guidelines

7. Components of ERAS-GC: General guidelines

8. Components of ERAS-GC: General guidelines

9. Components of ERAS-GC: General guidelines

10. Components of ERAS-GC: General guidelines

11. Components of ERAS-GC
➔ Procedure-specific guidelines

12. Components of ERAS-GC: Procedure-specific guidelines

13. Components of ERAS-GC: Procedure-specific guidelines

14. Components of ERAS-GC: Procedure-specific guidelines

15. Components of ERAS-GC: Procedure-specific guidelines

16. Outline
Introduction
ERAS-GC components
ERAS-GC introduced in our hospital
Cases presentation
References

17. ERAS-GC introduced in our hospital
Table1. ERAS perioperative protocol for patients undergoing gastrectomy implemented at Miri Hospital, October
2021
Preop
day
Day of Op
(Day 0)
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Education &
Planning
Education about
ERAS
Operative risk
assessment
Consider MIS
for appropriate
cases
Pain Control Epidural PCA or
Paravertebral
IV paracetamol
Diclofenac PR if
required
Remove
epidural/
paraverte
bral for
DG
Oral
analgesia
for DG
Remove
epidural/
paraverte
bral for
TG
Oral
analgesia
for TG
Antibiotics,
Antiemetics & DVT
prophylaxis(1,2)
IV antibiotics for
24 hours
postoperatively
Antiembolic
stockings
Routine
antiemetics
Add LMWH
injection

18. Table1. ERAS perioperative protocol for patients undergoing gastrectomy implemented at Miri Hospital, October
2021
Preop
day
Day of Op
(Day 0)
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Exercise(3) Supported to lie
upright in bed
Sit out in a chair
(In ward
depending on
time)
Leg movements
in bed
Breathing
exercises using a
spirometer
Sit out in chair
Support
patient to
mobilise 4
times per day
Other exercise
as per Day 0
NG Tube In place,
removed
immediately after
surgery
Abdominal Drain No drain for DG
1 or 2 drains
Consider
removal
Urinary Catheter In place Consider Consider
ERAS-GC introduced in our hospital

19. Table1. ERAS perioperative protocol for patients undergoing gastrectomy implemented at Miri Hospital, October
2021
Preop
day
Day of Op
(Day 0)
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
IV Fluids Fluid restriction
(1-2L)
Fluid
restriction(2L)
Consider
stopping
for DG
Consider
stopping
for TG
Eating and
Drinking(3)
Normal meal
allowed until 6
hours before
surgery and
carbohydrate
drink until 2
hours before
surgery
No bowel
preparation
NPO Sips of water
for DG
NPO for TG
Clear
liquids as
tolerated
for DG
Sips of
water for
TG
Advance
to soft
blended
diet for
DG
Clear
liquids as
tolerated
for TG
Continue
Clear
liquids as
tolerated
for TG
Advance
to soft
blended
diet for
TG
Wound Care Surgical
wounds
checked &
dressing
changed if
necessary
Leave
surgical
wound
undressed,
if dry and
healing
well
Investigations Monitor labs Monitor labs Monitor
labs
Monitor
labs
Check
discharge
Monitor
labs
Monitor
labs
Check
discharge
ERAS-GC introduced in our hospital

20. Table1. ERAS perioperative protocol for patients undergoing gastrectomy implemented at Miri Hospital, October
2021
Preop
day
Day of Op
(Day 0)
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Investigations Monitor labs Monitor labs Monitor
labs
Monitor
labs
Check
discharge
criteria for
DG
Monitor
labs
Monitor
labs
Check
discharge
criteria for
TG
Discharge criteria(4) ● Adequate pain control : patient should be able to tolerate pain without IV analgesics or with oral analgesic only (measured by
VAS pain score < or = 4 )
● Ability to mobilise and self-care: patient should be able to sit up, walk and perform activities of daily living (eg, go to the toilet,
dress, shower, etc)
● Tolerance of oral intake: patient should be able to tolerate given meals without adverse GI symptoms and not require IV
infusion to maintain hydration
● No abnormal physical signs or laboratory test: Pulse, blood pressure, respiratory rate and body temperature should be
stable and consistent with preoperative levels. White blood cell count, serum hemoglobin, and other blood chemistry should be
stable within acceptable levels
MIS = minimally invasive surgery; DG = distal gastrectomy; TG = total gastrectomy; PCA = patient controlled anesthesia with IV narcotic; DVT = deep vein
thrombosis, LMWH = low molecular weight heparin; GI = gastrointestinal; NPO = nil per os; labs = complete blood count, urea, creatinine & electrolytes; VAS =
visual analog scale.
ERAS-GC introduced in our hospital

21. Outline
Introduction
ERAS-GC components
ERAS-GC introduced in our hospital
Cases presentation
References

22. Cases presentation
Patient under ERAS protocol Patient under TRADITIONAL protocol
Hx 52 y.o F on background of hypothyroidism, ℅
epigastric pain + repeated vomiting for 4 mo.
exacerbated by food
● UGI: gastric antral tumor with GOO
● CT: features highly suggestive of gastric
antrum neoplastic mass
● Bx: diffuse gastric carcinoma with signet ring
differentiation
● Sx: Distal gastrectomy
57 y.o F ℅ epigastric pain for 5 mo. + weight
loss, underwent 4 sessions of chemo.
● UGI: gastric body fungating mass
● CT: fungating gastric neoplasia at lesser
curvature, 4 cm distal to GEJ
● Bx: poorly differentiated carcinoma with
signet ring cell differentiation
● Sx: Total gastrectomy
PreOp Normal meal allowed 6 hrs bfr surgery +
carbohydrate drink until 2 hrs bfr surgery
No solid foods at dinner + no liquids 12 hrs bfr
surgery;

23. Cases presentation
Patient under ERAS protocol Patient under TRADITIONAL protocol
Intra -
op
Open access
4L crystalloids, 500ml colloid, 3FFPs, 2PRBCs
3 intra-abdominal drains
Epidural insertion
Removal of NGT on table
Open access
4L crystalloids, 500ml colloid, 4FFPs, 2PRBCs
3 intra-abdominal drains
Epidural insertion
Removal of NGT on table
Post -
op
No complication
Duration of urinary catheter: 2 days
Duration to peristalsis: 2 days
Duration to oral intake: 1 day
Duration to 1st mobilisation: 1 day
Duration of epidural: 1 day
Duration of hospital stay: 8 days
Admission in ICU for respiratory acidosis (3
days)
Other complications: moderate wound infection
Duration of urinary catheter: 4 days
Duration to peristalsis: 2 days
Duration to oral intake: 5 days
Duration to 1st mobilisation: 2 days
Duration of epidural: 2 days
Duration of hospital stay: 12 days

24. References
● Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg. 2008
Aug;248(2):189-98.
● Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray F. Cancer incidence and
mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer. 2015 Mar
1;136(5):E359-86.
● Tanaka, R., Lee, SW., Kawai, M. et al. Protocol for enhanced recovery after surgery improves short-term outcomes for
patients with gastric cancer: a randomized clinical trial. Gastric Cancer 20, 861–871 (2017).
● Jeong O, Kim H. Implementation of Enhanced Recovery after Surgery (ERAS) Program in Perioperative
Management of Gastric Cancer Surgery: a Nationwide Survey in Korea. J Gastric Cancer. 2019 Mar 1;19.
● Kang SH, Lee Y, Min S-H, Park YS, Ahn S-H, Park DJ, et al. Multimodal Enhanced Recovery After Surgery (ERAS)
Program is the Optimal Perioperative Care in Patients Undergoing Totally Laparoscopic Distal Gastrectomy for
Gastric Cancer: A Prospective, Randomized, Clinical Trial. Ann Surg Oncol. 2018 Oct 1;25(11):3231–8.
● Ford SJ, Adams D, Dudnikov S, Peyser P, Rahamim J, Wheatley TJ, et al. The implementation and effectiveness of
an enhanced recovery programme after oesophago-gastrectomy: A prospective cohort study. Int J Surg. 2014 Apr
1;12(4):320–4.
● Jeong O, Ryu SY, Park YK. Postoperative Functional Recovery After Gastrectomy in Patients Undergoing Enhanced
Recovery After Surgery. Medicine (Baltimore). 2016 Apr 8;95(14):e3140.