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NIHR Signal Enhanced recovery programmes after stomach cancer surgery reduce hospital stay without increasing complications

Published on 18 July 2018

doi: 10.3310/signal-000623

Enhanced recovery programmes reduce length of hospital stay and associated healthcare costs after stomach cancer surgery, with no impact on short-term mortality or post-operative complications. They also improve post-operative quality of life.

The enhanced recovery approach includes a range of components designed to help people to recover more quickly and have better outcomes after surgery. These include optimising people's health preoperatively, attention to detail during anaesthesia and surgery, early return to feeding and encouraging people onto their feet as soon as possible afterwards.

Enhanced recovery is already established practice for many types of surgery, including for stomach cancer, in many UK hospitals.

This review included trials from Asia, but these followed internationally accepted protocols. Its findings support programmes already in place and add evidence for hospitals that have not yet implemented them.

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Why was this study needed?

Each year around there are around 7,000 people in the UK with stomach cancer, making it the 16th most common cancer. Survival rates for people with stomach cancer are not as good as for other cancers, partly because of late diagnosis. Once it has spread further and it is more difficult to treat.

Surgery to remove all or part of the stomach, gastrectomy, is commonly used to remove all or most of the cancerous tissue. Chemotherapy and radiotherapy are also used, either alone or in combination with surgery, depending on the spread of the cancer.

Enhanced recovery programmes are designed to help people to recover quicker and better from all kinds of surgery. A Cochrane review in 2016 found benefits from enhanced recovery for a range of upper digestive tract conditions. This meta-analysis looked at using enhanced recovery programmes to improve outcomes after stomach cancer surgery.

What did this study do?

This meta-analysis combined the results of 13 randomised controlled trials comparing outcomes for people after stomach cancer surgery with enhanced recovery (ERAS) or usual care. There were 1,092 participants.

Trials included eight or more components out of the 25 components recommended in 2014 guidelines on enhanced recovery after gastrectomy. These include optimising nutrition before surgery, not performing mechanical bowel preparation, and getting people mobile as soon as possible after their operation.

Some studies were small and in several of the individual analyses. The confidence intervals are wide, and the trials are statistically different (heterogeneous). These factors reduce our confidence in some of the results. The included trials are mainly from Asian countries, where stomach cancer is more common and may be diagnosed earlier. This may reduce applicability to the UK population.

What did it find?

  • Deaths were rare (one person, in the enhanced recovery group).
  • Overall post-operative complications were the same in the enhanced recovery group (186/545) compared with usual care (188/547) (risk ratio [RR] 1.03, 95% confidence interval [CI] 0.73 to 1.44).
  • Lung infections were fewer amongst those on the enhanced recovery programme compared to usual care (RR 0.52, 95% CI 0.20 to 0.94).
  • ERAS reduced the length of hospital stay overall (mean difference [MD] ‑1.65 days, 95% CI ‑2.09 to ‑1.21 days). This was the case when looking just at trials using laparoscopic (minimally invasive) surgery and traditional open surgery.
  • Readmission rates were higher in the enhanced recovery group, (22/390) compared with usual care (7/387), (RR 2.86, 95% CI 1.31 to 6.24).
  •  Overall healthcare costs were reduced by ERAS (MD -$5,000, 95% CI ‑$6,900 to ‑$3,000) and when looking at ERAS versus usual care in laparoscopic and open surgery. Costs were based on healthcare in China and Japan.

What does current guidance say on this issue?

International consensus guidance was published in 2014 on enhanced recovery after surgery to remove the stomach (for reasons including cancer). The consensus group noted that evidence was lacking for some recommendations, such as whether to give pre-operative food supplements to stimulate the immune system and on how best to carry out the surgery.

What are the implications?

This meta-analysis reinforces the evidence base supporting the UK policy of enhanced recovery programmes after most gastrointestinal surgery including stomach cancer surgery. It may also inform decision-making in hospitals where enhanced recovery is not in place or has not been implemented for stomach cancer surgery.

UK-based assessments of the resource required to set-up and manage programmes will be needed by those considering implementation.

Future research could usefully focus on analysing which components of enhanced recovery provide the greatest benefits.

Citation and Funding

Wang LH, Zhu RF, Gao C, et al. Application of enhanced recovery after gastric cancer surgery: an updated meta-analysis. World J Gastroenterol. 2018;24(14):1562-78.

Individual authors of the review were supported by grants from the National Natural Science Foundation of China, the Priority Academic Program Development of Jiangsu Higher Education Institutions and the Key Medical Talents Program of Jiangsu Province. They declared no conflicts of interest.

Bibliography

CRUK. Cancer incidence for common cancers. London: Cancer Research UK; updated 2018.

Macmillan Cancer Support. Surgery for stomach cancer. London: Macmillan Cancer Support; updated 2016.

Mortensen K, Nilsson M, Slim K et al. Consensus guidelines for enhanced recovery after gastrectomy: enhanced recovery after surgery (ERAS®) society recommendations. Br J Surg. 2014;101(10):1209-29.

NHS Choices. Enhanced recovery. London: Department of Health; updated 2016.

NHS Choices. Stomach cancer. London: Department of Health; updated 2015.

NICE. Laparoscopic gastrectomy for cancer. IPG269. London: National Institute for Health and Care Excellence; 2008.

NICE. Oesophago-gastric cancer: assessment and management in adults. NG83. London: National Institute for Health and Care Excellence; 2018.

Why was this study needed?

Each year around there are around 7,000 people in the UK with stomach cancer, making it the 16th most common cancer. Survival rates for people with stomach cancer are not as good as for other cancers, partly because of late diagnosis. Once it has spread further and it is more difficult to treat.

Surgery to remove all or part of the stomach, gastrectomy, is commonly used to remove all or most of the cancerous tissue. Chemotherapy and radiotherapy are also used, either alone or in combination with surgery, depending on the spread of the cancer.

Enhanced recovery programmes are designed to help people to recover quicker and better from all kinds of surgery. A Cochrane review in 2016 found benefits from enhanced recovery for a range of upper digestive tract conditions. This meta-analysis looked at using enhanced recovery programmes to improve outcomes after stomach cancer surgery.

What did this study do?

This meta-analysis combined the results of 13 randomised controlled trials comparing outcomes for people after stomach cancer surgery with enhanced recovery (ERAS) or usual care. There were 1,092 participants.

Trials included eight or more components out of the 25 components recommended in 2014 guidelines on enhanced recovery after gastrectomy. These include optimising nutrition before surgery, not performing mechanical bowel preparation, and getting people mobile as soon as possible after their operation.

Some studies were small and in several of the individual analyses. The confidence intervals are wide, and the trials are statistically different (heterogeneous). These factors reduce our confidence in some of the results. The included trials are mainly from Asian countries, where stomach cancer is more common and may be diagnosed earlier. This may reduce applicability to the UK population.

What did it find?

  • Deaths were rare (one person, in the enhanced recovery group).
  • Overall post-operative complications were the same in the enhanced recovery group (186/545) compared with usual care (188/547) (risk ratio [RR] 1.03, 95% confidence interval [CI] 0.73 to 1.44).
  • Lung infections were fewer amongst those on the enhanced recovery programme compared to usual care (RR 0.52, 95% CI 0.20 to 0.94).
  • ERAS reduced the length of hospital stay overall (mean difference [MD] ‑1.65 days, 95% CI ‑2.09 to ‑1.21 days). This was the case when looking just at trials using laparoscopic (minimally invasive) surgery and traditional open surgery.
  • Readmission rates were higher in the enhanced recovery group, (22/390) compared with usual care (7/387), (RR 2.86, 95% CI 1.31 to 6.24).
  •  Overall healthcare costs were reduced by ERAS (MD -$5,000, 95% CI ‑$6,900 to ‑$3,000) and when looking at ERAS versus usual care in laparoscopic and open surgery. Costs were based on healthcare in China and Japan.

What does current guidance say on this issue?

International consensus guidance was published in 2014 on enhanced recovery after surgery to remove the stomach (for reasons including cancer). The consensus group noted that evidence was lacking for some recommendations, such as whether to give pre-operative food supplements to stimulate the immune system and on how best to carry out the surgery.

What are the implications?

This meta-analysis reinforces the evidence base supporting the UK policy of enhanced recovery programmes after most gastrointestinal surgery including stomach cancer surgery. It may also inform decision-making in hospitals where enhanced recovery is not in place or has not been implemented for stomach cancer surgery.

UK-based assessments of the resource required to set-up and manage programmes will be needed by those considering implementation.

Future research could usefully focus on analysing which components of enhanced recovery provide the greatest benefits.

Citation and Funding

Wang LH, Zhu RF, Gao C, et al. Application of enhanced recovery after gastric cancer surgery: an updated meta-analysis. World J Gastroenterol. 2018;24(14):1562-78.

Individual authors of the review were supported by grants from the National Natural Science Foundation of China, the Priority Academic Program Development of Jiangsu Higher Education Institutions and the Key Medical Talents Program of Jiangsu Province. They declared no conflicts of interest.

Bibliography

CRUK. Cancer incidence for common cancers. London: Cancer Research UK; updated 2018.

Macmillan Cancer Support. Surgery for stomach cancer. London: Macmillan Cancer Support; updated 2016.

Mortensen K, Nilsson M, Slim K et al. Consensus guidelines for enhanced recovery after gastrectomy: enhanced recovery after surgery (ERAS®) society recommendations. Br J Surg. 2014;101(10):1209-29.

NHS Choices. Enhanced recovery. London: Department of Health; updated 2016.

NHS Choices. Stomach cancer. London: Department of Health; updated 2015.

NICE. Laparoscopic gastrectomy for cancer. IPG269. London: National Institute for Health and Care Excellence; 2008.

NICE. Oesophago-gastric cancer: assessment and management in adults. NG83. London: National Institute for Health and Care Excellence; 2018.

Application of enhanced recovery after gastric cancer surgery: An updated meta-analysis

Published on 18 April 2018

Wang, L. H.,Zhu, R. F.,Gao, C.,Wang, S. L.,Shen, L. Z.

World J Gastroenterol Volume 24 Issue 14 , 2018

AIM: To provide an updated assessment of the safety and efficacy of enhanced recovery after surgery (ERAS) protocols in elective gastric cancer (GC) surgery. METHODS: PubMed, Medline, EMBASE, World Health Organization International Trial Register, and Cochrane Library were searched up to June 2017 for all available randomized controlled trials (RCTs) comparing ERAS protocols and standard care (SC) in GC surgery. Thirteen RCTs, with a total of 1092 participants, were analyzed in this study, of whom 545 underwent ERAS protocols and 547 received SC treatment. RESULTS: No significant difference was observed between ERAS and control groups regarding total complications (P = 0.88), mortality (P = 0.50) and reoperation (P = 0.49). The incidence of pulmonary infection was significantly reduced (P = 0.03) following gastrectomy. However, the readmission rate after GC surgery nearly tripled under ERAS (P = 0.009). ERAS protocols significantly decreased the length of postoperative hospital stay (P < 0.00001) and medical costs (P < 0.00001), and accelerated bowel function recovery, as measured by earlier time to the first flatus (P = 0.0004) and the first defecation (P < 0.0001). Moreover, ERAS protocols were associated with a lower level of serum inflammatory response, higher serum albumin, and superior short-term quality of life (QOL). CONCLUSION: Collectively, ERAS results in accelerated convalescence, reduction of surgical stress and medical costs, improved nutritional status, and better QOL for GC patients. However, high-quality multicenter RCTs with large samples and long-term follow-up are needed to more precisely evaluate ERAS in radical gastrectomy.

Expert commentary

Operations for stomach cancer have traditionally been viewed as dangerous when compared to other types of surgery. In recent years death rates after surgery have fallen dramatically, and now the focus is upon delivering faster recovery and improved quality of life for patients. 

This latest analysis of the published evidence confirms the benefits of enhanced recovery programmes after stomach cancer surgery. 

The majority of high-quality surgical centres now provide enhanced recovery programmes for all-comers. Patients facing surgery for stomach cancer should now expect their surgical team to provide this proven strategy for the best possible care. Future research will not need to ask the question “does enhanced recovery work for stomach cancer?” but rather “how can enhanced recovery in hospital be improved, and can we improve recovery after discharge from hospital?”

Tim Underwood, Professor of GI Surgery, CRUK & Royal College of Surgeons of England Advanced Clinician Scientist Fellow, University of Southampton

Expert commentary

This is the largest meta-analysis of enhanced recovery after gastric surgery and has shown a significant improvement in short-term outcomes but an increase in readmission rate.

However, the interpretation of the results is affected by the inclusion of trials using both minimally invasive and open surgical techniques, one study of elderly patients and the exclusion of patients undergoing neoadjuvant chemotherapy. Therefore, the results of this study may not be replicable in the Western world where the disease is generally diagnosed at a later stage necessitating neoadjuvant chemotherapy.

More research is required in the use of these programmes as well as prehabilitation in oesophago-gastric cancer surgery with neoadjuvant and adjuvant chemotherapy.

Muntzer Mughal, Honorary Clinical Professor & Consultant Surgeon, University College London Hospitals