The earlier the better?

Abstract

In the past, post-gastrectomy patients had to undergo fasting with a nasogastric tube for as long as 5–7 days. Then, patients would be started on a liquid diet and gradually transitioned to a soft diet, upon confirming that the esophagogastrogram detected no sign of leakage. Early oral feeding was avoided because it was believed to increase the risk of postoperative complications. In the late 1990s, however, a combination of early oral feeding, early mobilization, and sufficient pain control using epidural analgesia reportedly improved the recovery of patients with colorectal cancer [1]. This protocol was further refined and integrated into a fast-track methodology or enhanced recovery after surgery (ERAS) [2], which rapidly spread throughout the world with the widespread acceptance of laparoscopic minimal invasive surgery. Several randomized controlled trials (RCTs) [3, 4] and meta-analyses [5, 6] revealed that ERAS reduced the length of hospital stay and morbidity after colorectal surgery without compromising patient safety. European guidelines strongly recommend postoperative early feeding and perioperative oral nutritional support, such as carbohydrate administration, along with preoperative education, adequate postoperative analgesia, and early mobilization [7, 8]. In gastric cancer, introduction of early oral feeding has been very limited, possibly because of the fear of increasing postoperative complications related to upper gastrointestinal anastomosis. Hirao et al. [9] evaluated the feasibility of early oral feeding in patients with gastric cancer. In that study, patients in the early oral feeding group were started on a liquid diet on the 2nd postoperative day (POD 2) and transitioned to a solid diet on POD 6, and their outcomes were compared with those of control patients undergoing the conventional regimen, i.e., initiation of a solid diet on the POD 10. A significant decrease in the length of postoperative hospital stay and higher daily oral intake of calories on POD 10 were observed in the early oral feeding group. Although this study was the first to demonstrate the feasibility of early oral feeding in patients with gastric cancer, the regimen was far from being ‘‘fast track,’’ as the length of postoperative hospital stay was 18.5 days even in the early oral feeding group. Implementation of various ERAS programs for gastric cancer has been reported since 2010. Grantcharov and Kehlet [10] evaluated the efficacy of an ERAS program in 32 patients with gastric cancer, gastrointestinal stromal tumor (GIST), and benign diseases, who, after undergoing laparoscopic gastrectomy, were started on oral feeding on POD 2 with planned discharge on POD 3. Two major complications were reported, but morbidity was sufficiently low, with no deaths within 30 days. Median length of hospital stay was only 4 days. Yamada et al. [11] also evaluated the feasibility and efficacy of an ERAS program, in which 91 post-gastrectomy patients were placed on oral nutritional supplementation on POD 2 and then transitioned to a soft diet on POD 3. Compared with 100 control patients, those in the ERAS group had a significantly earlier oral intake start day, oral intake recovery, flatus, and defecation, and also had significantly less postoperative pain. Two RCTs on ERAS have been reported in Korea. The first trial was conducted at Catholic University [12], where 54 patients scheduled to undergo gastrectomy were randomly allocated into control and early feeding groups; the control group was started on a soft diet on POD 4, whereas This editorial refers to the article doi:10.1007/s10120-013-0275-5.