Enhanced recovery after surgery for gastric cancer and an assessment of preoperative carbohydrate loading.

BACKGROUND: We previously reported on the feasibility of enhanced recovery after surgery (ERAS) protocol for gastric cancer with a prospective phase II study, but the superiority of this approach over non-ERAS perioperative management remains unclear. Preoperative carbohydrate loading, an important element of the ERAS protocol, has been shown to reduce insulin resistance, but its effects on clinical endpoints in gastric cancer surgery remain controversial. The aim of this study was to clarify the efficacy of the ERAS protocol for gastric cancer surgery, with particular focus on preoperative carbohydrate loading. METHODS: In this ERAS case-control study, we enrolled 121 patients as a case group and 259 patients undergoing gastrectomy for gastric cancer with our conventional perioperative management as a control group. Matched-pair analysis was performed to balance the patients' characteristics for comparison analysis. RESULTS: After matching, 108 patients were included in each group. Postoperative hospital stay was significantly shorter in the ERAS group than in the control group (8 days vs. 9 days, p < 0.001), while the incidence of Clavien-Dindo classification grade II or more postoperative complication was similar between the groups (11.1% vs. 15.7%, p = 0.325). No significant differences were found in serum albumin level, body weight, or grip strength between the groups before surgery and at 1 week and 1 month after surgery. CONCLUSION: Use of the ERAS protocol for gastric cancer shortened the length of postoperative hospital stay without increasing complications. Preoperative carbohydrate loading didn't improve the postoperative nutritional status or maintain the muscle strength postoperatively.

[A case of sudden death during postoperative Holter ECG examination in a patient who experienced intraoperative cardiac arrest].

We report a case of postoperative sudden death during Holter-ECG examination in a 62-yr-old male, who experienced intraoperative cardiac arrest possibly due to myocardial ischemia. Although the patient recovered from intraoperative event without any neurological sequelae, he suffered from spontaneous ventricular tachycardia following mild ST segment depression that led to cardiac arrest on the 58th postoperative day. Precise mechanism of sudden death was not clear because coronary angiography or autopsy was not performed. However, the postoperative Holter-ECG revealed frequent episodes of silent 0.5-1.0 mm ST segment depression during tachycardia which had not been observed in the preoperative 12-lead ECG. Thus a likely explanation would be that the patient had the undetected coronary artery disease with frequent episodes of silent ischemia and finally was led to the fatal arrhythmia. In this case, so called "stunned myocardium" following repeated silent ischemia may have also contributed to the life-threatening arrhythmias. This case suggests that even mild ST depression might lead to life-threatening arrhythmias in the patients with silent ischemia. Adequate preoperative evaluation and careful perioperative observation are necessary for these patients.