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3642 June 21, 2013|Volume 19|Issue 23|WJG|www.wjgnet.com

Fast-track surgery could improve postoperative recovery in
radical total gastrectomy patients

Fan Feng, Gang Ji, Ji-Peng Li, Xiao-Hua Li, Hai Shi, Zheng-Wei Zhao, Guo-Sheng Wu, Xiao-Nan Liu,
Qing-Chuan Zhao

Fan Feng, Gang Ji, Ji-Peng Li, Xiao-Hua Li, Hai Shi, Zheng-
Wei Zhao, Guo-Sheng Wu, Xiao-Nan Liu, Qing-Chuan Zhao,
Department of Digestive Surgery, Xijing Hospital of Digestive
Diseases, the Fourth Military Medical University, Xi’an 710032,
Shaanxi Province, China
Author contributions: Feng F, Ji G and Li JP contributed
equally to this work; Feng F and Zhao QC designed the study and
wrote the manuscript; Ji G, Li JP and Liu XN performed all the
operations; Li XH and Shi H were mainly in charge of periopera-
tive management of patients; Zhao ZW and Wu GS were mainly
in charge of evaluating postoperative outcomes, discharge,
follow-up and data analysis.
Supported by National Natural Scientific Foundation of China,
No. 31100643
Correspondence to: Dr. Qing-Chuan Zhao, Department of
Digestive Surgery, Xijing Hospital of Digestive Diseases, the
Fourth Military Medical University, 127 West Changle Road 7,
Xi’an 710032, Shaanxi Province, China. [email protected]
Telephone: +86-29-84771503 Fax: +86-29-84771503
Received: December 25, 2012 Revised: March 20, 2013
Accepted: April 27, 2013
Published online: June 21, 2013

Abstract
AIM: To assess the impact of fast-track surgery (FTS)
on hospital stay, cost of hospitalization and complica-
tions after radical total gastrectomy.

METHODS: A randomized, controlled clinical trial was
conducted from November 2011 to August 2012 in the
Department of Digestive Surgery, Xijing Hospital of
Digestive Diseases, the Fourth Military Medical Univer-
sity. A total of 122 gastric cancer patients who met the
selection criteria were randomized into FTS and con-

All patients received elective standard D2 total gastrec-
tomy. Clinical outcomes, including duration of flatus
and defecation, white blood cell count, postoperative
pain, duration of postoperative stay, cost of hospitaliza-
tion and complications were recorded and evaluated.

Two specially trained doctors who were blinded to the
treatment were in charge of evaluating postoperative
outcomes, discharge and follow-up.

RESULTS: A total of 119 patients finished the study,
including 60 patients in the conventional care group
and 59 patients in the FTS group. Two patients were
excluded from the FTS group due to withdrawal of con-
sent. One patient was excluded from the conventional
care group because of a non-resectable tumor. Com-
pared with the conventional group, FTS shortened the

vs
P
h vs P = 0.000), accelerated the de-
crease in white blood cell count [P < 0.05 on postop-

after surgery (P
complications (P < 0.05), shortened the duration of

vs P =

vs P = 0.005),
and promoted recovery of patients.

CONCLUSION: FTS could be safely applied in radical
total gastrectomy to accelerate clinical recovery of gas-
tric cancer patients.

Key words: Fast-track surgery; Gastric cancer; Radical
total gastrectomy; Perioperative care; Outcomes

Core tip: Fast-track surgery (FTS) is a promising pro-
gram for surgical patients, and has been applied in sev-
eral surgical diseases. The value of FTS in radical distal
gastrectomy has been demonstrated recently, but the

requires further evaluation. The present study showed
that FTS was feasible for perioperative care in radical
total gastrectomy. Compared with conventional care,
FTS could shorten the duration of flatus and defeca-

BRIEF ARTICLE

Online Submissions: http://www.wjgnet.com/esps/
[email protected]
doi:10.3748/wjg.v19.i23.3642

World J Gastroenterol 2013 June 21; 19(23): 3642-3648
ISSN 1007-9327 (print) ISSN 2219-2840 (online)

© 2013 Baishideng. All rights reserved.

Page 2

tion, accelerate the decrease in white blood cell count,
decrease postoperative complications, shorten the post-
operative stay, reduce the cost of hospitalization, and
promote postoperative recovery of patients.

Feng F, Ji G, Li JP, Li XH, Shi H, Zhao ZW, Wu GS, Liu XN,
Zhao QC. Fast-track surgery could improve postoperative recov-
ery in radical total gastrectomy patients. World J Gastroenterol
2013; 19(23): 3642-3648 Available from: URL: http://www.wjg-
net.com/1007-9327/full/v19/i23/3642.htm DOI: http://dx.doi.
org/10.3748/wjg.v19.i23.3642

INTRODUCTION
Fast-track surgery (FTS) was initiated by the Danish sur-

in the 1990s[1,2], and has rapidly gained popularity around
[3].

[4]. The combina-
-

tion in complication rates, morbidity and mortality rates,

[5-7]. In
-

eases, include radical prostatectomy[8], cardiac surgery[9],
total knee replacement[10], cesarean section[11], coronary

[12]

procedures in children[13] and the elderly[14].

-
tality[15]

countries. Up to now, surgery has been the most com-

-

d[17]

-

been demonstrated recently[18,19] -

MATERIALS AND METHODS
Patients

-

-

on clinical symptoms, imaging and pathology; (2) age be-

or chemotherapy; (4) no distant metastasis; (5) no history

cardiopulmonary diseases, and immune related diseases;
-

Ⅰ or Ⅱ; (8)

-

Randomization and implementation

-

did not contact the patients throughout the clinical trial.

process. Two specially trained doctors who were blinded
-

Interventions

by Kehlet et al[20] was used in the present FTS group. Pa-
-

nurses to ensure compliance.

Discharge criteria and readmission

-

exceeding 80, and willing to go home.

specially trained surgeons through telephone within the

-

3643 June 21, 2013|Volume 19|Issue 23|WJG|www.wjgnet.com

Feng F et al . FTS improves gastric surgery recovery

Page 3

hyperpyrexia, abdominal pain, bowel obstruction, gastro-
intestinal hemorrhage, malnutrition, infection and poor
healing of the wound.

Data collection
The primary clinical endpoints were the duration of
hospital stay and the cost of hospitalization. The sec-
ond clinical endpoints were incidence of complications
such as pneumonia, surgical site infection, abdominal
infection, anastomotic leak, and bowel obstruction. We
recorded preoperative data on age, sex, body mass index
(BMI), nutritional risk screening (NRS) 2002 score, ASA

score, differentiation status, TNM classification, white
blood cell (WBC) count, hemoglobin, albumin, alanine
aminotransferase (ALT) and aspartate aminotransferase
(AST). Surgical-related data such as operation time and
blood loss were also recorded. Postoperative data such as
timing of first flatus and defecation, duration of hospital
stay, the cost of hospitalization and complications were
recorded. WBC was measured from postoperative day
(POD) 1 to POD 5. Pain intensity was evaluated from
POD 1 to POD 5 using a visual analog scale (VAS).

Statistical analysis
Data were processed using SPSS 16.0 for Windows (SPSS
Inc., Chicago, IL, United States). Numerical variables were
expressed as the mean ± SD unless otherwise stated. Dif-
ferences between the two groups were tested using a two-
tailed Student t test. Discrete variables were analyzed us-
ing the χ 2 test or Fisher’s exact test. A P value < 0.05 was
considered statistically significant.

RESULTS
Clinical characteristics
A total of 119 patients finished the study, including 60
patients in the conventional care group and 59 patients
in the FTS group. Two patients were excluded from the
FTS group after withdrawing consent. One patient was
excluded from the conventional care group because of an
irresectable tumor (Figure 1). The preoperative baseline
characteristics of the two groups are compared in Table
2. There were no significant differences between the two
groups in age, sex, BMI, NRS 2002 score, ASA score, dif-
ferentiation status, TNM classification, WBC count, he-

3644 June 21, 2013|Volume 19|Issue 23|WJG|www.wjgnet.com

Table 1 Comparison of fast-track surgery and conventional perioperative intervention protocols

Perioperative intervention Conventional Fast-track surgery

Diet before surgery No intake of food and drink after supper the day before
surgery

Intake of 1000 mL 14% carbohydrate drink 12 h before
and 350 mL 14% carbohydrate drink 3 h before surgery.

Anesthesia Tracheal intubation and general anesthesia Tracheal intubation and general anesthesia
Thermal insulation during
operation

No thermal insulation, room temperature was maintained
at 22 ℃

Thermal insulation of the body and extremities, body
temperature was maintained at 36 ℃

Operation procedure Standard laparotomy approach Standard laparotomy approach
Placement of abdominal drainage Use of abdominal drainage tube No routine use of abdominal drainage tube
Analgesia after operation Standard use of patient-controlled analgesic pump Infiltration of surgical wounds with ropivacaine at the

end of surgery and 24 h after surgery. Oral intake of 200
mg celecoxib twice daily

Mobilization after operation Mobilize out of bed on patients’ own request Encourage patients to mobilize out of bed
Diet after operation Oral intake initiated after flatus (following a stepwise plan

from water to other liquids to semi-fluids to normal food)
Oral intake of 500-1000 mL glucose saline on the day

of surgery. Intake of 2000-3000 mL liquid food contain-
ing 1000 kcal to 1200 kcal per day from the 1st day after

surgery
Intravenous nutrition after opera-
tion

Infusion of glucose saline and amino acid injection iv on the
day of surgery. Infusion of parenteral nutrition (25 kcal/kg
of body weight) iv before oral intake. Appropriate level of

iv fluid intake based on the volume of liquid intake and out-
put, and physiological need

Infusion of parenteral nutrition iv if oral intake is not
adequate. Appropriate level of iv fluid intake based on

the volume of liquid intake and output, and physiologi-
cal need

Removal of nasogastric tube Removal of nasogastric tube after flatus Removal of nasogastric tube within 24 h after surgery
Removal of urine catheter Removal of urine catheter on the 3rd or 4th day

after surgery
Removal of urine catheter within 24 h after surgery

Antibiotics Standard use of antibiotics for 3 d after surgery Standard use of antibiotics before and once after surgery

Assessed for eligibility (n = 122)

Randomized (n = 122)

Allocated to conventional
care group (n = 61)
Received allocated

intervention (n = 60)
Did not receive allocated

intervention (n = 1)
1Irresectable tumor (n = 1)

Allocated to FTS group
(n = 61)

Received allocated
intervention (n = 59)

Did not receive allocated
intervention (n = 2)

2Withdrew consent (n = 2)

Analyzed (n = 60) Analyzed (n = 59)

Figure 1 Flow diagram of the randomized control trial designed to com-
pare the safety and efficacy of fast-track surgery and conventional care
groups. 1One patient had an irresectable tumor in theconventional care group;
2Two patients withdrew consent in the fast-track surgery (FTS) group. All three
patients were excluded from the analysis.

Feng F et al . FTS improves gastric surgery recovery

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3645 June 21, 2013|Volume 19|Issue 23|WJG|www.wjgnet.com

POD 2, the WBC count in the FTS group began to drop
(P < 0.05). The WBC count in the conventional care
group began to drop on POD 3, but was significantly
higher than in the FTS group (P < 0.05).

Outcomes
The outcomes were summarized in Table 4. Compared
with the conventional care group, the patients in the FTS
group showed significantly accelerated recovery of gas-
trointestinal function in terms of time to first flatus and
first defecation (P < 0.05). The duration of postoperative
stay of the FTS group was significantly shorter than that
of the conventional care group (P < 0.05) and the cost
of hospitalization was also significantly lower (P < 0.05).

Complications and readmissions
Table 4 summarizes the complications and readmissions
in each group. The overall complication rate in the FTS
group (10.17%) was significantly lower than in the con-
ventional group (28.33%, P = 0.019). In the conventional
care group, 10 patients suffered from pneumonia, 3 pa-
tients suffered from incision infection, 1 patient experi-
enced urinary infection, 1 patient experienced abdominal
infection, and 1 patient underwent reoperation because
of ileus. In the FTS group, 5 patients suffered from
pneumonia and 1 experienced incision infection. All the
patients were cured by surgery or conservative treatment.

DISCUSSION
The aim of the present study was to evaluate the safety,
efficacy and outcome of FTS protocol employed in the
perioperative treatment of gastric cancer in comparison
with conventional perioperative treatment. The data of
the present study showed that the FTS protocol was
feasible for perioperative care of gastric cancer patients
who underwent radical total gastrectomy. Compared with

moglobin, albumin, ALT, AST, operation time and blood
loss (all P > 0.05).

Pain intensity
Pain intensity was evaluated from POD 1 to POD 5 in
the two groups (Table 3). VAS analysis showed that pain
intensity of patients in the FTS group was significantly
lower than that of patients in the conventional care
group on POD 1-3 (P < 0.05).

White blood cell count
The WBC counts of patients in the two groups were
measured in the morning of POD 1 to POD 5 (Table 3).
The WBC count in the conventional care group and FTS
group were both elevated on POD 1. Although the WBC
count in the conventional care group continued to rise on

Table 2 Comparison of baseline characteristics of the two
groups (mean ± SD)

Characteristics Conventional Fast-track surgery P value

Age, yr 55.79 ± 10.06 54.98 ± 11.35 0.682
Sex 0.689
Male/female 44/16 41/18
BMI 21.01 ± 1.78 22.44 ± 3.51 0.061
NRS 2002 score 0.81 ± 1.10 1.08 ± 1.41 0.424
ASA score 0.364
Ⅰ/Ⅱ 1/59 3/56
Differentiation status 0.857
Well differentiated 6 4
Moderately differentiated 20 17
Poorly differentiated 34 38

0.324
Ⅰ/Ⅱ/Ⅲ 8/31/2021 14/12/33
White blood cell 6.20 ± 1.74 6.05 ± 2.08 0.671
Hemoglobin, g/L 133.36 ± 22.03 130.65 ± 22.41 0.52
Albumin, g/L 44.42 ± 4.89 42.83 ± 4.65 0.082
ALT 17.91 ± 11.35 21.29 ± 15.55 0.195
AST 21.84 ± 11.46 25.83 ± 17.00 0.151
Operation time, min 242.38 ± 72.89 226.11 ± 65.87 0.214
Blood loss, mL 221.17 ± 122.55 230.55 ± 171.82 0.735

BMI: Body mass index; ASA: American Society of Anesthesiologists; NRS:
Nutritional risk screening; TNM: Tumor node metastases; ALT: Alanine
aminotransferase; AST: Aspartate aminotransferase.

Time Conventional Fast-track surgery P value

Postoperative pain intensity
POD 1 5.41 ± 1.45 4.32 ± 1.65 0.000
POD 2 4.43 ± 1.54 3.39 ± 1.65 0.001
POD 3 3.63 ± 1.48 2.76 ± 1.36 0.002
POD 4 3.02 ± 1.45 2.51 ± 1.87 0.119
POD 5 2.21 ± 1.39 2.30 ± 1.56 0.789
White blood cell count
POD 1 14.81 ± 5.34 14.55 ± 5.04 0.793
POD 2 15.36 ± 5.36 12.26 ± 4.78 0.002
POD 3 11.80 ± 4.80 9.35 ± 3.83 0.005
POD 4 8.56 ± 3.70 7.52 ± 3.57 0.223
POD 5 6.37 ± 2.34 6.91 ± 3.34 0.684

Table 3 Comparison postoperative pain intensity and white
blood cell count between the two groups (mean ± SD)

POD: Postoperative day.

Table 4 Comparison clinical outcomes and postoperative
complications between the two groups

Conventional Fast-track surgery P value

Clinical outcomes
79.03 ± 20.26 60.97 ± 24.40 0.000

First defecation, h 93.03 ± 27.95 68.00 ± 25.42 0.000
Postoperative stay, d 7.10 ± 2.13 5.68 ± 1.22 0.000
Cost of
hospitalization, RMB

43783.25 ± 8102.36 39597.62 ± 7529.98 0.005

Postoperative complications
Total cases 17 6 0.019
Pneumonia 10 5 0.269
Incision infection 3 1 0.619
Urinary infection 1 0 1.000
Abdominal infection 1 0 1.000
Gastric retention 0 0
Anastomotic leak 0 0
Deep-vein thrombosis 0 0
Ileus 1 0 1.000
Reoperation 1 0 1.000
Readmission 0 0
Mortality 0 0

Feng F et al . FTS improves gastric surgery recovery

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3646 June 21, 2013|Volume 19|Issue 23|WJG|www.wjgnet.com

-

patients.

only result in stress[21]

-

only increases muscle loss and insulin resistance, but also

tissues[22]. It has been reported that opioids may result in

[23]

-
-

-

group.

-
nal obstruction and anastomotic leak in clinical practice.

surgery[24] -
pression vs no decompression demonstrated that a gastric

cancer surgery
[27]

present study, a nasogastric tube was not routinely used in

-
[28]. The placement

[17] et al[29]

patients who underwent total gastrectomy with abdomi-

-
-

enhance portal circulation[30]

[31].

-
tions and mortality[32]

[33], and be
[34]. In the present study, the

distension did occur in some patients, the symptoms only

group[35]

-
-

-
.

patients with medical and FTS protocols.
-

-
-

age[37]

FTS[38]

a researcher, surgeons, anesthesiologists and nurses. We

-

-
-

[39]. In our pres-
ent study, tracheal intubation and general anesthesia were
applied in both groups, which may partially decrease the

Feng F et al . FTS improves gastric surgery recovery

Page 6

3647 June 21, 2013|Volume 19|Issue 23|WJG|www.wjgnet.com

efficacy of FTS.
The present study indicates that FTS could promote

postoperative recovery, decrease the rate of complica-
tions, shorten the duration of hospital stay, and reduce
the cost of hospitalization. Our data indicate that FTS is
a safe and efficient perioperative management strategy in
patients undergoing radical total gastrectomy. Along with
the further understanding of stress and development of
FTS perioperative care, FTS could probably be safely ap-
plied in critically ill patients and emergency surgery, and
major operations such as tumor resection may become
day procedures in the near future.

COMMENTS
Background
Fast-track surgery (FTS) is a promising comprehensive program for surgical
patients in elective surgery. In recent years, FTS has been applied in several
surgical diseases, include radical prostatectomy, cardiac surgery, total knee
replacement, cesarean section, and coronary artery bypass grafting. It has also
been used for specific procedures in children and elderly. The value of FTS in
radical distal gastrectomy has been demonstrated recently, but the safety and
efficacy of FTS in radical total gastrectomy still requires further evaluation.
Research frontiers
The value of FTS in radical distal gastrectomy has been demonstrated recently.
Chen et al evaluate the safety and effectiveness of fast-track surgery com-
bined with laparoscopy-assisted radical distal gastrectomy for gastric cancer.
They found that a combination of FTS and laparoscopy-assisted radical distal
gastrectomy in gastric cancer is safe, feasible, and efficient and can improve
nutritional status, lessen postoperative stress, and accelerate postoperative
rehabilitation.
Innovations and breakthroughs
The present study showed that the FTS protocol was feasible for perioperative
care of gastric cancer patients. Compared with conventional care, FTS could
shorten the duration of flatus and defecation, accelerate the decrease in white
blood cell count, decrease postoperative complications, shorten the duration of
postoperative stay, reduce the cost of hospitalization, and eventually promote
postoperative recovery of patients.
Applications
The data indicate that FTS is a safe and efficient perioperative management
strategy in patients undergoing radical total gastrectomy. Along with further un-
derstanding of stress, and development of FTS perioperative care, FTS could
probably be safely applied in critically ill patients and emergency surgery, and
major operations such as tumor resection may become day procedures in the
near future.
Terminology
FTS: Fast-track surgery, initiated by the Danish surgeon H Kehlet in the field of
elective colorectal surgery in the 1990s, is a promising comprehensive program
for surgical patients in elective surgery; the visual analogue scale is a psycho-
metric response scale which can be used in questionnaires. It is a measure-
ment instrument for subjective characteristics that cannot be directly measured.
Peer review
This was a good study in which the authors indicates that FTS could promote
postoperative recovery, decrease rate of complications, shorten duration of
hospital stay, and reduce the cost of hospitalization. However, the author should
think about the reason of more pneumonia in conventional care group although
it is not significant.

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Feng F et al . FTS improves gastric surgery recovery

COMMENTS

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