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Preoperative oral carbohydrate loading is one of the main elements of the ERAS protocol and has been demon- strated by several studies to reduce insulin resistance after surgery.10e12 However, its effects on clinical endpoints, such as the occurrence of postoperative complications and maintenance of muscle strength, remain controversial because of inconsistencies possibly due to small numbers of participants and heterogeneous groups of patients under- going surgical procedures of differing degrees of severity.

and the European Society of Surgical Oncology. All rights reserved.

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211R. Makuuchi et al. / EJSO 43 (2017) 210e217

We previously reported a prospective phase II study to evaluate the feasibility of the ERAS protocol for gastric can- cer in 121 patients undergoing gastrectomy with curative intent.13 This study investigated a number of factors, namely omission of bowel preparation, preoperative oral carbohy- drate loading, shortening of the perioperative fasting period, use of epidural analgesia, and early postoperative mobiliza- tion. We concluded that the ERAS protocol can be safely used for gastric cancer surgery, with an incidence of postop- erative complications of 10.7%. Although we previously included several elements of the ERAS protocol in our con- ventional preoperative care, preoperative oral carbohydrate loading and initiation of postoperative feeding on postopera- tive day (POD) 2, 1 day earlier than our conventional care, were newly introduced to the ERAS study.

It remained unclear whether the ERAS protocol improved clinical endpoints compared with conventional perioperative management, and the validity of preoperative oral carbohydrate loading for gastric cancer surgery was uncertain. We therefore conducted a caseecontrol study with patients in the ERAS study as the case group and pa- tients undergoing gastrectomy with our conventional peri- operative care as the control group. The aim of this study was to clarify the validity of the ERAS protocol for gastric cancer surgery, with particular focus on the efficacy of pre- operative oral carbohydrate loading.

Patients and methods

Patients

The 121 patients in our ERAS investigation were enrolled in this study as the case group (the ERAS group). Between January 2011 and December 2012, 680 patients underwent gastrectomy with conventional perioperative care in Shizuoka Cancer Center, Shizuoka, Japan; of these, 259 patients who met the inclusion criteria were enrolled to form the control group. Inclusion criteria were the same as for the ERAS study, namely age 20e75 years, histological- ly confirmed adenocarcinoma of the stomach for which curative gastrectomy was expected without simultaneous resection of other organs except for the gallbladder, no involvement of the duodenum or esophagus, sufficient oral intake, an Eastern Cooperative Oncology Group (ECOG) performance status (PS) of 0, no contraindication for epidural anesthesia, no prior chemotherapy or radio- therapy for any malignancy, and adequate organ function. Patients who had uncontrolled diabetes or who needed the administration of insulin were excluded.

The data collection and analysis were approved by the institutional review board of the Shizuoka Cancer Center.

Matching

As the number of patients undergoing laparoscopic or robotic gastrectomy had been increasing during the study

period, we performed matched-pair analysis to balance pa- tient characteristics for the comparison analysis. Each pa- tient in the ERAS group was matched with one patient in the control group on the basis of sex, age, and surgical approach (open or laparoscopic/robotic gastrectomy).