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Enhanced recovery is a package of care that helps people recover from stomach surgery: a dietitian's assessment and feeding support for anyone undernourished, keyhole surgery for early cancers where suitable, no routine nose tube or drain, drinking and eating from the day after surgery and building up slowly, extra feeding support if eating stays low, and checking that every step happens.
The ERAS Society gastrectomy guideline (2014; 25 items, 8 procedure-specific, graded by GRADE) is the only ERAS gastrectomy edition. Its full text could not be read; its procedure-specific items and grades are quoted from the reproduction in Yamagata et al. (2019). Strong: no routine preoperative artificial nutrition, but optimise significantly malnourished patients with oral supplements or enteral nutrition (very low evidence); laparoscopy-assisted distal gastrectomy for early gastric cancer (high); no routine nasogastric or nasojejunal tube (high); avoid abdominal drains (high); individualised nutritional support for those clearly malnourished or unable to meet 60% of needs by day 6 (moderate); systematic audit (low). Weak: preoperative oral pharmaconutrition (insufficient evidence for gastrectomy), laparoscopy-assisted total gastrectomy, wound catheters and TAP block (no gastrectomy evidence), and drink and food at will from day 1 after total gastrectomy, increasing by tolerance (moderate). A 2025 meta-analysis of 27 randomised trials (3,274 patients) found ERAS shortened stay and sped bowel recovery without more complications or readmissions, with low to moderate certainty. NICE NG83 offers specialist dietetic support throughout radical treatment for oesophago-gastric cancer; NICE NG180 offers enhanced recovery for elective major surgery, clear fluids until 2 hours before, and suggests carbohydrate drinks for abdominal surgery. Japanese guidelines (2018) describe a slower model pathway.
Why: Stomach cancer often causes weight loss, and poor nutrition raises the risk of complications.
“Offer nutritional assessment and tailored specialist dietetic support to people with oesophago‑gastric cancer before, during and after radical treatments.”
NICE 2018 · Not graded (NICE NG83 1.6.1, 'offer')
Why: Extra feeding helps those who are undernourished; for well-nourished people it adds nothing.
“Routine use of preoperative artificial nutrition is not warranted, but significantly malnourished patients should be optimized with oral supplements or enteral nutrition before surgery”
Annals of Gastroenterological Surgery 2019 · Evidence level: Very low. Recommendation grade: Strong (ERAS 2014, as reproduced by Yamagata et al.)
Why: Long fasting leaves people thirsty and weaker; a sugary drink before abdominal surgery is safe.
“Consider carbohydrate drinks before surgery for people having abdominal major or complex surgery .”
NICE 2020 · Not graded (NICE NG180 1.4.2, 'consider')
Why: Keyhole surgery for early stomach cancer causes fewer complications and faster recovery, with the same cancer outcome as open surgery.
“Evidence supports LADG in early gastric cancer as it results in fewer complications, faster recovery and may be carried out to a standard that is oncologically equivalent to open surgery”
Annals of Gastroenterological Surgery 2019 · Evidence level: High. Recommendation grade: Strong (ERAS 2014, as reproduced by Yamagata et al.)
Why: A tube through the nose is uncomfortable and does not prevent leaks or vomiting after stomach surgery.
“Nasogastric tubes should not be used routinely”
Annals of Gastroenterological Surgery 2019 · Evidence level: High. Recommendation grade: Strong (ERAS 2014, as reproduced by Yamagata et al.)
Why: Drains bring their own complications and lengthen the hospital stay.
“Avoiding the use of abdominal drains may reduce drain‐related complications and shorten hospital stay after gastrectomy”
Annals of Gastroenterological Surgery 2019 · Evidence level: High. Recommendation grade: Strong (ERAS 2014, as reproduced by Yamagata et al.)
Why: Eating early is safe and helps recovery; without a stomach, small amounts often work best.
“Patients undergoing total gastrectomy should be offered drink and food at will from POD 1. They should be advised to begin cautiously and increase intake according to tolerance”
Annals of Gastroenterological Surgery 2019 · Evidence level: Moderate. Recommendation grade: Weak (ERAS 2014, as reproduced by Yamagata et al.)
Why: People who cannot eat enough after stomach surgery need extra feeding to heal.
“Patients clearly malnourished or those unable to meet 60% of daily requirements by POD 6 should be given individualized nutritional support”
Annals of Gastroenterological Surgery 2019 · Evidence level: Moderate. Recommendation grade: Strong (ERAS 2014, as reproduced by Yamagata et al.)
Why: These are the elements most strongly tied to faster recovery in the randomised trials.
“prioritizing early oral feeding, early mobilization, and opioid‑sparing multimodal analgesia as non‑negotiable drivers of recovery”
BMC Surgery 2025 · Authors' recommendation from a meta-analysis (certainty of evidence generally low to moderate)
Why: Units that measure how often each step is delivered improve compliance and results.
“Systematic audit improves compliance and clinical outcomes”
Annals of Gastroenterological Surgery 2019 · Evidence level: Low. Recommendation grade: Strong (ERAS 2014, as reproduced by Yamagata et al.)
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
The ERAS Society gastrectomy guideline (2014) remains the only specialty guideline and the current standard; read here through its abstract and a reproduction of its procedure-specific items with their grades. Its strongest items, on high-quality evidence, are laparoscopy-assisted distal gastrectomy for early cancer, no routine nasogastric tube and no routine abdominal drain. A 2025 meta-analysis of 27 randomised trials supports the pathway as a whole (shorter stay, faster bowel recovery, no excess complications or readmissions; low to moderate certainty). NICE NG83 and NG180 agree on dietetic support, enhanced recovery for major surgery and the 2-hour clear-fluid fast. Where practice differs most is in Japan, where the national guideline's model pathway starts food later and drains are still often placed after D2 surgery.
ERAS Society (British Journal of Surgery) 2014 · Annals of Gastroenterological Surgery 2019 · BMC Surgery 2025 · NICE 2018 · NICE 2020
Where it differs: Nasogastric tube out by day 1, drinks after day 1, solid food from day 2 to 4, and any drain out by day 5.
Evidence: As reported by Yamagata et al. (2019), who call it 'a bit slow from the viewpoint of ERAS'. A Japanese multicentre trial (2018) cited there found early oral feeding did not shorten stay and increased complications after distal gastrectomy, while it may shorten stay after total gastrectomy. The Japanese guideline itself was not read.
Where it differs: Places a drain after gastrectomy, often to measure drain amylase for early detection of pancreatic fistula.
Evidence: Common in Japan, according to Yamagata et al.; ERAS 2014 recommends avoiding drains (high, strong), and there is no evidence that drain amylase monitoring improves short-term outcomes.
Annals of Gastroenterological Surgery 2019 · ERAS Society (British Journal of Surgery) 2014
Where it differs: Gives arginine and omega-3 enriched drinks before surgery.
Evidence: ERAS 2014: benefit shown in major gastrointestinal surgery in general has not been reproduced in gastrectomy trials (moderate evidence, weak). Later meta-analyses cited by Yamagata et al. show effects on inflammation but no clear improvement in clinical outcomes.
Enhanced recovery pathways feed people sooner, limit drips and drains and get them walking the day after an operation. Sixteen randomised trials in bowel surgery found 40 per cent fewer complications and stays more than two days shorter, but in 151 American hospitals given a full implementation programme, most failed to improve compliance with its elements.
Anaesthetic guidelines since at least 2011 say adults can drink clear fluids up to two hours before planned surgery and eat up to six hours before. In a study of 50 women having breast cancer surgery published in 2026, the average fast was 15 hours from food and 12 hours from fluids.
| Recommendation | Grade, as printed | Source |
|---|---|---|
| ERAS gastrectomy guideline: 25 items graded by GRADE “Results The available evidence has been summarized and recommendations are given for 25 items, eight of which contain procedure-specific evidence.” | GRADE: evidence high, moderate, low or very low; recommendation strong or weak | ERAS Society (British Journal of Surgery) 2014 |
| Laparoscopy-assisted total gastrectomy “There is some evidence supporting LATG owing to lower postoperative complications, shorter hospital stay and oncological safety. However, LATG is technically demanding” | Evidence level: Moderate. Recommendation grade: Weak | Annals of Gastroenterological Surgery 2019 |
| TAP block for gastrectomy “Evidence is strong in support of TAP block in abdominal surgery, although the effect is evident only during the first 48 h after surgery and none of the evidence is from gastrectomies” | Evidence level: Low. Recommendation grade: Weak | Annals of Gastroenterological Surgery 2019 |
| ERAS versus conventional care after gastrectomy “ERAS significantly shortened length of stay and accelerated gastrointestinal recovery.” | Meta-analysis of 27 randomised trials; certainty generally low to moderate | BMC Surgery 2025 |
| Offer an enhanced recovery programme for elective major or complex surgery “Offer an enhanced recovery programme to people having elective major or complex surgery .” | Not graded (NICE NG180 1.2.1) | NICE 2020 |
Shares Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Clear drinks until two hours before an operation, rather than nothing from midnight, Enhanced recovery after liver surgery (ERAS pathway for hepatectomy), Prehabilitation (the pre-treatment window).
Shares Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Clear drinks until two hours before an operation, rather than nothing from midnight, Enhanced recovery after liver surgery (ERAS pathway for hepatectomy), Prehabilitation (the pre-treatment window).
Shares Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Clear drinks until two hours before an operation, rather than nothing from midnight, Prehabilitation (the pre-treatment window), Blood clot prevention around cancer surgery, including extended prophylaxis after major abdominal and pelvic operations.
Shares Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Clear drinks until two hours before an operation, rather than nothing from midnight, Enhanced recovery after liver surgery (ERAS pathway for hepatectomy), Prehabilitation (the pre-treatment window).
Shares Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Clear drinks until two hours before an operation, rather than nothing from midnight, Enhanced recovery after liver surgery (ERAS pathway for hepatectomy), Prehabilitation (the pre-treatment window).
Shares Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Prehabilitation (the pre-treatment window), Blood clot prevention around cancer surgery, including extended prophylaxis after major abdominal and pelvic operations, Enhanced recovery after cancer surgery, with each element's compliance measured and fed back.
Shares Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Blood clot prevention around cancer surgery, including extended prophylaxis after major abdominal and pelvic operations, Enteral and parenteral nutrition support, Enhanced recovery after cancer surgery, with each element's compliance measured and fed back.
Shares Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Clear drinks until two hours before an operation, rather than nothing from midnight, Blood clot prevention around cancer surgery, including extended prophylaxis after major abdominal and pelvic operations, Enhanced recovery after cancer surgery, with each element's compliance measured and fed back.