Enhanced recovery after surgery for gastric cancer with HIPEC: feasibility and outcomes in a complex setting

Enhanced Recovery After Surgery (ERAS) pathways improve outcomes following gastrectomy, but their applicability to procedures involving hyperthermic intraperitoneal chemotherapy (HIPEC) remains uncertain.

All patients undergoing total or subtotal gastrectomy for gastric cancer at our center between January 2017 and June 2024 were included. The institutional ERAS protocol, originally designed for standard gastrectomy, was prospectively applied to patients undergoing concomitant cisplatin-based HIPEC (CB-HIPEC). Twelve ERAS items were assessed, and adherence ≥70% was considered optimal. Clinical and perioperative outcomes were analyzed retrospectively.

Among 670 patients, 44 underwent gastrectomy with CB-HIPEC and 626 underwent gastrectomy alone. HIPEC patients were younger (median age 55 vs. 68 years, p < 0.001) and had more advanced disease. Overall ERAS compliance ≥70% was achieved in 75% of the standard group but only 25% of the HIPEC group (p < 0.001). Major deviations involved delayed removal of the nasogastric tube (77% retained postoperatively vs. 18%, p < 0.001) and urinary catheter (98% vs. 28%, p < 0.001), as well as slower progression to oral intake (liquids by POD 1: 52% vs. 88%; soft diet by POD 3: 36% vs. 76%, p < 0.001). Despite reduced adherence, rates of active ambulation by POD 2 were comparable (82% vs. 88%). Overall complication rates were higher after CB-HIPEC (54.5% vs. 38%, p = 0.039), but CB-HIPEC itself was not an independent predictor of morbidity.

HIPEC substantially impairs ERAS adherence, mainly due to delayed gastrointestinal and urinary recovery, without directly increasing postoperative morbidity. Procedure-specific ERAS adaptations are warranted for gastrectomy with CB-HIPEC.