ERAS in laparoscopic-assisted total gastrectomy.

Sir,

I happened to read the aforementioned article with great interest.[1] It is commendable to have carried out this study in a Government Medical College setup. However, I had several questions regarding the article.

Why did the author keep conversion to open procedure an exclusion criteria? It exposes the study to the bias that only patients with smooth intraoperative course were included and, therefore, were more likely to have a good outcome anyway.

Were any of the patients suffering from gastric outlet obstruction prior to operation? If so, it would have been interesting to know the challenges in the nutrition of these patients preoperatively.

What were the practices at the author's institution prior to adoption of ERAS (enhanced recovery/early rehabilitation after surgery) regarding removal of nasogastric tubes, urinary catheters and drains? How did these practices change?

What was the antibiotic regimen preoperatively and postoperatively in the ERAS group? Was metronidazole given for all patients (of foregut surgery) as mentioned under conventional care?

There seems to be a discrepancy in [Table 1]. It describes the removal of epidural catheter on day 2 but does not mention when it was inserted or whether it was inserted in all patients.

As an ERAS enthusiast, I would also like to know whether it was possible to adhere to all the elements of the protocol in all the patients. This has historically been difficult in almost all studies.[2]

What was the duration of mobilization on the day of surgery in the ERAS group? Was it enforced mobilization or voluntary?

The need to catheterise patients arose in four patients in the control group. The reasons for the same are not made clear. Did they have epidural catheters? When were they able to void the second time?

Was the postoperative nourishment always provided by mouth? Did any patient have a feeding jejunostomy in the study or control group?

Did the analgesic requirements of the patient increase when on either protocol given a 10 cm epigastric incision was made? Was a local anaesthetic agent injected peri-incisionally after any surgery?

Indian surgeons need to begin sharing their experience with ERAS in various settings seen in our country. It was (in spite of the above) very nice to see a study regarding ERAS from India done in a public sector hospital.