In the present study, the NGT was removed from all patients in the modified group at the end of the surgery, and oral intake was started on POD 1. The modified ERAS protocol including omitting the NGT and early oral intake did not increase postoperative complications even in the PSM analysis. In all patient analyses, the postoperative time when the discharge criteria were met was shorter in the modified group compared with that in the conventional group.

In general, the length of postoperative hospital stays and reduction in hospital costs were the main outcomes of ERAS. Our hospital is in a rural city, and older patients were enrolled in this study. Thus, the patients tended to remain in the hospital after meeting the discharge criteria. It is difficult for patients to return home under the clinical protocol procedures. Although the duration of the postoperative hospital stay was shorter in the modified group compared with that in the conventional group, the hospital stay was longer than that in high-volume centers in Japan [10, 11]. Long hospital stays are also attributed to the Japanese Diagnosis Procedure Combination-based Payment System. Thus, we investigated the day at which the discharge criteria were met. Although there was no statistically significant difference in PSM, the time until the discharge criteria were met was shorter in the modified group compared with that in the conventional group in all patient analyses. We believe that the improvement in patient care obtained by implementing ERAS contributed to reducing the length of the hospital stay.

Early postoperative oral feeding accelerates the patient’s recovery after gastrectomy [12]. However, it is difficult to implement oral feeding after total gastrectomy because of concerns that early food intake would allow the passage of food near the anastomotic site and that the intraluminal pressure would increase, which could result in anastomotic leakage. Many surgeons routinely restrict oral intake in patients receiving conventional care. Recently, patients in Japan have generally been allowed to start oral feeding on an early POD [1]. Total gastrectomy is likely to be more complicated than distal gastrectomy because it is difficult to perform esophagojejunostomy; however, there is no definite evidence to support this hypothesis for total gastrectomy. Patients start oral food intake at POD 2 as part of our conventional management, but after ERAS protocol modification, patients started the oral food intake on POD 1. There was no anastomotic leakage in the modified group. ERAS, unlike conventional care, does not require long postoperative fasting periods. A recent prospective study confirmed that early oral food intake after laparoscopic gastric surgery is safe and might be associated with enhanced recovery with a shorter hospital stay [13,14,15]. The ERAS guidelines for gastrectomy also recommend early initiating postoperative oral nutrition, but a delay in bowel recovery may hamper early oral nutrition in some patients after gastrectomy. However, there are no serious compilations associated with early oral nutrition occurred, such as aspiration or anastomosis leakage. Therefore, if careful monitoring is performed, ileus may not be a major concern when implementing early oral nutrition in patients who have undergone total gastrectomy.

Many surgeons think that NGT is useful to reduce the passage of food by the anastomotic site and to maintain calm conditions near the anastomotic site. But, in bariatric surgery, routine placement of NGT in patients operated on laparoscopic sleeve gastrectomy was not useful in reducing anastomotic leakage [16]. It is unclear whether early removal of NGT prevents anastomotic leakage and accelerates the recovery of bowel movement. This study showed that the following gastrectomy, omitting NGT placement after surgery was safe, and there was no increase in anastomotic-related complications. In this study in the modified group, four patients experienced postoperative ileus, and two patients required NGT reinsertion, but these patients recovered without surgery. Prolonged perioperative fasting and NGT are likely to induce nausea and delay bowel function recovery, and the patients without a postoperative NGT recovered postoperative bowel movement earlier than patients with an NGT and that routine postoperative NGT intubation is unnecessary after elective surgery [17]. Although previous reports suggested omitting NGT placement does not enhance the postoperative recovery in gastric cancer [17], our modified ERAS included that omitting NGT enhanced the postoperative recovery. It is speculated that this is the effect of multiple items such as early oral intake, reduction of intestinal edema due to early termination of infusion, and administration of herbal medicine: Dai-kenchu-to.

The first flatus and defecation indicate recovery of bowel movement, and these factors occurred earlier in the modified group than in the conventional group in our study. A previous report suggested that the first day of flatus after gastric surgery was earlier in patients who underwent modified ERAS care than in those who received conventional care [18]. After modifying the ERAS protocol, many additional modifications were made including administering herbal medicine, Dai-kenchu-to medicine, routinely to reduce the time to first flatus and defecation. DKT has been clinically used to treat various gastrointestinal diseases, including postoperative ileus, abdominal bloating, and cold sensation in the abdomen. DKT has specific functions such as improving intestinal movement, increasing colonic blood flow, and suppressing inflammation. These effects may influence the early recovery from the postoperative course [3, 4].

ERAS factors include early ambulation, early postoperative nutrition, and early elements that can contribute together to reducing the length of the hospital stay without increasing postoperative complications [19]. Other factors such as MIS may also have influenced the length of stay [20, 21]. Thus, we performed PSM to eliminate the effects of the patient’s background. In the ERAS group, patients with more advanced cancer were treated, and minimally invasive surgery including laparoscopic and robotic surgery was performed frequently. However, even after PSM, there was no increase in the number of postoperative complications, although there was no significant shorter hospital stay.

Recently, there have been many older patients who underwent total gastrectomy, and an early recovery prevents postoperative complications from developing in these patients. Thus, more ERAS should be performed, and the postoperative activity must be increased.

In Asian countries, ERAS was analyzed frequently and had a positive effect on the postoperative course [19]. On the other hand, in European countries, ERAS was not prevalent [22]. But recently, Spanish institutions reported the usefulness of ERAS [23]. Although gastric cancer is more common in Asian countries, this ERAS will be more popular in European countries.

This study had several limitations. The sample size was small, the study had a retrospective design, and there was no randomization for the two treatment arms.