ASA Grade III and Total Gastrectomy Drive ERAS Failure After Laparoscopic Gastrectomy in Older Patients

Older patients undergoing laparoscopic radical gastrectomy with an enhanced recovery after surgery protocol are most likely to miss the protocol’s recovery targets when they carry an ASA grade III classification or undergo total rather than subtotal removal of the stomach, according to a retrospective cohort study published in BMC Surgery.

The study analyzed a consecutive cohort of 307 older patients who underwent elective laparoscopic radical gastrectomy under an ERAS protocol between January 2021 and December 2025. The researchers set out to identify risk factors associated with ERAS failure in this population, noting that while ERAS protocols have demonstrated significant benefits in gastric cancer surgery, data on risk factors for ERAS failure specifically in older patients remain limited.

ERAS failure was defined as a composite endpoint with three components: a prolonged postoperative hospital stay exceeding the 75th percentile, meaning more than nine days, attributable to postoperative complications; an unplanned readmission within 30 days after discharge; or death within 30 days. This composite definition allowed the team to capture several distinct ways in which an accelerated recovery pathway can fall short of its intended outcome.

Among the 307 enrolled patients, 76, or 24.76 percent, encountered ERAS failure. Notably, there were no fatalities in the cohort, meaning the 30-day mortality component of the composite endpoint did not contribute any cases. Pneumonia, which occurred in 13 patients, was the most significant postoperative complication leading to an extended postoperative hospital stay.

To identify independent predictors of failure, the researchers performed univariate and multivariate logistic regression analyses. Two factors emerged as independent risk factors. ASA grade III carried an odds ratio of 1.969, with a 95 percent confidence interval of 1.109 to 3.495 and a P value of 0.021. Total gastrectomy carried an odds ratio of 2.567, with a 95 percent confidence interval of 1.472 to 4.476 and a P value of 0.001.

These findings indicate that, after accounting for other variables in the multivariable model, patients classified as ASA grade III had roughly twice the odds of ERAS failure compared with patients in lower ASA grades, while patients who underwent total gastrectomy had more than two and a half times the odds of failure compared with those who did not. The confidence intervals for both estimates exclude the null value of one, and the reported P values fall below the conventional 0.05 threshold.

The authors concluded that ASA grade III and total gastrectomy were identified as independent risk factors for ERAS failure after laparoscopic radical gastrectomy in older patients with gastric cancer. They further stated that preoperative risk stratification and optimization are crucial for enhancing ERAS outcomes in this vulnerable population, and that sensitivity analyses confirmed the robustness of the findings.

As a retrospective analysis of a single consecutive cohort, the study identifies associations rather than causal effects, and its conclusions apply to older patients undergoing elective laparoscopic radical gastrectomy under an ERAS protocol within the studied period. The published version analyzed here is an early-share, peer-reviewed accepted version that carries a permanent DOI and remains subject to further edits before the final Version of Record replaces it.

For surgical teams applying enhanced recovery pathways in older gastric cancer patients, the study suggests that preoperative assessment of ASA grade and the planned extent of gastric resection may help identify patients at elevated risk of an extended hospital stay, unplanned readmission, or other components of the failure endpoint, allowing risk stratification to be integrated into preoperative planning.

Subject of Research: Risk factors for failure of enhanced recovery after surgery protocols in older patients undergoing laparoscopic radical gastrectomy

Article Title: Risk factors for failure of enhanced recovery after surgery protocols following laparoscopic radical gastrectomy in older patients

Article References: Zhu, Y., Lin, S., Zhong, J., Li, C., Chen, J., & Xu, D. (2026). Risk factors for failure of enhanced recovery after surgery protocols following laparoscopic radical gastrectomy in older patients. BMC Surgery. https://doi.org/10.1186/s12893-026-04294-0

Image Credits: AI Generated

DOI: 10.1186/s12893-026-04294-0

Keywords: ERAS, laparoscopic radical gastrectomy, gastric cancer, older patients, ASA grade III, total gastrectomy, postoperative complications, pneumonia, hospital stay, readmission, risk factors, BMC Surgery