What are the guidelines for prehabilitation, preoperative considerations, intraoperative management, and postoperative care for a patient undergoing surgery for stomach carcinoma?

Comprehensive Management of Gastric Carcinoma Surgery: Prehabilitation Through Postoperative Care

Prehabilitation (Preoperative Optimization)

Multimodal prehabilitation programs combining exercise, nutrition, and psychological support should be implemented for 4-8 weeks preoperatively in gastric cancer patients, as this approach demonstrates a 51% reduction in postoperative medical complications and significantly improves functional recovery. 1, 2

Patient Selection and Risk Stratification

• Screen all patients using Nutritional Risk Screening (NRS 2002) on admission to identify those requiring intensive preoperative optimization 1
• Identify severe nutritional risk by presence of any: weight loss >10-15% within 6 months, BMI <18.5 kg/m², Subjective Global Assessment Grade C, NRS >5, or serum albumin <30 g/L (without hepatic/renal dysfunction) 1
• Target high-risk patients including elderly (>70 years), those with poor functional status (ECOG ≥2), frail patients, and those with sarcopenia for intensive prehabilitation 1, 2
• Assess exercise tolerance through stair climbing test: inability to climb two flights of stairs without stopping predicts 90% risk of cardiorespiratory complications 1

Exercise Component (Duration: 4-8 Weeks Optimal)

Programs must run minimum 3-4 weeks preoperatively, with optimal duration of 6-8 weeks, at frequency of 3 sessions per week. 2

• Aerobic training: Progressive walking starting at 10-minute periods, advancing to 30-60 minutes daily 2, 3
• Resistance training: Low-resistance exercises with multiple repetitions (3 sets of 8-10 repetitions at 50-70% of 1 repetition maximum) 2
• Core stabilization: Closed kinetic chain exercises for lower extremity and core strengthening 4
• Functional activities: Balance training, fall prevention, and activities of daily living optimization 2
• Monitoring requirement: Exercise must be supervised and adapted dynamically by trained therapists 2

Nutritional Optimization (Duration: 7-14 Days Minimum)

For malnourished patients (NRS >5 or meeting severe risk criteria), initiate oral nutritional supplementation 7-10 days preoperatively, extending to 10-14 days for severe metabolic risk. 1

• Protein supplementation: Initiate immediately to augment muscle mass improvements and attenuate lean body mass loss 2, 4
• Caloric targets: Optimize total body calorie and protein intake to achieve measurable improvements in nutritional parameters 5
• Route of administration: Prioritize oral supplementation; add parenteral nutrition only when oral route inadequate 1
• Immunonutrition: Consider formulas with arginine, omega-3 fatty acids, and nucleotides for "ecoimmunonutrition" targeting gut microbiome 1

Metabolic Conditioning

• Preoperative carbohydrates: Administer to reduce insulin resistance, prevent hypoglycemia, and reduce surgical stress response 1
• Avoid prolonged fasting: Traditional NPO protocols increase insulin resistance and should be minimized 1

Psychological Support

• Mental health assessment: Establish baseline psychological status, particularly important in cancer diagnosis context 2
• Relaxation strategies: Incorporate stress-reduction techniques into multimodal program 1
• Anxiety management: Use Hospital Anxiety and Depression Score (HADS) for monitoring 6

Cardiopulmonary Exercise Testing (When Available)

• CPX testing: Provides objective assessment of cardiorespiratory reserve through VO₂max and anaerobic threshold measurement 1, 6
• Predictive value: Can detect previously undiagnosed ischemic heart disease in 24% of patients 1
• Functional capacity threshold: 6-minute walk distance improvement >20 meters considered clinically significant (baseline range 278-560 meters) 6

Critical Timing Consideration

Cancer surgeries cannot be delayed indefinitely—balance optimization benefits against oncologic timing, with 4-8 week programs representing optimal compromise. 2

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Preoperative Considerations and Optimization

Nutritional Assessment and Intervention

All gastric cancer patients require formal nutritional screening using validated tools (NRS 2002, SGA) with documentation of oral intake, weight trends, and BMI. 1

• Albumin measurement: Preoperative serum albumin <30 g/L predicts complications and requires aggressive nutritional intervention 1
• Weight loss significance: Unintentional loss of 5-10% or more increases complication risk substantially 1
• BMI thresholds: <18.5 kg/m² defines malnutrition; <20 kg/m² with >5% weight loss in 3-6 months requires intervention 1

Anemia Management

Screen all patients for anemia (Hb <130 g/L for both men and women) and treat iron deficiency preoperatively to optimize hemoglobin and reduce transfusion requirements. 1

• Prevalence: 31% of surgical patients present with anemia 1
• Iron deficiency: 25% of women with Hb 120 g/L are iron deficient, limiting hemopoietic response to blood loss 1
• Treatment timing: Initiate iron supplementation or intravenous iron therapy as soon as anemia identified 1

Smoking Cessation

Patients must stop smoking immediately upon diagnosis—even short-term cessation reduces postoperative complications. 1

Thromboprophylaxis Planning

Initiate low molecular weight heparin (LMWH) prophylaxis perioperatively and continue until hospital discharge for standard-risk patients; extend to 28 days for high-risk patients. 1

• Mechanical prophylaxis: Well-fitting compression stockings and/or intermittent pneumatic compression should be used only until discharge, not for extended 28-day periods 1
• Risk stratification: Identify high-risk patients (cancer, prolonged surgery, prior VTE) requiring extended prophylaxis 1

Antibiotic Prophylaxis

Administer prophylactic antibiotics at appropriate timing relative to surgical incision (typically within 60 minutes). 1

Anesthesia Considerations

Gastric cancer surgery anesthesia should only be conducted by anesthetists experienced with epidural analgesia and familiar with upper gastrointestinal surgical requirements. 1

Quality of Life Assessment

Measure baseline quality of life using validated instruments (SF-36) to guide treatment planning and establish comparison for postoperative recovery. 1, 6

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Intraoperative Management

Surgical Approach and Extent

For gastric cancer, perform subtotal gastrectomy for distal (antral) tumors and total gastrectomy for proximal tumors, with D2 lymphadenectomy as standard for curable cancers. 1

• Lymphadenectomy extent: D2 dissection should be standard for stage II-III disease, tailored to patient age, fitness, tumor location and stage 1
• Spleen preservation: Do not remove spleen for distal two-thirds gastric cancers; consider splenic hilar node dissection only for proximal greater curvature tumors 1
• Pancreas preservation: Remove distal pancreas only with direct invasion in proximal gastric cancer when curative resection still possible 1
• Resection margins: Ensure adequate longitudinal and radial margins with R0 (curative) resection rates exceeding 30% 1

Minimally Invasive Surgery

Laparoscopic approach demonstrates high-quality evidence for equivalent oncologic outcomes with potential benefits in recovery, though technique selection should match surgeon expertise. 1

Anastomotic Technique

Single-layer manual or stapled anastomoses are both acceptable, with clinical anastomotic leakage rates not exceeding 5%. 1

Peritoneal Drainage

Routine peritoneal drainage is not recommended based on current evidence. 1

Nasogastric Intubation

Routine nasogastric tube placement is not required and should be avoided when possible. 1

Intraoperative Warming

Maintain normothermia through active patient warming (prewarming and intraoperative warming) to reduce complications. 1

Fluid Management

Goal-directed fluid therapy should be employed to optimize hemodynamics while avoiding fluid overload. 1

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Postoperative Management

Early Mobilization and Activity

Begin walking immediately postoperatively with 10-minute periods, advancing to 30-60 minutes daily, while limiting lifting to ≤10 pounds for 4 weeks after open surgery. 3, 4

• Progressive ambulation: Start day of surgery or postoperative day 1, with breaks every 20-30 minutes initially 3, 4
• Lifting restrictions: Maximum 10 pounds for 2 weeks after laparoscopic procedures, 4 weeks after open surgery 3
• Low-resistance exercises: Prevent increased intra-abdominal pressure to reduce herniation risk 3
• Posture and breathing: Maintain proper technique to avoid surgical site strain 3

Nutritional Management

Remove nasogastric tube early (if placed), initiate oral fluids within 24 hours, and advance to solid food as tolerated, typically by postoperative day 3-5. 1

• Early oral feeding: Strongly recommended to support recovery and prevent complications 4
• Protein supplementation: Continue postoperatively to attenuate lean body mass loss from immobilization 4
• Nutritional monitoring: Regular assessment of intake, weight, and nutritional parameters 1

Pain Management

Epidural analgesia provides optimal pain control for open gastric surgery; multimodal analgesia including NSAIDs and acetaminophen for laparoscopic approaches. 1

• Epidural for open surgery: Strong recommendation with high-quality evidence 1
• Laparoscopic surgery: Epidural shows weak recommendation; consider multimodal alternatives 1
• Opioid minimization: Use multimodal approach to reduce opioid requirements and side effects 1

Urinary Drainage

Remove urinary catheter by postoperative day 1-2 to reduce infection risk and promote early mobilization. 1

Glycemic Control

Implement stress-reducing elements of enhanced recovery protocols to minimize hyperglycemia; target glucose <180 mg/dL. 1

• Evidence quality: Moderate for using ERAS elements to control glucose 1
• Avoid hypoglycemia: Balance tight control against risk of hypoglycemic episodes 1

Prevention of Postoperative Ileus

Early mobilization, early oral feeding, and minimization of opioids form the cornerstone of ileus prevention; chewing gum is no longer recommended. 1

Intravenous Fluid Management

Discontinue intravenous fluids once oral intake adequate, typically by postoperative day 2-4. 1

Clinical Pathway Timing (Standard Recovery)

Core pathway milestones for gastric cancer surgery: 1

• Postoperative day 1: Remove nasogastric tube (if placed), begin ambulation, continue IV fluids
• Postoperative day 2: Initiate oral fluids, remove urinary catheter
• Postoperative day 3-5: Advance to solid food as tolerated
• Postoperative day 5-7: Discontinue IV fluids when oral intake adequate
• Postoperative day 7-10: Target discharge for uncomplicated cases

Note: High-risk patients with cardiac, pulmonary, hepatic, or renal impairment require individualized modifications to this timeline. 1

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Postoperative Complications and Management

Expected Complication Rates (Quality Benchmarks)

Hospital mortality should be <10% for total gastrectomy and <5% for subtotal gastrectomy; overall complication rates should not exceed institutional benchmarks. 1

• Anastomotic leak: Should not exceed 5% 1
• R0 resection rate: Should exceed 30% for curative intent surgery 1

Common Complications

Multimodal prehabilitation reduces overall complications by 10% (risk difference -0.1) and nutritional intervention reduces complications by 18% (risk difference -0.18). 7

• Infectious complications: Reduced with preoperative nutritional optimization (7-10 days) 1
• Cardiorespiratory complications: Predicted by inability to climb stairs preoperatively; reduced with prehabilitation 1, 5
• Anastomotic complications: Reduced with adequate nutritional status and technical factors 1

Warning Signs Requiring Immediate Evaluation

Stop activity and seek medical attention for: 3, 4

• Severe pain at surgical site
• Shortness of breath
• Fever or signs of infection (warmth, erythema, drainage)
• Inability to tolerate oral intake
• Persistent nausea/vomiting

Clavien-Dindo Classification

Grade complications using standardized Clavien-Dindo system; major complications defined as grade ≥3. 5, 6

• Prehabilitation impact: Significantly associated with reduced Clavien-Dindo classification severity 5

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Adjuvant Therapy Considerations

Timing of Adjuvant Chemotherapy

For stage II-III gastric cancer, initiate S-1 adjuvant chemotherapy within 6 weeks of surgery after sufficient recovery from surgical intervention. 1

S-1 Dosing Schedule (Japanese Guidelines)

Administer S-1 at 80 mg/m² daily for 4 weeks followed by 2 weeks rest, repeated for 8 cycles (12 months total). 1

• Dose modifications: Postoperative patients more vulnerable to adverse events; consider 2 weeks on/1 week off schedule if needed 1
• Recovery requirement: Ensure adequate recovery from surgery before initiating chemotherapy 1

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Follow-Up Surveillance

Stage I Gastric Cancer Follow-Up Schedule

Structured surveillance with decreasing frequency over 5 years: 1

• Months 1,6,12,18,24,36,48,60: Medical examination, performance status, body weight, blood tests including tumor markers 1
• Months 1,6,12,24,36,48,60: CT and/or ultrasound 1
• Months 6,18,36,60: Endoscopy 1

Stage II-III Gastric Cancer Follow-Up Schedule

More intensive surveillance for higher-stage disease: 1

• Months 1,3,6,9,12,15,18,21,24: Medical examination, performance status, body weight, blood tests including tumor markers 1
• More frequent imaging: CT/ultrasound and endoscopy at closer intervals during first 2 years 1

Additional Surveillance Considerations

Consider chest X-ray, gastrography, barium enema, colonoscopy, bone scintigraphy, or PET scan when clinically indicated; continue surveillance beyond 5 years. 1

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Key Pitfalls to Avoid

• Delaying surgery excessively for prehabilitation: Balance optimization against oncologic timing—4-8 weeks maximum 2
• Ignoring nutritional risk: Failure to identify and treat malnutrition preoperatively increases complications substantially 1
• Inadequate prehabilitation duration: Programs <3-4 weeks show poor results; meaningful changes require 4-5 weeks minimum 1, 2
• Unimodal prehabilitation: Exercise alone shows modest benefits; multimodal programs (exercise + nutrition + psychological) demonstrate superior outcomes 1, 2
• Prolonged bed rest postoperatively: Early mobilization critical to prevent muscle loss and complications 4
• Routine nasogastric decompression: No longer recommended; early feeding preferred 1
• Extended mechanical thromboprophylaxis: Limit compression devices to hospital stay, not 28 days 1
• Inadequate pain control: Compromises early mobilization and recovery 1