Beyond the QoR-15K: addressing clinical nuances and fasting-related symptom burden in gastric cancer ERAS

Dear Editor, We read with great interest the randomized controlled trial by Lee et al on the effectiveness of an evidence-based, multimodal Enhanced Recovery After Surgery (ERAS) program on early postoperative recovery (QoR-15K) after gastric cancer surgery[1]. While we commend the focus on patient-reported outcomes, several clinical and methodological nuances merit clarification. First, regarding enrolment feasibility, baseline characteristics were recorded in the outpatient clinic at the time of the surgical decision. In many settings, definitive surgical planning for gastric cancer requires comprehensive inpatient evaluation. We would appreciate further details on the feasibility and generalizability of this outpatient-centric workflow. Second, the baseline psychological data are intriguing. The median preoperative Hospital Anxiety and Depression Scale scores were reported as 0 [0–1]. Given that anxiety and depression symptoms are commonly observed in oncologic surgical populations, these values raise the possibility of floor effects or differences in assessment timing and administration[2]. Could the authors clarify whether any structured psychological prehabilitation was provided beyond the optimization video? Third, we noted a potential inconsistency between the statistical reporting and Figure 2 of the original trial report by Lee et al. Although the group × time interaction for QoR-15K was not significant (P = 0.284), Figure 2 in the original trial report by Lee et al appears to indicate time-point-specific between-group differences. Could the authors clarify whether these were derived from pre-specified simple-effects analyses, and whether multiplicity adjustment was applied? In addition, despite significant between-group differences in cumulative fentanyl consumption (P < 0.001), postoperative nausea and vomiting (PONV) incidence did not differ between groups (e.g., P = 0.424 for 0–24 h). This seems counterintuitive given the well-established dose-dependent association between opioids and PONV[3]. Additional details on antiemetic prophylaxis and rescue therapy, as well as outcome ascertainment, may help contextualize these findings. As perioperative fasting was shortened in the ERAS group, future studies may benefit from incorporating patient-reported hunger- and appetite-related outcomes to capture symptom burden that may not be fully reflected by global recovery scores. Recent evidence suggests that approximately 62.7% of hospitalized adults experience distressing hunger during recovery transitions[4]. This could inform more targeted, nurse-led assessment and supportive care addressing physiological and psychological factors, complementing recovery gains achieved by ERAS protocols[5]. Overall, we appreciate the authors’ contribution and believe that clarification of these points may further strengthen the interpretation and clinical translation of this important work. We look forward to the authors’ response and future research in this area.