From feasibility to biological recovery: Reframing enhanced recovery pathways for elderly gastric cancer patients

Enhanced recovery after surgery (ERAS) has reshaped perioperative care in gastrointestinal oncology, but its application in elderly gastric cancer patients requires a shift from feasibility toward a biologically grounded understanding of recovery. Aging is characterized by frailty, sarcopenia, multimorbidity, chronic inflammation, and circadian vulnerability, which collectively influence postoperative resilience. Contemporary evidence shows that ERAS pathways remain feasible and safe in older adults, yet responsiveness varies widely due to physiological heterogeneity rather than chronological age alone. This Editorial reframes recovery as a multidomain process encompassing nutritional-inflammatory balance, sleep-circadian regulation, psychological resilience, and functional mobility. Targeted perioperative nutrition may support metabolic competence; structured sleep-protection strategies can stabilize endocrine-immune rhythms; psychological interventions may mitigate stress-related inflammatory activation; and digital monitoring using step-count trajectories or heart-rate variability provides early indicators of recovery deviation. Implementation challenges-including clinical workload, variable frailty, cognitive impairments, digital acceptance, and uneven access to multidisciplinary expertise-highlight the need for adaptive and pragmatic pathways. As global aging accelerates, ERAS must evolve from standardized protocols to biologically informed, patient-centered systems that align interventions with host physiology and real-time recovery signals. Such an approach may better capture recovery depth, enhance functional outcomes, and promote equitable care for elderly surgical populations.