Application of the quality of recovery-40 questionnaire to evaluate the effectiveness of enhanced recovery after surgery protocols in gastric cancer

Abstract

Patient reported outcomes is currently considered to be an important supplement to evaluate the effectiveness of enhanced recovery after surgery (ERAS) clinical practice. The Quality of Recovery-40 Questionnaire (QoR-40) is one of the most frequently used and validation tool to assess the subjective feelings of quality of life after surgery. The present study aimed to use the QoR-40 to evaluate the effectiveness of ERAS protocols in gastric cancer from the perspective of patient-reported quality of recovery. The study was designed as a prospective, non-randomized clinical trial, conducted in a single center. Patients in our hospital who were scheduled to undergo radical surgery for gastric cancer were divided into ERAS group and control group (Contr group). The QoR-40 were administered one day before surgery (Baseline) and on postoperative day 1, 3, 6, and 30. The difference in QoR-40 scores between the ERAS and Contr groups was compared by repeated-measures ANOVA. A total of 200 patients completed the study, including 100 patients in the ERAS group and 100 patients in the Contr group. The Baseline time point QoR-40 scores of the ERAS and Contr groups were 179.68 ± 14.46 and 180.12 ± 17.12, respectively, and no significant difference was noted between the two groups (p = 0.845). The postoperative QoR-40 score of the ERAS group was significantly higher than that of the Contr group, and the difference was statistically significant (p = 0.006). This study demonstrated that, in terms of patient-reported quality of recovery, the postoperative recovery effect of ERAS protocols in gastric cancer is significantly better than that of the traditional treatment model.

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Updates in Surgery
https://doi.org/10.1007/s13304-023-01719-w
ORIGINAL ARTICLE
Application ofthequality ofrecovery‑40 questionnaire toevaluate
theeffectiveness ofenhanced recovery aftersurgery protocols
ingastric cancer
YeyangChen1,2,3 · SiyuLiu1,2· BopeiLi1,2· RujingLin1,2· WeikunLai1,2· DejunLiu1,2· ZhenWang1,2· JinluLiu1,2·
XinganQin1,2· XianghuaWu1,2· JiehuaLi1,2· KuiJia1,2· JunqiangChen1,2
Received: 11 April 2023 / Accepted: 29 November 2023
© The Author(s) 2024
Abstract
Patient reported outcomes is currently considered to be an important supplement to evaluate the effectiveness of enhanced
recovery after surgery (ERAS) clinical practice. The Quality of Recovery-40 Questionnaire (QoR-40) is one of the most
frequently used and validation tool to assess the subjective feelings of quality of life after surgery. The present study aimed
to use the QoR-40 to evaluate the effectiveness of ERAS protocols in gastric cancer from the perspective of patient-reported
quality of recovery. The study was designed as a prospective, non-randomized clinical trial, conducted in a single center.
Patients in our hospital who were scheduled to undergo radical surgery for gastric cancer were divided into ERAS group and
control group (Contr group). The QoR-40 were administered one day before surgery (Baseline) and on postoperative day
1, 3, 6, and 30. The difference in QoR-40 scores between the ERAS and Contr groups was compared by repeated-measures
ANOVA. A total of 200 patients completed the study, including 100 patients in the ERAS group and 100 patients in the
Contr group. The Baseline time point QoR-40 scores of the ERAS and Contr groups were 179.68 ± 14.46 and 180.12 ± 17.12,
respectively, and no significant difference was noted between the two groups (p = 0.845). The postoperative QoR-40 score
of the ERAS group was significantly higher than that of the Contr group, and the difference was statistically significant
(p = 0.006). This study demonstrated that, in terms of patient-reported quality of recovery, the postoperative recovery effect
of ERAS protocols in gastric cancer is significantly better than that of the traditional treatment model.
Keywords Enhanced recovery after surgery· The Quality of Recovery-40 Questionnaire· Gastric cancer· Patient-
reported· Effectiveness
Introduction
Globally, gastric cancer (GC) is the fifth most common
malignant tumor in terms of new incidence each year and
is the fourth leading cause of cancer-related deaths [1]. The
incidence of GC is considerably regional, and East Asia,
including China, is reported to have the highest incidence of
GC [2]. According to the statistical data, the 5-year overall
survival rate of patients with GC in China in 2015 was
35.1% and that of patients with GC in the United States in
2014 was 33.1% [3, 4]. Treatment methods for GC include
surgery, chemotherapy, radiotherapy, and targeted therapy.
At present, surgery is the primary method of treatment for
GC [5, 6].
Enhanced recovery after surgery (ERAS) is a
comprehensive management plan for the perioperative
period combined with evidence-based medicine. The
primary goal of ERAS is to reduce trauma and stress. ERAS
adopts a series of optimized measures in the perioperative
period to promote rapid postoperative recovery, shorten the
average length of hospital stay, and reduce hospitalization
cost without affecting the incidence of postoperative
Yeyang Chen and Siyu Liu contributed equally to this study.
* Junqiang Chen
gxhans@163.com
1 Department ofGastrointestinal Surgery, The First Affiliated
Hospital ofGuangxi Medical University, 6 Shuangyong
Road, Nanning530021, China
2 Guangxi Key Laboratory ofEnhanced Recovery After
Surgery forGastrointestinal Cancer, Guangxi, China
3 Department ofThyroid andBreast surgery, The First People’s
Hospital ofYulin, Yulin, China

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complications. Therefore, while evaluating the effects of
ERAS, researchers often use objective indicators from
doctor-reported outcomes, such as average hospital stay,
hospitalization cost, and postoperative complications, to
evaluate its effectiveness [7, 8]. Studies on the effectiveness
of ERAS, however, should include not only the objective
data but also the subjective feelings of patients. In recent
years, “patient-reported outcomes (PROs),” which are based
on the concept of the bio-psycho-social medicine model,
have been used to evaluate the effects of ERAS. The Quality
of Life Assessment questionnaire is the most commonly
used PRO tool.
The Quality of Recovery-40 Questionnaire (QoR-40)is a
commonly used patient-rated quality of life questionnaire.
It was developed and validated by Dr. Myles in Australia
in 2000 [9]. It is mainly used to assess the early postopera-
tive recovery of quality of life after general anesthesia and
surgery. At present, QoR-40 has been validated and used in
various countries and has been successfully used to evaluate
the quality of recovery after different surgical methods or
anesthesia [10–14]. Our previous study reported the devel-
opment of the official Chinese version of QoR-40 (QoR-
40C) and confirmed that it has good reliability, validity, and
responsiveness and can be used to evaluate the quality of
recovery of surgical patients [15].
In the present study, patients undergoing radical GC sur-
gery were selected as the research population. The QoR-40
was used to evaluate the effectiveness of ERAS protocols
in GC by comparing the ERAS and traditional intervention
model and to determine theappropriate time to discharge
from the perspective of patient-reported quality of recovery.
Methods
Study population
This study was approved by the Ethics Committee of the
First Affiliated Hospital of Guangxi Medical University
[Approval Number: 2020 (KY-E-078)], and all patients
participating in this study were required to sign written
informed consent. The study was designed as a prospective,
non-randomized clinical trial, conducted in a single center in
the First Affiliated Hospital of Guangxi Medical University.
This study included patients who underwent radical surgery
for GC from August 2019 to February 2021. During this
period, patients were continuously recruited into the trial
and divided into ERAS group and Contr group according
to their wishes. The inclusion criteria were as follows: (1)
the ability to take care of oneself, engage in light physi-
cal activity, and eat using the mouth; (2) organ function is
sound or is compensated; (3) possibility to undergo D2 rad-
ical resection; (4) American Society of Anesthesiologists
(ASA) grade ≤ III; (5) the patient and family members agree
to participate in this project after being informed. The exclu-
sion criteria were as follows: (1) no possibility to undergo
D2 radical surgery; (2) ASA grade > III or advanced age
(≥ 80years old); (3) poor comprehension ability; (4) psy-
chiatric/central nervous system disorders, history of alcohol
or drug addiction, or presence of severe underlying diseases
that prevent the subjective completion of the QoR-40. The
included patients were divided into the ERAS group and
the control group (Contr group). Patients were required to
complete the QoR-40 on one day before surgery (Baseline)
and on postoperative day (POD) 1, 3, 6, and 30. The ERAS
group received ERAS protocol intervention, and the Contr
group received traditional protocol intervention. The sample
size was calculated as follows: (1) the pre-collection data of
30 patients were analyzed by PASS software version 15.0.5
and (2) the significance level was set at α = 0.05 (two-sided),
and the power of test was set as 1−β = 0.90. Based on the
calculation, each group required a sample size of N = 83,
assuming that the withdrawal rate was 10%, each group
required at least 93 participants. Hence, considering that the
study had two groups, a total of at least 186 patients needed
to be included in this study.
Perioperative management protocols
The ERAS protocols of our center have been developed by
referring to the “Consensus guidelines for enhanced recov-
ery after gastrectomy Enhanced Recovery After Surgery
(ERAS®) Society recommendations” [16] and are based
on the five core elements proposed by the proponent of the
ERAS concept, Professor Kehle [17]. Together with our
center’s experience on clinical practice of ERAS, we formu-
lated ERAS perioperative management protocols containing
22 items (Table1).
QoR‑40 structure andscoring rules
The QoR-40 is a self-rated 40-item questionnaire used to
assess the recovery of the quality of life. The questionnaire
consists of five dimensions: emotional status (9 items),
physical comfort (12 items), psychological support (7
items), physical independence (5 items), and pain (7 items).
All the items are rated on a five-point scale ranging from
1 to 5. The initial point and conversion score of each item
are calculated. Depending on the question, 5 points or 1
point may be the best answer. The best answers to positive
questions are scored 5, while the best answers to negative
questions are assigned the score of 1. The total score of the
QoR-40 is the sum of the scores of all items. The score of
each dimension is the sum of the total scores of the items in
the corresponding dimension. The total score ranges from

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Table 1 Perioperative management protocols for the ERAS and control groups
Perioperative management Control group ERAS group
Admission Preoperative education
No smoking and no alcohol consumption, lung function training if
necessary
Preoperative education
No smoking and no alcohol consumption, lung function training if
necessary
Preoperative
Preoperative nutritional support For those with obvious malnutrition, take nutritional powder or enteral
nutrient solution orally before surgery, and supplement with paren-
teral nutrition if necessary
For those with obvious malnutrition, take nutritional powder or enteral
nutrient solution orally before surgery, and supplement with parenteral
nutrition if necessary
Fasting before surgery Fasting for 12h before surgery and no water consumption for 6h Oral energy solution 10h and 2h before surgery
Bowel preparation Routine oral laxative one day before surgery Nonroutine mechanical bowel preparation
Preoperative drug application Unconventional use of diazepam for sedation Unconventional use of diazepam for sedation
Antibacterial prevention and skin preparation Prepare the skin the night before surgery, and use antibiotics 30min
before the surgery
Prepare the skin the night before surgery, and use antibiotics 30min
before the surgery
Intraoperative
Anesthesia protocol Traditional anesthesia protocol Optimize anesthesia protocol (general anesthesia combined with epi-
dural anesthesia)
Type of surgery No special requirements Priority is given to laparoscopic or robotic surgery or short incision
surgery
Body temperature intervention No special intervention required unless the patient is hypothermic Use heaters and other equipment to maintain stable body temperature
Preventive analgesia No preventive analgesia Apply TAP and PCA, local infiltration anesthesia with ropivacaine
before abdominal closure
Drainage tube Routine use of three abdominal drainage tubes (under the liver, pelvis,
and splenic fossa)
Avoid using abdominal drainage tube; if used, remove it early after
surgery
Liquid management Do not deliberately limit the amount of liquid Strict fluid control, preferentially select vasoconstrictor drugs to control
blood pressure
Gastrointestinal decompression Routine gastrointestinal decompression before surgery Nonroutine gastrointestinal decompression before surgery
Postoperative
Postoperative antiemetic Use antiemetics only when the patient needs Routine preventive use of antiemetic drugs
Postoperative analgesia Indwelling PCA, providing analgesics only when the patient needs, and
performing VAS scores daily
Indwelling PCA,multimodal analgesia from the day after surgery, and
performing VAS scores daily
Catheter and gastrointestinal decompression Routine indwelling for 3days or more; to decide whether to remove
according to the drainage volume and the nature of the drainage fluid
Remove the nasogastric tube and drainage tube as soon as possible after
the operation, and remove the urinary tube on the first day after the
operation
Early postoperative eating After the operation, take oral food according to the removal of the
gastric tube and the patient's wish
From the first day after the operation, the patient is instructed to take
saline and gradually transition to clear liquid, liquid, semi-liquid, and
pharmacological nutrients if necessary
Blood sugar control Measure blood glucose only when abnormal blood glucose level is
suspected
Measure blood glucose level three times a day, and perform timely inter-
vention for patients with abnormal blood glucose level
Promote recovery of bowel function No special treatment; wait for the patient to recover on their own Lactulose oral liquid 15ml/time, 2–3 times a day

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40 to 200. The higher the score, the better is the quality of
life [18].
Data collection
On the Baseline day, the investigator briefly explained the
purpose and significance of the study and the anonymity
and confidentiality of the study data. The patients were then
required to sign a written informed consent form, and they
were asked to complete the QoR-40 to determine the Base-
line health status before surgery. The patients also completed
the QoR-40 on POD1, 3, 6, and 30 according to their actual
situation. If required, the investigator provided the neces-
sary assistance to the patient to complete the QoR-40. The
patient demographic and perioperative data were collected
simultaneously, including postoperative complications, albu-
min (Alb), hemoglobin (Hb), score of patient-generated sub-
jective global assessment (PG-SGA), ASA grading, visual
analog scale (VAS), type of surgery, first time off-bed activ-
ity, first time of flatus, time to removal of nasogastric tube,
time of removal of urine catheter, length of postoperative
hospital stay, hospitalization cost, and hospital readmission
within 30days. Postoperative complications were classified
according to the Clavien-Dindo postoperative complications
classification standard [19]. Discharge standard (based on
the discharge standard of the General Hospital of Nanjing
Military Region, China) was as follows: intestinal function
recovery, oral intake of 70% of the preoperative intake level;
no requirement for intravenous rehydration; no pain or pain
can be effectively relieved by oral analgesics; ability to com-
plete daily activities normally and to take care of themselves;
and willingness to be discharged from the hospital.
Statistical analysis
All statistical analyses, including data entry, descriptive
statistical analysis, paired t-test, and analysis of variance
(ANOVA), were performed using SPSS 25.0 software (IBM,
Corp.). Measurement data were expressed as mean ± stand-
ard deviation (χ± s). The measurement data were compared
between the two groups by using t-test, while the chi-square
test was used to compare count data. Statistical significance
for all analyses was set at p < 0.05.
Results
A total of 221 patients undergoing radical GC surgery were
enrolled in this study. Of these patients, 21 patients could not
complete the QoR-40 for various reasons and were excluded
from the study. Finally, a total of 200 patients effectively
completed the QoR-40, including 100 patients in the ERAS
group and 100 patients in the Contr group. The demographic
Table 1 (continued)
Perioperative management Control group ERAS group
Postoperative activities Decide the time of getting out of bed according to the patient's wish On the first day after surgery, the patient should sit up for at least 6h.
From the second day onwards, the patient should get out of bed for 2h,
and the amount of exercise should gradually increase
Quality of life assessment Use QoR-40 to assess the quality of life of patients after surgery Use QoR-40 to assess the quality of life of patients after surgery
ERAS enhanced recovery after surgery, TAP Transversus Abdominis Plane, PCA Patient controlled analgesia, VAS visual analogue scale, QoR-40 the Quality of Recovery-40 Questionnaire

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and basic clinical characteristics of the patients during the
perioperative period are shown in Table2. No significant
difference was observed between the ERAS and Contr
groups in gender, age, height, weight, body mass index
(BMI), education level, and ASA grading for anesthesia
(p = 0.083, 0.058, 0.963, 0.964, 0.416, 0.337, and 0.092,
respectively). In terms of preoperative nutritional indicators,
the comparison of Alb, Hb, and PG-SGA scores between
the two groups showed no significant difference (p = 0.144,
0.169, and 0.133, respectively).In the ERAS group, there
were 61 cases of laparoscopic surgery and 39 cases of
robotic surgery, while in the control group, there were 17
cases of open surgery, 72 cases of laparoscopic surgery, and
11 cases of robotic surgery. Significant differences were
observed between the two groups (p < 0.001) with regard to
the type of surgery performed. The clinical outcomes of the
patients are detailed in Table3. Postoperative diet initiation
time in the ERAS group was significantly earlier than that in
the Contr group (p < 0.001). The removal of the nasogastric
tube in the ERAS group was 1.79 ± 0.98days after surgery,
which was significantly earlier than that 3.94 ± 2.26days
after surgery in the Contr group (p < 0.001). The removal of
the urine catheter in the ERAS group was also significantly
earlier than that in the Contr group (p = 0.005). The length of
hospital stay after surgery was 6.55 ± 1.43days for the ERAS
group and 12.79 ± 9.28days for the Contr group, which was
statistically significant (p < 0.001). There was significant
difference in postoperative complications between the ERAS
and Contr groups (p < 0.001). The hospitalreadmission
rate of the two groups was 3% within 30days. In terms of
hospitalization cost, the average hospitalization cost of the
ERAS group was 79,772.88 ± 25,816.84 yuan and that of the
Contr group was 88,602.45 ± 28,288.84 yuan. A significant
difference in hospitalization cost was observed between the
two groups (p = 0.022).
Table 2 Participant
characteristics (n = 200)
ERAS enhanced recovery after surgery, BMI body mass index, ASA American society of anesthesiologists,
Alb albumin, Hb hemoglobin, PG-SGA scored patient-generated subjective global assessment
Characteristics Control ERAS p-value
No. of patients 100 100
Gender: Female/Male 34/66 46/54 0.083
Age (years) 54.59 ± 9.16 52.13 ± 11.57 0.058
Height (cm) 161.07 ± 12.88 161.14 ± 7.93 0.963
Weight (kg) 59.25 ± 15.84 59.16 ± 10.37 0.964
BMI (kg/m2)25.73 ± 3.70 22.71 ± 3.09 0.416
Education: primary or below/secondary/high/
university or above
36/31/19/14 27/35/24/14 0.337
ASA: I/II/III 3/62/35 3/74/23 0.092
Alb 36.25 ± 4.48 37.12 ± 3.88 0.144
Hb 115.87 ± 25.57 120.96 ± 26.59 0.169
PG-SGA 5.18 ± 3.72 4.42 ± 3.41 0.133
Resection range: total/subtotal gastrectomy 19/81 10/90 0.071
Operation: open/laparoscopic/robotic 17/72/11 0/61/39 < 0.001
Table 3 Clinical outcomes
(n = 200)
ERAS enhanced recovery after surgery
Characteristics Control ERAS P-value
No. of patients 100 100
First flatus (hour) 82.63 ± 41.31 44.70 ± 16.32 < 0.001
Off-bed activity (hour) 43.82 ± 18.43 22.73 ± 10.60 < 0.001
Diet initiation (hour) 111.62 ± 49.40 51.14 ± 27.49 < 0.001
Removal of nasogastric tube(day) 3.94 ± 2.26 1.79 ± 0.98 < 0.001
Removal of urine catheter(day) 1.35 ± 0.76 1.11 ± 0.37 0.005
Postoperative complications: yes/no 32/68 10/90 < 0.001
Hospital stay after surgery (day) 12.79 ± 9.28 6.55 ± 1.43 < 0.001
Cost(yuan) 88,602.45 ± 28,288.84 79,772.88 ± 25,816.84 0.022
Hospitalreadmission (%) 3 (3.0%) 3 (3.0%) 1.000

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The changes in VAS scores in the ERAS and Contr
groups at each time point are shown in Table4 and Fig.1.
There was no significant difference in VAS scores between
the two groups at Baseline (p = 0.162). However, each time
point after surgery, the VAS score of the ERAS group was
significantly lower than that of the Contr group (p = 0.002,
0.003, < 0.001, 0.001, and < 0.001). Repeated-measures
ANOVA revealed that the VAS scores at multiple time
points showed significant differences between the ERAS
and Contr groups (p < 0.001), indicating that patients in the
ERAS group had less postoperative pain than those in the
Contr group.
Table5 and Fig.2 show the changes in the QoR-40 score
in the ERAS and Contr groups at each time point. On the
Baseline day, the QoR-40 score was 179.68 ± 14.46 in the
ERAS group and 180.12 ± 17.12 in the Contr group, and
no significant difference was observed between the two
groups (p = 0.845). The QoR-40 scores of POD1, POD3,
POD6, and POD30 in the ERAS group were 153.65 ± 20.92,
158.15 ± 19.98, 171.78 ± 20.37, and 182.28 ± 13.57,
respectively, which were higher than those of the Contr
group (148.92 ± 20.03, 151.76 ± 18.70, 159.83 ± 18.97, and
177.48 ± 14.74, respectively). No significant difference was
observed between the two groups on POD1 (p = 0.105),
while the QoR-40 scores of the remaining time points
(POD3, POD6, and POD30) were significantly different
(p = 0.018, < 0.001, and 0.019, respectively). A comparison
of the QoR-40 scores at multiple time points between
the ERAS and Contr groups by using repeated-measures
ANOVA revealed significant differences (p = 0.006). The
Table 4 Changes in VAS in
ERAS group and control group
at different assessment time
points
VAS visual analog scale, ERAS enhanced recovery after surgery, Baseline one day before surgery, POD
postoperative day
Group Baseline POD0 POD1 POD2 POD3 POD4 Total
Control 0.46 ± 0.93 4.70 ± 2.47 4.25 ± 2.27 3.60 ± 1.70 3.27 ± 1.60 2.22 ± 1.44
ERAS 0.29 ± 0.78 3.56 ± 2.56 3.26 ± 2.38 2.51 ± 2.21 2.35 ± 2.13 1.24 ± 1.69
p-value 0.162 0.002 0.003 < 0.001 0.001 < 0.001 < 0.001
Fig. 1 Changes (mean ± SD)
in VAS score in ERAS group
and Control group at different
time. *p < 0.05. VAS visual
analog scale, ERAS enhanced
recovery after surgery, Baseline
one day before surgery, POD
postoperative day
Table 5 Changes in QoR-40
score in ERAS group and
control group at different
assessment time points
QoR-40 the Quality of Recovery-40 Questionnaire, ERAS enhanced recovery after surgery, Baseline one
day before surgery, POD postoperative day
Group Baseline POD1 POD3 POD6 POD30 Total
Control 180.12 ± 17.12 148.92 ± 20.03 151.76 ± 18.70 159.83 ± 18.97 177.48 ± 14.74
ERAS 179.68 ± 14.46 153.65 ± 20.92 158.15 ± 19.98 171.78 ± 20.37 182.28 ± 13.57
p-value 0.845 0.105 0.018 < 0.001 0.019 0.006

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results of these time-dependent changes clearly showed that
the patients in the ERAS group recovered faster than those
in the Contr group from the perspective of patient-reported
quality of recovery.
In the ERAS group, the QoR-40 score at the Baseline was
179.68 ± 14.46 and decreased significantly on POD1 and
POD3 to 153.65 ± 20.92 and 158.15 ± 19.98, respectively
(both p < 0.001). On POD6, the QoR-40 score increased to
171.78 ± 20.37, but was still significantly lower than that at
the Baseline (p < 0.001). On POD30, the QoR-40 score was
182.28 ± 13.57, which was not significantly different from
that at the Baseline (p = 0.070) (Table6).
The scores of the five dimensions of the QoR-40 at each
time point in the ERAS group are shown in Table7 and
Fig.3. In all five dimensions, compared with the Baseline,
the POD1 and POD3 scores were significantly decreased
(all p < 0.05). On POD6, the scores of the two dimensions
Fig. 2 Changes (mean ± SD) in QoR-40 score in ERAS group and
Control group at different time. *p < 0.05. QoR-40 the Quality of
Recovery-40 Questionnaire, ERAS enhanced recovery after surgery,
Baseline one day before surgery, POD postoperative day
Table 6 The QoR-40 scores
in ERAS group at different
assessment time points
QoR-40 the Quality of Recovery-40 Questionnaire, ERAS enhanced recovery after surgery, Baseline one
day before surgery, POD postoperative day
ERAS Baseline-POD1 Baseline-POD3 Baseline-POD6 Baseline-POD30
Mean ± SD 26.03 ± 18.57 21.53 ± 19.35 7.90 ± 19.22 −2.68 ± 14.48
P-value < 0.001 < 0.001 < 0.001 0.070
Table 7 The QoR-40 scores of
the five dimensions before and
after surgery in ERAS group
QoR-40 the Quality of Recovery-40 Questionnaire, ERAS enhanced recovery after surgery, Baseline one
day before surgery, POD postoperative day
*p < 0.05 (compared to baseline)
ERAS (max) Baseline POD1 POD3 POD6 POD30
Physical comfort (60) 38.51 ± 4.28 35.65 ± 6.26* 35.69 ± 5.24* 38.22 ± 5.12 39.43 ± 4.38*
Emotion state (45) 53.67 ± 5.62 47.32 ± 6.40* 48.14 ± 5.74* 51.68 ± 6.08* 54.08 ± 5.04
Physical independence (25) 31.73 ± 4.69 30.38 ± 5.48* 30.33 ± 4.94* 31.61 ± 4.30 32.67 ± 3.70
Psychological support (35) 24.00 ± 2.74 12.41 ± 5.41* 15.03 ± 5.55* 19.65 ± 5.39* 23.90 ± 2.86
Pain (35) 31.79 ± 3.06 27.88 ± 4.07* 28.95 ± 3.58* 30.70 ± 3.60* 32.19 ± 2.97
Fig. 3 Changes (mean ± SD)
in QoR-40 subscale scores
in ERAS group at different
time. QoR-40 the Quality of
Recovery-40 Questionnaire;
ERAS enhanced recovery after
surgery, Baseline one day before
surgery, POD postoperative day

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of “Physical comfort” and “Physical independence” returned
to the Baseline level, while the scores of the dimensions
of “Emotional status” “Psychological support” and “pain”
were significantly lower than those at the Baseline level.
On POD30, the scores of all five dimensions recovered to
the baseline level; whatis more, the score of the “Physical
comfort” dimension (39.43 ± 4.38) was still significantly
higher than the Baseline score (38.51 ± 4.28) (p < 0.005).
Discussion
In recent years, the ERAS protocols in GC have matured,
and many studies have reported its safety and effectiveness
[20–22]. The safety and effectiveness indicators of ERAS
protocols include objective indicators such as the length of
hospital stay after surgery, hospitalization cost, and postop-
erative complications and subjective indicators such as the
quality of life assessment questionnaire from the perspective
of PROs. Presently, most studies are based on the results
of objective indicators from doctor-reported outcomes, and
there are few studies on the quality of life assessment from
PROs. In the present study, the QoR-40 was used to investi-
gate the postoperative recovery effect of ERAS protocols in
GC from the perspective of patients’ subjective perception.
ERAS is a dynamic process, we do not have to implement
all elements of ERAS, but the core elements should be
implemented, as stated by Professor Kehlet, who proposed
the ERAS concept [17]. The clinical practice of ERAS for
GC in our center comprises 22 items including six core
elements. Our present study showed no significant difference
between the ERAS and Contr groups in terms of age, gender,
height, weight, BMI, education, ASA grading for anesthesia,
and nutrition. All parameters of the two groups were at the
same baseline level before surgery. Compared to the Contr
group, minimally invasive surgery with laparoscopic and
robotic assistance was performed more in the ERAS group.
The 2014 ERAS guidelines recommend to use minimally
invasive surgery to shorten the incision length and reduce
tissue trauma [16]. Some researchers have shown that
minimally invasive surgery can significantly reduce the level
of traumatic stress factors such as interleukin-6 after surgery
[23]. A recent multicenter clinical study in China showed that
ERAS combined with the laparoscopic approach achieves the
same therapeutic effect as open surgery; does not increase the
incidence of postoperative complications; shortens the time
of early off-bed activity, early diet initiation, and first flatus
time; and shortens hospital stay [24]. Our center adopted this
opinion and has prioritized minimally invasive surgery in the
ERAS protocols of GC. In terms of VAS scores, the ERAS
group showed significantly lower VAS scores than those of
the Contr group, which indicates that multimodal analgesia
is effective in the ERAS group. This result is similar to that
reported by Yamada etal. [25]. The ERAS group started
recovery activities significantly earlier than the Contr group in
terms of early off-bed activity, early removal of the nasogastric
tube, early diet initiation, and first flatus time. There findings
are consistent with those of previous studies. Compared to the
traditional treatment group, the application of ERAS protocols
can quickly restore the gastrointestinal function after surgery
[26]. In the present study, there was no significant difference
between the ERAS and Contr groups in terms of 30-day
hospitalreadmission rates. Several studies have confirmed
no significant difference between the ERAS and control
groups in 30-day hospitalreadmission rates, which objectively
demonstrates the safety of ERAS protocols for GC [27, 28].
In the present study, the average length of hospital stay after
surgery in the ERAS group was 6.55 ± 1.43days, which was
significantly lower than that 12.79 ± 9.28daysof the Contr
group. Sugisawa etal. [28] reported that the median hospital
stay of the ERAS group after surgery was 8days, which was
significantly lower than that of the control group (p < 0.001).
In terms of hospitalization cost, the ERAS group in the
present study showed significantly lower hospitalization cost
than the Contr group; a finding similar that found in the report
of Wang etal. [29]. Li etal. [30] showed that the clinical
practice of ERAS for GC by using laparoscopic surgery leads
to quicker postoperative recovery and does not increase the
rate of readmission and complications, thereby reducing
hospital stay after surgery and the subsequent hospitalization
cost. In general, our objective indicator-based results of ERAS
clinical practice for GC are consistent with those of other
centers, which demonstrates the safety and effectiveness of
ERAS protocols from objective indicators.
The present study used the QoR-40 to investigate the
effectiveness of ERAS protocols in GC from the perspective
of PROs. Our previous study showed that despite cultural
differences, the QoR-40 has acceptable validity, reliability,
and responsiveness in assessing the health status of Chinese
patients after surgery [15].The QoR-40 has been widely used
to evaluate the quality of recovery after surgery [31, 32]. Jr
etal. [33] used the QoR-40 to evaluate the effect size for the
transversus abdominis plane infiltration on quality of post-
operative recovery in patients undergoing laparoscopic gas-
tric band surgery. Some researchers have used the QoR-40
to evaluate the quality of recovery after general anesthesia
in patients undergoing laparoscopic cholecystectomy [34].
Therefore, the present study used the QoR-40 to evaluate the
effect of ERAS protocols in GC. This study showed that the
QoR-40 scores of the ERAS and Contr groups were the same
on the Baseline day, which indicated that the two groups
showed similar characteristics at the baseline level before
surgery. Subsequently, the QoR-40 scores of the ERAS
group were higher than those of the Contr group at each
time point after the surgery. Except for POD1, significant
differences in the QoR-40 scores were observed between

Updates in Surgery
1 3
the ERAS and Contr groups on POD3, POD6, and POD30.
Repeated-measures ANOVA showed that the QoR-40 scores
at multiple time points were significantly different between
the two groups. According to the QoR-40 scores, which are
based on PROs, the postoperative recovery of the ERAS
group was found to be significantly better than that of the
Contr group. Thus, the present study using the QoR-40
revealed the effectiveness of ERAS protocols in GC on the
basis of the subjective perception of patients.
In the ERAS group, the QoR-40 score of patients with
GC decreased significantly on POD1 and gradually recov-
ered on POD3 and POD6. No significant difference in the
QoR-40 score was observed between POD30 and Baseline.
These results of time-dependent changes showed that the
QoR-40 scores of the ERAS group gradually recovered over
time after surgery, but did not return to the baseline level
at the average hospital stay (POD6). On POD6, the scores
of the two dimensions of “Physical comfort” and “Physical
independence” in the QoR-40 returned to the baseline level,
while the scores of the other three dimensions of “Emotional
status,” “Psychological support,” and “Pain” were still sig-
nificantly lower than the Baseline. On POD30, the scores of
all the five dimensions of the QoR-40 recovered to the base-
line level, but the score of the “Physical comfort” dimension
was still significantly higher than the baseline level. Other
researchers have used the QoR-40 to evaluate the quality
of recovery after different types of surgery; however, their
results were inconsistent with those of our present study
for GC surgery. Wang etal. [35] showed that the QoR-40
scores of patients who underwent upper gastrointestinal sur-
gery were significantly lower on POD1 and POD2 than on
the Baseline day; a finding which was consistent with our
research results. Shida etal. [32] used the QoR-40 in ERAS
protocols in colorectal cancer to determine the postoperative
recovery of patients, and their results showed that the QoR-
40 score on POD6 had returned to the preoperative baseline
level. Recently, Yin etal. [36] also obtained similar results
in ERAS protocols in colorectal cancer combined with
minimally invasive surgery, and in their study, the QoR-40
score returned to the preoperative baseline level on the day
of discharge. Myles etal. [18] used the QoR-40 in studies on
recovery after cardiac surgery and showed that the quality of
life of patients did not return to baseline levels up to POD30.
Poitras etal. [37] used the QoR-40 in patients who under-
went joint replacement surgery and showed that compared
to the baseline, the QoR-40 score did not show any signifi-
cant difference even on POD1. Kobari etal. [38] studied
patients who underwent robot-assisted partial nephrectomy
under general anesthesia; in their study, the QoR-40 score
decreased on POD1, but returned to the preoperative level on
the average discharge day (3 ± 0.7days). All these findings
imply that different types of surgeries have different postop-
erative recovery conditions, which require a specific analysis
for each surgery type. GC surgery is more traumatic, and
therefore, postoperative recovery may take longer.
The present study has several limitations. First, this study
is a single-center study, and prospective studies with multiple
centers and larger sample sizes are needed in the future to ver-
ify the results of this study. Second, this study did not comply
with the principle of completely randomized controlled trials.
Thus, a certain degree of selection bias is inevitable in this
study. The strength of this study is that it is the first study to
use the QoR-40 to assess the quality of postoperative recovery
of ERAS protocols in GC.
Conclusion
From the results of this study, the following conclusions can be
derived: (1) objective indicators confirm that ERAS protocols
in GC are safe and effective and (2) according to the PROs,
the postoperative recovery effect of ERAS protocols in GC is
significantly better than that of the traditional treatment model,
and that the patients discharged from the hospital on POD6 do
not achieve recovery to the preoperative level.
Acknowledgements We would like to extend our heartfelt gratitude to
all patients for their participation.
Author contributions All authors made substantial contributions to
conception and design, acquisition of data, or analysis and interpreta-
tion of data; took part in drafting the article or revising it critically for
important intellectual content; agreed to submit to the current journal;
gave final approval of the version to be published; and agree to be
accountable for all aspects of the work.
Funding The study was supported by the National Natural Science
Foundation of China (no. 82060430); the Guangxi Clinical Research
Center for Enhanced Recovery after Surgery, Guangxi Science
and Technology Base and Talent Project (nos. AD19245196,
AB18126058); the Guangxi Zhuang Autonomous Region Health
and Family Planning Commission (no. Z-K20221813); the Scientific
Research and Technology Development Program of Yulin (no.
202235069); the Guangxi key Laboratory of Enhanced Recovery after
Surgery for Gastrointestinal Cancer (YYZS2020003).
Data availability All data generated or analysed during this study are
included in the article, further inquiries can be directed to the cor-
responding author.
Declarations
Conflict of interest The authors report no conflicts of interest in this
work.
Ethics and Consent This study was approved by the Ethical Committee
of the First Affiliated Hospital of Guangxi Medical University
(Approval Number: 2020 (KY-E-078)). Its procedure followed the
Declaration of Helsinki. Informed consent was obtained from all
patients included in this study.
Open Access This article is licensed under a Creative Commons
Attribution 4.0 International License, which permits use, sharing,
adaptation, distribution and reproduction in any medium or format,

Updates in Surgery
1 3
as long as you give appropriate credit to the original author(s) and the
source, provide a link to the Creative Commons licence, and indicate
if changes were made. The images or other third party material in this
article are included in the article’s Creative Commons licence, unless
indicated otherwise in a credit line to the material. If material is not
included in the article’s Creative Commons licence and your intended
use is not permitted by statutory regulation or exceeds the permitted
use, you will need to obtain permission directly from the copyright
holder. To view a copy of this licence, visit http://creativecommons.
org/licenses/by/4.0/.
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