CIRENG 2881 1–13

cir esp. 2023;xx(xx):xxx–xxx

CIRUGÍA ESPAÑOLA

www.elsevier.es/cirugia

Original article

Association between use of enhanced recovery

after surgery protocols and postoperative
complications after gastric surgery for cancer
(POWER 4): a nationwide, prospective multicentre
study

Javier Ripollés-Melchor,a,b,c,d Ane Abad-Motos,a,b,c,*,1 Marcos Bruna-Esteban,b,c,e

Marı́a Garcı́a-Nebreda,c,d,f Isabel Otero-Martı́nez,g Omar Abdel-lah Fernández,h
Marı́a P. Tormos-Pérez,i Gloria Paseiro-Crespo,c,d,f Raquel Garcı́a-Álvarez,b,j
Marı́a A Mayo-Ossorio,k Orreaga Zugasti-Echarte,l Paula Nespereira-Garcı́a,m
Lucia Gil-Gómez,b,c,n Margarita Logroño-Ejea,b,c,o Raquel Risco,p
Felipe C Parreño-Manchado,h Silvia Gil-Trujillo,b,c,q Carmen Benito,r Carlos Jericó,b,c,s
Marı́a I De-Miguel-Cabrera,t Bakarne Ugarte-Sierra,b,c,u Cristina Barragán-Serrano,v
José A. Garcı́a-Erce,b,c,w Henar Muñoz-Hernández,x Sabela del- Rı́o-Fernández,b,c,y
Marı́a L. Herrero-Bogajo,c,z Alma M. Espinosa-Moreno,c,aa Vanessa Concepción-Martı́n,c,ab
Andrés Zorrilla-Vaca,b,ac,ad Laura Vaquero-Pérez,ae Irene Mojarro,af Manuel Llácer-Pérez,ag
Leticia Gómez-Viana,ah Marı́a T. Fernández-Martı́n,ai Alfredo Abad-Gurumeta,a,b,c,d
Carlos Ferrando-Ortolà,b,c,p,aj José M. Ramı́rez-Rodrı́guez,b,c,ak César Aldecoa,b,c,ah on behalf
of the POWER Study Investigators Groupd
a
Department of Anaesthesia and Perioperative Medicine, Infanta Leonor University Hospital, Madrid, Spain
b
Spanish Perioperative Audit and Research Network (REDGERM), Zaragoza, Spain
c
Grupo Español de Rehabilitación Multimodal (GERM), Zaragoza, Spain
d
Universidad Complutense de Madrid, Madrid, Spain
e
Department of General Surgery, La Fe University Hospital, Valencia, Spain
f
Department of General Surgery, Infanta Leonor University Hospital, Madrid, Spain
g
Department of General Surgery, Hospital Álvaro Cunqueiro de Vigo (Complejo Hospitalario Universitario de Vigo), Vigo, Spain
h
Department of General Surgery, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
i
Department of Anaesthesia and Perioperative Medicine, Vall d’Hebrón University Hospital, Barcelona, Spain
j
Department of Anaesthesia and Perioperative Medicine, 12 de Octubre University Hospital, Madrid, Spain
k
Department of General Surgery, Hospital Universitario Puerta del Mar Cádiz, Cádiz, Spain
l
Department of Anaesthesia and Perioperative Medicine, Complejo Hospitalario Navarra, Pamplona, Spain
m
Department of Anaesthesia and Perioperative Medicine, Hospital POVISA Vigo, Vigo, Spain

* Corresponding author.
E-mail address: ane.abadmotos@osakidetza.eus (A. Abad-Motos).
1
Current address: Hospital Universitario Donostia, Paseo Doctor Beguiristain s/n. 20014. Donostia-San Sebastián. Spain
http://dx.doi.org/10.1016/j.cireng.2023.04.011
2173-5077/# 2023 AEC. Published by Elsevier España, S.L.U. All rights reserved.

Please cite this article in press as: Ripollés-Melchor J, et al. Association between use of enhanced recovery after surgery protocols and
postoperative complications after gastric surgery for cancer (POWER 4): a nationwide, prospective multicentre study. Cir Esp. 2023. http://
dx.doi.org/10.1016/j.cireng.2023.04.011
CIRENG 2881 1–13

2 cir esp. 2023;xx(xx):xxx–xxx

n
Department of Anaesthesia and Perioperative Medicine, Hospital de Sant Joan Despı́ Moisès Broggi, Spain
o
Department of Anaesthesia and Perioperative Medicine, Hospital Universitario de Alava, Vitoria, Spain
p
Department of Anesthesiology and Critical Care, Hospital Clı́nic, Institut D’investigació August Pi i Sunyer, Barcelona, Spain
q
Department of Anaesthesia and Perioperative Medicine, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
r
Department of Anaesthesia and Perioperative Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain
s
Department of Internal Medicine, Hospital Moisès Broggi, Consorci Sanitari Integral, Sant Joan Despı́, Spain
t
Department of Anaesthesia and Perioperative Medicine, Hospital General Universitari Castelló, Castellón de La Plana, Spain
u
Department of General Surgery, Hospital Galdakao-Usansolo, Spain
v
Department of General Surgery, Fundación Jiménez Dı́az University Hospital, Madrid, Spain
w
Banco de Sangre y Tejidos de Navarra, Pamplona, Spain
x
Department of Anaesthesia and Perioperative Medicine, Hospital Clı́nico de Valladolid, Spain
y
Department of Anaesthesia and Perioperative Medicine, Complexo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
z
Department of General Surgery, Hospital General La Mancha Centro, Alcázar de San Juan, Spain
aa
Department of Anaesthesia and Perioperative Medicine, Hospital Universitario Fundación Alcorcón, Alcorcón, Spain
ab
Department of General Surgery, Nuestra Señora de Candelaria Hospital Universitario, Spain
ac
Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
ad
Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA,
USA
ae
Department of Anaesthesia and Perioperative Medicine, Hospital Universitario Rı́o Hortega, Valladolid, Spain
af
Department of Anaesthesia and Perioperative Medicine, Juan Ramón Jiménez University Hospital, Huelva, Spain
ag
Department of Anaesthesia and Perioperative Medicine, Hospital Costa del Sol, Marbella, Spain
ah
Department of Anaesthesia and Perioperative Medicine, Complejo Hospitalario Universitario de Ourense, Ourense, Spain
ai
Department of Anaesthesia and Perioperative Medicine, Hospital Medina del Campo, Medina del Campo, Spain
aj
CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
ak
Department of General Surgery, Lozano Blesa University Hospital, Universidad de Zaragoza, Zaragoza, Spain

ar ticle i n f o abstract

Article history: Introduction: The effectiveness of the Enhanced Recovery After Surgery (ERAS) protocols in
Received 27 December 2022 gastric cancer surgery remains controversial.
Accepted 21 February 2023 Methods: Multicentre prospective cohort study of adult patients undergoing surgery for
Available online xxx gastric cancer. Adherence with 22 individual components of ERAS pathways were assessed
in all patients, regardless of whether they were treated in a self-designed ERAS centre. Each
Keywords: centre had a three-month recruitment period between October 2019 and September 2020.
ERAS The primary outcome was moderate-to-severe postoperative complications within 30 days
gastric surgery after surgery. Secondary outcomes were overall postoperative complications, adherence to
postoperative complications the ERAS pathway, 30 day-mortality and hospital length of stay (LOS).
perioperative management Results: A total of 743 patients in 72 Spanish hospitals were included, 211 of them (28.4 %)
optimization from self-declared ERAS centres. A total of 245 patients (33 %) experienced postoperative
enhanced recovery complications, graded as moderate-to-severe complications in 172 patients (23.1 %). There
were no differences in the incidence of moderate-to-severe complications (22.3% vs. 23.5%;
OR, 0.92 (95% CI, 0.59 to 1.41); P = 0.068), or overall postoperative complications between the
self-declared ERAS and non-ERAS groups (33.6% vs. 32.7%; OR, 1.05 (95 % CI, 0.70 to 1.56);
P = 0.825). The overall rate of adherence to the ERAS pathway was 52% [IQR 45 to 60]. There
were no differences in postoperative outcomes between higher (Q1, > 60 %) and lower (Q4, 
45 %) ERAS adherence quartiles.
Conclusions: Neither the partial application of perioperative ERAS measures nor treatment in
self-designated ERAS centres improved postoperative outcomes in patients undergoing
gastric surgery for cancer.
Trial Registration: ClinicalTrials.gov Identifier NCT03865810
# 2023 AEC. Published by Elsevier España, S.L.U. All rights reserved.

Please cite this article in press as: Ripollés-Melchor J, et al. Association between use of enhanced recovery after surgery protocols and
postoperative complications after gastric surgery for cancer (POWER 4): a nationwide, prospective multicentre study. Cir Esp. 2023. http://
dx.doi.org/10.1016/j.cireng.2023.04.011
CIRENG 2881 1–13

cir esp. 2023;xx(xx):xxx–xxx 3

Asociación entre el uso de protocolos de recuperación intensificada y

complicaciones postoperatorias tras cirugı́a gástrica por cáncer (POWER
4): estudio nacional, prospective multicéntrico
resumen

Palabras clave: Introducción: La efectividad de los protocolos de recuperación intensificada o ERAS en la

ERAS cirugı́a del cáncer gástrico sigue siendo controvertida.
cirugı́a gástrica Métodos: Estudio de cohortes prospectivo multicéntrico de pacientes intervenidos de cáncer
complicaciones postoperatorias gástrico. Se evaluó la adherencia a 22 elementos ERAS en todos los pacientes, indepen-
manejo perioperatorio dientemente de la existencia de un protocolo ERAS. Cada centro tuvo un perı́odo de
recuperación intensificada reclutamiento de tres meses, con un seguimiento de 30 dı́as. La medida de resultado
primario fue el numero de complicaciones posoperatorias moderadas a graves. Las medidas
de resultado secundarias fueron el número total de complicaciones, la adherencia a los
elementos ERAS, la mortalidad y la estancia.
Resultados: Se incluyeron 743 pacientes en 72 hospitales, 211 (28,4 %) en centros ERAS. 245
pacientes (33 %) experimentaron complicaciones posoperatorias, moderadas o graves en 172
(23,1 %). No hubo diferencias en la incidencia de complicaciones moderadas a graves (22,3 %
vs. 23,5 %; OR, 0,92 (IC 95 %, 0,59 a 1,41); P = 0,068), o complicaciones posoperatorias totales
entre los centros ERAS y no ERAS (33,6 % vs. 32,7 %; OR, 1,05 (IC 95 %, 0,70 a 1,56); P = 0,825). La
adherencia a los elementos ERAS fue del 52% [IQR 45 a 60]. No hubo diferencias entre los
cuartiles de cumplimiento ERAS más alto (Q1, > 60 %) y más bajo (Q4,  45 %).
Conclusiones: Ni la aplicación parcial de medidas ERAS ni el tratamiento en centros ERAS
mejoraron los resultados en pacientes sometidos a cirugı́a gástrica por cáncer.
# 2023 AEC. Publicado por Elsevier España, S.L.U. Todos los derechos reservados.

Methods
Introduction
Study design and participants
Gastric cancer is the fifth most frequent malignant tumour
worldwide, and accounts for 732,000 deaths per year, ranking The POWER 4study was a multicentre, prospective, three-
it as the fourth leading cause of cancer-related death.1 month cohort study. The study was approved by the Ethics
Gastrectomy for cancer is a technically challenging procedure, Committee of the Instituto Aragonés de Ciencias de la Salud,
with postoperative complications occurring in 20 to 46 % of Zaragoza, Spain (C.P.-C.I. PI19/106, March 27, 2019) and was
patients2,3 prospectively registered (NCT03865810). The study protocol
Enhanced Recovery After Surgery (ERAS) is a multidisci- was published,12 and approved by the ethics committees or
plinary perioperative approach that provides standardized institutional review boards of each centre. All patients signed
evidence-based recommendations for the care of patients a written informed consent before inclusion. This study
undergoing specific types of surgery.4 ERAS began in patients followed the STROBE reporting guideline for cohort studies,13
undergoing colorectal surgery,5 and resulted in a decrease in and the Reporting on ERAS Compliance, Outcomes, and
postoperative complications and length of hospital stay (LOS) Elements Research Checklist.14 The hospital and investigator
when adequate adherence to the protocols was achieved.6,7 involvement were provided through the Spanish Perioperative
The ERAS model is well established for colorectal surgery as Audit and Research Network (RedGERM). All Spanish centres
the optimal perioperative care. ERAS implementation in were invited to participate regardless of having or not an
gastric surgery8 has shown discrete decreases in LOS.9 established ERAS pathway.
Moreover, despite the clinical reported benefits of ERAS, its
implementation in clinical practice has been quite slow for a Procedures
variety of reasons, such as lack of convincing data, low level of
knowledge about ERAS, or expertise and institutional limita- All consecutive adult patients scheduled for elective gastric
tions,10,11 and lack of large studies assessing the association surgery for cancer were assessed for inclusion during a single
between ERAS adherence and postoperative outcomes. period of three months of recruitment at each participating
The aim of this study was to assess perioperative care in hospital between October 2019 and October 2020. Subtotal and
patients undergoing elective gastric surgery for cancer in total gastrectomies were included, both laparoscopic and
Spain, and to analyse the association between the individual open. Exclusion criteria were emergency surgery, endoscopic
ERAS elements and postoperative complications. procedures, non-oncological gastric surgery and patient

Please cite this article in press as: Ripollés-Melchor J, et al. Association between use of enhanced recovery after surgery protocols and
postoperative complications after gastric surgery for cancer (POWER 4): a nationwide, prospective multicentre study. Cir Esp. 2023. http://
dx.doi.org/10.1016/j.cireng.2023.04.011
CIRENG 2881 1–13

4 cir esp. 2023;xx(xx):xxx–xxx

refusal. Each patient was followed up for 30 days after surgery. performed for each ERAS element. We then analysed the rate
Patient information was acquired from hospital and primary of moderate-to-severe complications for each ERAS element
care medical records. using Fisher’s exact test, and we performed a multivariate
Data was collected using the Castor EDC platform15 in a analysis to study the association between the rate of each of
case record form designed specifically for POWER 4. Centres the ERAS elements and the clinical and demographic
declared themselves as centres with or without an established variables. We also used the same model in a multilevel
multidisciplinary ERAS pathway for gastric surgery, regardless multivariable logistic regression model to explore indepen-
of the items that conformed the pathway and their current dent factors associated with moderate-to-severe postopera-
adherence. tive complications assessing the variability of each centre.
The definition of the individual ERAS components was In order to avoid errors in the multiple comparisons, the
based on the ERAS Society1 Guidelines for gastric surgery.8 respective q value was calculated for each P value in order to
For a simpler and more accurate data collection, some of the 25 maintain a false discovery rate of less than 5 %. Comparisons
items of these guidelines8 were grouped and POWER4 included in which the P value and q value were less than 0.05 were
22 elements of perioperative care12 (Table S1 supplementary considered statistically significant.
data).
Data included patient characteristics, surgical procedure,
surgical approach, duration of surgery, preoperative labora-
Results
tory results, ERAS elements, and 30-day outcomes (postope-
rative complications, LOS, readmission, reoperation, and 30- Participants
day mortality). Thirty-day postoperative complications were
predefined and graded as mild, moderate, or severe as A total of 743 patients from 72 centres were included in the
described by the European Perioperative Clinical Outcome analysis (Fig. 1), of which 211 (28.4%) were included in self-
definitions (EPCO)16 (Table S2, supplementary data). declared ERAS centres; 444 (60 %) were men, and median age
Data was censored at 30 days following surgery for patients was 70 years [IQR 61 to 77]. Other characteristics are shown in
who remained at the hospital. To ensure the validity of the Table 1. More patients in the ERAS group received preoperative
data, they were validated and audited by another site neoadjuvant therapy and were treated in a centre with a
investigator who was not involved in the initial data Patient Blood Management (PBM) program. Duration of
collection. Our aim was to recruit as many hospitals and surgery was longer in the ERAS group. (Table 1).
patients in Spain as possible.
Outcomes in self-declared ERAS vs. non-ERAS groups
Outcomes
A total of 172 patients (23.1%) suffered moderate-to-severe
The primary outcome measure was 30-day moderate-to- complications, and 245 patients (33 %) experienced overall
severe postoperative complications. Secondary outcomes postoperative complications. There were no differences in the
were occurrence of overall postoperative complications, incidence of moderate-to-severe complications (47 (22.3%) vs.
adherence to the ERAS pathway, 30 day-mortality and LOS.
Adherence to the ERAS pathway was defined as the
percentage of ERAS items that were applied to each patient
over the total number of interventions recommended by the
ERAS Society.

Statistical analysis

The results were analysed according to whether the patient

underwent surgery in a self-designed ERAS centre or in a non-
ERAS centre. Discrete variables were described as absolute
frequencies and percentages and their differences were
analysed using Fisher’s or Pearson’s exact tests. Continuous
variables were presented with medians with their correspon-
ding interquartile ranges (IQR) and statistical differences were
calculated using the Wilcoxon rank sum test. Adherence to the
ERAS pathway was calculated for each individual patient
according to the number of the ERAS items achieved over the
22 analysed items (ERAS adherence). Subsequently, the
analysis was repeated, subdividing the entire sample into
four quartiles according to the rate of adherence to the ERAS
items (Q1: highest adherence, Q4: lowest adherence), regar-
dless of whether or not the patients was treated at a self-
designed ERAS centre. Highest and lowest adherence quartiles
were compared, and linear adjustments of adherence were Fig. 1 – STROBE flow diagram for included patients.

Please cite this article in press as: Ripollés-Melchor J, et al. Association between use of enhanced recovery after surgery protocols and
postoperative complications after gastric surgery for cancer (POWER 4): a nationwide, prospective multicentre study. Cir Esp. 2023. http://
dx.doi.org/10.1016/j.cireng.2023.04.011
CIRENG 2881 1–13

cir esp. 2023;xx(xx):xxx–xxx 5

Table 1 – Patient characteristics.

All patients (N = 743) Self-declared ERAS (N = 211) Non-ERAS (N = 532) P overall

Age, years 70 [61-77] 69 [59-77] 70 [61-77] 0.379
Sex: male 444 (60%) 136 (65%) 308 (58%) 0.118
BMI, kg/m2 25.6 [23 - 28.7] 26 [23.1 - 29.2] 25.6 [22.9 - 28.6] 0.366
ASA physical status
I 27 (4%) 8 (4%) 19 (4%) 0.111
II 353 (48%) 110 (52%) 243 (46%) .
III 336 (45%) 82 (39%) 254 (48%) .
IV 27 (4%) 11 (5%) 16 (3%) .
Smoking status
Smoker 107 (14%) 33 (16%) 74 (14%) 0.188
Ex-smoker > 1 year 207 (28%) 61 (29%) 146 (27%) .
Ex-smoker < 1 year 30 (4%) 13 (6%) 17 (3%) .
Rockwood Clinical Frailty Scale
Score  4 656 (88%) 190 (90%) 466 (88%) 0.417
Score > 4 87 (12%) 21 (10%) 66 (12%) .
Hypertension 369 (50%) 102 (48%) 267 (50%) 0.709
Diabetes Mellitus 178 (24%) 46 (22%) 132 (25%) 0.440
Ischaemic heart disease 88 (12%) 22 (10%) 66 (12%) 0.531
Heart Failure 46 (6%) 13 (6%) 33 (6%) 1.000
Stroke 2 (0.3%) 0 (0%) 2 (0.4%) 1.000
Chronic obstructive pulmonary disease 103 (14%) 31 (15%) 72 (14%) 0.769
Chronic kidney disease 64 (9%) 14 (7%) 50 (9%) 0.287
Liver cirrhosis 11 (2%) 2 (1%) 9 (2%) 0.737
Preoperative laboratory tests
Haemoglobin (g/dl) 12.4 [11.1- 13.6] 12.6 [11.2 -13.7] 12.4 [11- 13.5] 0.264
Creatinine (mg/dl) 0.8 [0.7 - 0.9] 0.8 [0.7- 0.9] 0.8 [0.7- 1] 0.872
Albumin (g/dl) 3.9 [3.5 - 4.3] 3.9 [3.4 - 4.3] 3.9 [3.5 - 4.3] 0.672
TNM staging
IA 120 (16.5%) 32 (15.5%) 88 (16.9%) 0.130
IB 102 (14.1%) 21 (10.2%) 81 (15.6%) .
II A 128 (17.6%) 38 (18.5%) 90 (17.3%) .
II B 112 (15.4%) 30 (14.6%) 82 (15.8%) .
III A 114 (15.7%) 30 (14.6%) 84 (16.2%) .
III B 73 (10.1%) 28 (13.6%) 45 (8.7%) .
III C 21 (2.9%) 10 (4.9%) 11 (2.1%) .
IV 56 (7.7%) 17 (8.3%) 39 (7.5%) .
Preoperative neoadjuvancy 292 (39%) 106 (50%) 186 (36%) <0.001
Surgical Procedure
Subtotal Gastrectomy 472 (64%) 123 (58%) 349 (66%) 0.065
Total Gastrectomy 269 (36%) 88 (42%) 181 (34%) .
Duration of surgery, minutes 235 [180 - 300] 245 [188 - 300] 215 [170 - 270] <0.001
Intraoperative fluid balance, ml 850 [493 -1394] 851 [490 - 1369] 850 [495 -1437] 0.777
Centre with an established PBM protocol 444 (60%) 171 (81%) 273 (51%) <0.001
ASA: American Society of Anesthesiology; ERAS: Enhanced recovery after surgery; PBM: Patient Blood Management.
Percentage reflects over non-missing sample size. Discrete variables n (%). Continuous variables Median[Q1-Q3].

125 (23.5%); OR, 0.92 (95% CI, 0.59 to 1.41); P = 0.068) or overall most of the individual ERAS elements was higher in the self-
postoperative complications (71 (33.6%) vs. 174 (32.7%); OR, declared ERAS cohort. Table 2 shows the adherence for each of
1.05, 95 % CI, 0.70 to 1.56; P = 0.825) between the self-declared the individual ERAS elements.
ERAS and non-ERAS groups. Patients in the ERAS group had
less bloodstream infection compared to the non-ERAS group. Outcomes in higher versus lower ERAS adherence groups
There were no differences in the rest of the predefined
complications and there were no differences in readmissions, Adherence to the ERAS elements in the highest adherence
reoperations, mortality and LOS. (Fig. 2). quartile (Q1) was > 60 %, while in the lowest adherence
quartile (Q4)  45 %. There were no differences in the number
Adherence data of patients with moderate to severe complications, overall
complications, readmissions, mortality or LOS. Patients in the
The overall adherence rate to the ERAS individual items was Q1 had more anastomotic leak compared with those in the low
52% [IQR 45 to 60]. Adherence was significantly higher in self- adherence group (Q4). There were no other differences in any
declared ERAS centres compared to non-ERAS centres 60% of the predefined complications between the highest and
[IQR 52 to 70] vs. 50% [IQR 43 to 57] (P < 0.001). Adherence to lowest adherence groups (Fig. 3). Linear adherence adjustment

Please cite this article in press as: Ripollés-Melchor J, et al. Association between use of enhanced recovery after surgery protocols and
postoperative complications after gastric surgery for cancer (POWER 4): a nationwide, prospective multicentre study. Cir Esp. 2023. http://
dx.doi.org/10.1016/j.cireng.2023.04.011
CIRENG 2881 1–13

6 cir esp. 2023;xx(xx):xxx–xxx

Fig. 2 – Title: Postoperative outcomes. Complications in all included patients and in patients who did or did not receive the
Enhanced Recovery After Surgery (ERAS) protocol.
Note. Data are expressed as number (%) or median (Q1-Q3).

Table 2 – Adherence to ERAS elements in self-declared ERAS and non-ERAS centres.

All patients Self-declared ERAS Non-ERAS P value

(N = 743) (N = 211) (N = 532)
ERAS overall adherence 52 [45 - 60] 60 [52 - 70] 50 [43 - 57] <0.001
Preadmission information, education and counselling 145 (19.5%) 114 (54%) 31 (5.8%) <0.001
Preoperative exercise and prehabilitation 115 (16%) 90 (43.9%) 25 (4.9%) <0.001
Preoperative optimisation 15 (14%) 5 (15.2%) 10 (13.5%) 0.773
Preoperative nutrition 217 (65.4%) 79 (79%) 138 (59.5%) 0.001
Avoid bowel preparation 632 (85.3%) 188 (89.5%) 444 (83.6%) 0.053
Preoperative fasting 281 (37.9%) 135 (64%) 146 (27.5%) <0.001
Preoperative carbohydrate loading 129 (17.4%) 86 (40.8%) 43 (8.1%) <0.001
Avoid preoperative administration of 604 (81.4%) 162 (76.8%) 442 (83.3%) 0.053
immediate or long-acting sedatives
Perioperative fluid management 202 (27.3%) 64 (30.3%) 138 (26%) 0.274
Deep neuromuscular block 361 (48.9%) 88 (41.7%) 273 (51.7%) 0.018
Anesthetic depth monitoring 699 (94.5%) 197 (93.4%) 502 (94.9%) 0.520
Laparoscopic approach 415 (55.85%) 116 (54.98%) 299 (56.20%) 0.731
Avoid nasogastric tube 446 (60%) 160 (75.8%) 286 (53.8%) <0.001
Avoid surgical drains 132 (17.8%) 38 (18%) 94 (17.7%) 0.998
Analgesia 458 (61.6%) 179 (84.8%) 279 (52.4%) <0.001
Antithrombotic prophylaxis 713 (96.1%) 210 (99.5%) 503 (94.7%) 0.005
Prevention of nausea and vomiting 717 (96.6%) 206 (97.6%) 511 (96.2%) 0.468
Prevention of intraoperative hypothermia 720 (97.3%) 208 (98.6%) 512 (96.8%) 0.269
Postoperative nutrition 419 (56.4%) 113 (53.6%) 306 (57.5%) 0.368
Postoperative glycaemic control 642 (86.4%) 185 (87.7%) 457 (85.9%) 0.604
Early mobilization n (%) 439 (60.2%) 143 (69.8%) 296 (56.5%) 0.001
Early feeding n (%) 51 (7%) 22 (10.7%) 29 (5.6%) 0.022
Time to oral intake (hours) 48 [24 - 96] 30 [24 -72] 72 [25 - 120] <0.001
Time to mobilization (hours) 24 [22 - 48] 24 21–30 24 [23 - 48] 0.001
Percentage reflects over non-missing sample size. Discrete variables n (%).
Continuous variables Median [Q1-Q3].

Please cite this article in press as: Ripollés-Melchor J, et al. Association between use of enhanced recovery after surgery protocols and
postoperative complications after gastric surgery for cancer (POWER 4): a nationwide, prospective multicentre study. Cir Esp. 2023. http://
dx.doi.org/10.1016/j.cireng.2023.04.011
CIRENG 2881 1–13

cir esp. 2023;xx(xx):xxx–xxx 7

Fig. 3 – Title: Postoperative outcomes and Enhanced Recovery After Surgery (ERAS) adherence.
Postoperative complications in all included patients depending on the quartile (Q) of adherence to the ERAS protocol.
Note. Data are expressed as number (%) or median (Q1-Q3).

also showed that additional adherence to the ERAS pathway in Individual ERAS elements and patients characteristics and
the Q1 did not improve any of the outcomes compared to Q4. LOS

Individual ERAS elements, patients characteristics and LOS was significantly lower in patients in whom nasogastric
moderate-to-severe postoperative complications tube was not used, and in those who received early feeding.
However, patients who underwent total gastrectomy and
Multivariable and multilevel analyses of individual ERAS those who received postoperative nutritional support had a
elements showed a statistically significant reduction of longer LOS. None of the other ERAS elements, neither being
moderate-to-severe complications in those patients in which treated at a self-declared ERAS centre, were associated with
early mobilization was achieved while patients not receiving shorter LOS (Table S4, supplementary data).
preoperative mechanical bowel preparation and postoperative
nutritional care had more moderate-severe postoperative
complications. No other associations were found for the other
Discussion
ERAS elements (Table S3, supplementary data.).
Patients who received neoadjuvant therapy had a lower The main finding of this study was that neither treatment at a
risk of moderate-severe postoperative complications. Frail self-declared ERAS centre nor high compliance (Q1) with ERAS
patients, patients with cirrhosis, patients undergoing total measures were associated with improved outcomes after
gastrectomy, and patients with a longer lasting surgery had a elective gastric cancer surgery.
higher risk of moderate-to-severe complications (Table S3, Given the success of ERAS in colorectal surgery, this
supplementary data). multimodal perioperative care approach has emerged as an

Please cite this article in press as: Ripollés-Melchor J, et al. Association between use of enhanced recovery after surgery protocols and
postoperative complications after gastric surgery for cancer (POWER 4): a nationwide, prospective multicentre study. Cir Esp. 2023. http://
dx.doi.org/10.1016/j.cireng.2023.04.011
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8 cir esp. 2023;xx(xx):xxx–xxx

optimal perioperative strategy to improve clinical outcomes in patients with neoadjuvant therapy presented fewer complica-
gastric cancer surgery and in many other procedures. However, tions, but longer surgeries and total gastrectomy were associated
numerous controversies exist regarding the practice of ERAS in with more postoperative complications. On the other hand,
patients undergoing gastrectomy. A recent meta-analysis of although the partial application of ERAS did not lead to better
randomized controlled trials which assessed the role of ERAS in outcomes, it was not associated with more readmissions or more
radical gastrectomy showed that ERAS results in accelerated reoperations, so its practice seems safe, and efforts should be
convalescence, improved nutritional status, and improved undertaken to achieve greater adherence to the protocol, since it
quality of life for gastric cancer patients.17 Similarly to our is ultimately the standard of care in many cases.
findings, Blumenthaler et al did not find that the application of an Most of the studies on gastric surgery were performed in the
ERAS pathway in gastric surgery resulted in fewer postoperative Asian population, and this study is the largest study to date on
complications.18 It has been reported that the efficacy of gastric surgery in the ERAS setting in a Western population;
protocols that are incompletely or incipiently applied is markedly however, we must acknowledge some limitations of the study.
reduced.18,19 Although this has been mainly reported for First, in an optimally designed study, the groups would be blindly
colorectal surgery 6,20 it was also recently shown that greater assigned to ERAS or non-ERAS for the same period of time to
adherence to ERAS recommendations for gastric surgery resulted avoid allocation bias. However, we consider that a randomized
in improved postoperative outcomes.21 However, we did not find clinical trial comparing an ERAS protocol versus a clinical
that greater adherence to protocols was associated with better practice in which none of the ERAS elements were used would be
outcomes, although the adherence in our highest adherence unethical. On the other hand, information bias may be inherent
quartile was lower than previously reported as required to in the design of this study, and could have influenced an increase
improve postoperative outcomes6, so it is possible that our low in adherence to the ERAS elements, so that the actual ERAS
overall adherence in Spain was one of the determinants of the adherence could even be lower. The elements of ERAS
ineffectiveness of the ERAS protocol in this cohort. themselves are interrelated. For example, conservative intrao-
Early mobilization was the only ERAS element that was perative fluid administration is arguably more applicable in
associated with fewer moderate-severe complications. Several patients who did not receive preoperative bowel preparation,
studies have shown that the application of this part of the ERAS and administration of carbohydrate drinks mandates adequate
program can significantly accelerate the recovery of postope- adherence to preoperative fasting time. In addition, the use of
rative intestinal function22,23 and improve postoperative outco- some of the ERAS elements are related to the severity of the
mes.7,24,25 On the other hand, those who received postoperative patient, e.g., goal-directed fluid therapy, usually recommended
nutritional support had more postoperative complications and for the high-risk patient.33,34 We tried to avoid selection bias by
higher LOS probably due to a previous poorer nutritional status or including a majority of Spanish centres that were performing
the presence of postoperative complications.. The length of stay gastrectomy, regardless of whether they self-designated as ERAS
was also shorter in patients who did not have a nasogastric tube or not. The effect of these problems was partly offset by the large
and who received an early feeding. The number and relative sample size and the number of institutions reporting data, but
combination of ERAS elements implemented, and the relative we also have to recognize that gastrectomy is not as frequent a
importance of individual items, especially those considered as procedure as, for example, colorectal surgery, and many centres
"core elements’’ of ERAS is currently a debated topic.26,27 It is recruited a low number of patients.
accepted that early mobilization is a core element in most ERAS The application of ERAS protocols for gastric surgery in our
guidelines4, its fulfilment may be due to both a dedicated effort by cohort was very low. Neither partial compliance with ERAS
the postoperative multidisciplinary team and a sign of favourable protocols nor treatment with self-designated ERAS centres
clinical outcome,28 and conversely, the inability to mobilize early improved postoperative outcomes in patients undergoing
in the immediate postoperative period may be considered as a gastric surgery for cancer.
warning sign of poor clinical outcome.29 Early deviation of
postoperative ERAS elements appears to be the most significant
in terms of association with ERAS failure and delayed dis-
Funding
charge.29 Early restoration of the oral feeding promotes early
recovery of normal bowel function, so it seems logical that Support was only provided by institutional sources. The
patients who achieve early tolerance will have a shorter LOS,30 POWER 4 study was supported by the Spanish Perioperative
while those with impediments to achieving this, such as the Audit and Research Network (RedGERM) and the Grupo
presence of a nasogastric tube or the need for nutritional support, Español de Rehabilitación Multimodal (GERM).
will have a longer LOS. Once again, this postoperative element RedGERM conducted and designed the study; provided
could be considered as a success of the pathway, or as an early collection and management of the data; but had no role in the
warning sign in those cases in which compliance is not analysis and interpretation of the data; preparation, review, or
achieved.31 approval of the manuscript; and decision to submit the
A recent study provided unique insight into changes in manuscript for publication.
gastric cancer presentation, management and outcomes over a
30-year period and highlighted the importance of perioperative
chemotherapy in long-term survival, as well as the reduction in
COI/Disclosures
the number of total gastrectomy as a milestone in the
management of patients undergoing gastric cancer surgery to Dr. Ripollés-Melchor reports personal fees from Edwards
improve postoperative outcomes.32 We found similar results, Lifesciences, Vifor Pharma, MSD and Fresenius Kabi outside

Please cite this article in press as: Ripollés-Melchor J, et al. Association between use of enhanced recovery after surgery protocols and
postoperative complications after gastric surgery for cancer (POWER 4): a nationwide, prospective multicentre study. Cir Esp. 2023. http://
dx.doi.org/10.1016/j.cireng.2023.04.011
CIRENG 2881 1–13

cir esp. 2023;xx(xx):xxx–xxx 9

the submitted work. Dr. Alfredo Abad-Gurumeta reports Rafael López-Pardo1,2 (Surgery Department); Marta Torres-
personal fees from Edwards Lifesciences, MSD, 3 M, Braun, Montalvo (Anesthesia Department)
Ferrer, Rovi and ALTAN outside the submitted work. Dr. Complejo Hospitalario Don Benito Villanueva de la Serena
Aldecoa reports personal fees from Fresenius Kabi and Isabel Pinilla-Pico, Enrique del-Cojo-Peces1,2, Marı́a del Pilar
Octapharma outside the submitted work. Dr Garcı́a-Erce Rodrı́guez-Chaparro (Anesthesia Department)
declares no conflict of interest with this study. However, he Complejo Hospitalario Universitario A Coruña
has previously given talks, chaired tables at congresses and Manuel Ángel Gómez-Rı́os1,2, Sara del-Rı́o-Regueira, Eva
conferences and organized courses with scholarships or Mosquera-Rodrı́guez (Anesthesia Department)
funding from Amgen, Jansen, Sandoz, Vifor Pharma and Complejo Hospitalario Universitario de Canarias
Zambon. Carlos Jericó has given talks and received consul- Jessica Hernández-Beslmeisl1,2, Marı́a Alejandra Perozo-
tancy fees from Viphor Pharma España SL, Bial and Zambon. Medina1, Beneharo Darias-Delbey, Marı́a del Carmen Martı́n-
Ane Abad-Motos, Marcos Bruna-Esteban, Marı́a Garcı́a- Lorenzo, Vanessa González-Fariña, Montserrat Rodrı́guez-
Nebreda, Isabel Otero-Martı́nez, Omar Abdel-lah Fernández, Domı́nguez, Jaime Fernández-de-la-Vega-Medina, Pilar Berro-
Marı́a P. Tormos-Pérez, Gloria Paseiro-Crespo, Raquel Garcı́a- tarán-Ayub (Anesthesia Department)
Álvarez, Marı́a A Mayo-Ossorio, Orreaga Zugasti-Echarte, Complejo Hospitalario Universitario Insular Materno
Paula Nespereira-Garcı́a, Lucia Gil-Gómez, Margarita Infantil de Gran Canaria
Logroño-Ejea, Raquel Risco, Felipe C Parreño-Manchado, Silvia José Valı́n-Martı́nez1,2, Laura Concepción-Santana, Raúl
Gil-Trujillo, Carmen Benito, Marı́a I De-Miguel-Cabrera, Cruz-Zorio, Dolores Betancort-Gutiérrez Rodrı́guez (Anesthe-
Bakarne Ugarte-Sierra, Cristina Barragán-Serrano, Henar sia Department)
Muñoz-Hernández, Sabela del- Rı́o-Fernández, Marı́a L. Complexo Hospitalario Universitario de Ourense
Herrero-Bogajo, Alma M. Espinosa-Moreno, Vanessa Concep- Leticia Gómez-Viana1,2, Olalla Figueiredo, Ariadna Rodrı́-
ción-Martı́n, Andrés Zorrilla-Vaca, Laura Vaquero-Pérez, Irene guez, Manuel González (Anesthesia Department); David
Mojarro, Manuel Llácer-Pérez, Leticia Gómez-Viana, Marı́a T. Iglesias, José Manuel Domı́nguez-Carrera (Surgery Depart-
Fernández-Martı́n, Carlos Ferrando-Ortolà, José M. Ramı́rez- ment); Jorge do Olmo (Adminisitrative support)
Rodrı́guez report no potential conflicts of interest. Complexo Hospitalario Universitario de Santiago
Sabela Del-Rı́o-Fernández1,2, Laura Dos-Santos-Carregal,
Marı́a Jesús Rodrı́guez-Forja, Olga Campaña-Figueira, Julián
POWER 4 Investigators Group Álvarez-Escudero (Anesthesia Department); Lucı́a Lesque-
reux-Martı́nez, Purificación Parada-González, Ricardo Monte-
Althaia. Xarxa Assistencial i Universitària de Manresa negro-Romero, Manuel Bustamante-Montalvo (Surgery
Mercè Güell Farré1,2, Roser Farré Font, Rafael Diaz del Department); Ana Rosa Garcı́a-Placı́n, Carmen Carpintero-
Gobbo, Raquel Sánchez Jimenez (Surgery Department) Isabel Rama, Sergio Brea-Bahamonde (Nursing Department)
Pérez Reche, Belen Gil Calvo, Jordi Llorca Garcı́a, Laura Fundación Jı́menez Dı́az
Carrasco Sánchez, Cristina Prat llimargas (Anesthesia Depart- José Ramón Torres-Alfonso1, Cristina Barragán-Serrano1,2,
ment). Marı́a Posada-González, Gabriel Salcedo-Cabañas, Peter Vor-
Complejo Asistencial de Zamora wald-Wolfgang (Surgery Department)
Ana Marı́a Garcı́a-Sánchez1, Gema Martı́nez-Ragüés1, Hospital Álvaro Cunqueiro de Vigo (Complejo Hospitalario
Marı́a Gómez-Fernández (Anesthesia Department); Álvaro Universitario de Vigo)
del-Castillo-Criado2, Ruth Martı́nez-Dı́az, Sara Alegrı́a-Rebollo Isabel Otero-Martı́nez1,2, Patricia Jove-Alborés, Marta López-
(Surgery Department) Otero, Hermelinda Pardellas-Rivera, Ignacio Maruri-Chimeno,
Complejo Asistencial Universitario de León Sonia González-Fernández, Raquel Sánchez-Santos (Surgery
Javier Ferrero-de-Paz1,2, Cristina Garcı́a-Pérez, Sergio Mar- Department); Luis Luna-Mendoza (Anesthesia Department)
cos-Contreras, Diana Fernández-Garcı́a, Maeva Torı́o-Marcos Hospital Arnau de Vilanova, Valencia
(Anesthesia Department) Enrique Lloria-Pons1,2, Francisco Gramuntell-Marco
Complejo Asistencial Universitario de Salamanca (Anesthesia Department) ; Raúl Cánovas-de-Lucas, Cristina
Omar Abdel-lah Fernández1,2, Felipe Carlos Parreño-Man- Sancho-Moya (Surgery Department)
chado1 (Surgery Department); Marı́a Ángeles Martı́n (Anest- Hospital Clı́nic de Barcelona
hesia Department) Raquel Risco1,2, Anna Fernández-Esmerats, Josep Martı́
Complejo Hospitalario de Mérida Sanahuja-Blasco, Manuel López-Baamonde, Marta Ubré, Gra-
José Marı́a Tena-Guerrero1,2, Estefanı́a Palma-González ciela Martı́nez-Pallı́ (Anesthesia Department); Dulce Momblán
(Anesthesia Department); Gustavo Flores-Flores1 (Surgery (Surgery Department); Nuria Rivas-Gallardo (Nurse)
Department) Hospital Clı́nico San Carlos
Complejo Hospitalario de Navarra Rubén Sánchez-Martı́n1,2, Pedro Moral, Rosalı́a Navarro,
Orreaga Zugasti-Echarte1,2, Elena Pérez-Bergara, Susana Luis Santé (Anesthesia Department); Esther Almenta (Surgery
Hernández-Garcı́a, Marta Martı́n-Vizcaı́no, Francisco Javier Department)
Yoldi-Murillo, Maider Valencia-Alzueta (Anesthesia Depart- Hospital Clı́nico Universitario de Valladolid
ment); Carlos Chaveli-Dı́az, Coro Miranda-Murua, Concepción Henar Muñoz-Hernández1,2, Rita Pilar Rodrı́guez-Jiménez,
Yárnoz-Irazábal (Surgery Department); Sonsoles Botella-Mar- Nuria Ruiz, Marı́a Teresa Peláez, Juan José Rojo, Carlota
tı́nez (Nutrition Department) Gordaliza (Anesthesia Department); Carlos Jezieniecki (Sur-
Complejo Hospitalario de Toledo gery Department)

Please cite this article in press as: Ripollés-Melchor J, et al. Association between use of enhanced recovery after surgery protocols and
postoperative complications after gastric surgery for cancer (POWER 4): a nationwide, prospective multicentre study. Cir Esp. 2023. http://
dx.doi.org/10.1016/j.cireng.2023.04.011
CIRENG 2881 1–13

10 cir esp. 2023;xx(xx):xxx–xxx

Hospital Comarcal de Inca Hospital Universitario 12 de Octubre

Carlos Jimenez-Viñas1,2, Carlo Brugiotti, Ulices Onchalos- Raquel Garcı́a-Álvarez1,2, Álvaro Ramiro-Ruı́z1,2, Marı́a
Lopez (Surgery Department) González-Cofrade, Estefanı́a Carvajal-Revuelta, Ana Bellido-
Hospital Costa del Sol, Marbella (Málaga) López, Guillermo Redondo-Cristóbal (Anesthesia Depart-
Manuel Llácer-Pérez1,2 (Anesthesia Department) ment);
Hospital de la Santa Creu i Sant Pau Hospital Universitario Central de Asturias
Astrid Batalla1,2, Gonzalo Azparren, Micaela Bastitta, Luisa Sonia Amoza-Pais1,2, Tamara Dı́az-Vico, Marı́a Moreno-
Cueva, Mar Felipe, Marta Giné, Ana M. Gómez, Inmaculada Gijón, Sandra Sanz-Navarro, Lourdes M Sanz-Álvarez, Estrella
India, Santiago Piñol (Anesthesia Department) Olga Turienzo-Santos, Jose Luis Rodicio-Miravalles, Amaya
Hospital de Sagunto Rizzo-Ramos (Surgery Department); Ana Cuéllar-Martı́nez,
Maria José Gimeno-Campos1,2, Aurora Moreno-Gázquez1, Rosa Ana Álvarez-Fernández, Carmen Fernández-Seijo, Ame-
Julio Llorens-Herrerı́as, Gema Del-Castillo-Rodrigo (Anesthe- lia Álvarez-Barrial, Carmen Gónzalez-Ortea, Silvia Fernández-
sia Department) Rodriguez, Nerea Garcı́a-González, Lorena Varela-Rodriguez,
Hospital General La Mancha Centro Elena Berzal-Canga, Ángela Garcı́a-Dı́az-Negrete, Helena
Marı́a Luz Herrero-Bogajo (Surgery Department) Garcı́a-Sánchez, Javier Saenz-Abos, Beatriz Ayuso-Iñigo, Marı́a
Hospital General Universitario de Castellon Vega-Colón (Anesthesia Department)
Marı́a Isabel De Miguel-Cabrera1,2, José Miguel España- Hospital Universitario Clı́nico San Cecilio, Granada
Pamplona, Marı́a Gellida-Vilarroig, Laura Jordá-Sanz (Anest- Ángela Catalina Palacios-Córdoba1, Marı́a Teresa Quel-
hesia Department) Collado2, Mercedes Olvera-Garcı́a, Agustina Martinez-Sán-
Hospital General Universitario de Ciudad Real chez, Carmen Serrano-Alvarez (Anesthesia Department)
Silvia Gil-Trujillo1,2, Laura Calatayud-Gómez, Juan David Hospital Universitario Cruces
Valencia-Echeverri, Vı́ctor Baladrón-González (Anesthesia Eunate Ganuza-Martı́nez, Marı́a Jesús Maroño-Boedo2,
Department); Aurora Gil-Rendo1,2, Susana Sanchez-Garcı́a, Alberto Sánchez-Campos, Blanca Anuncia Escontrela-Rodrı́-
Esther Garcı́a-Santos (Surgery Department) guez, Alberto Martı́nez-Ruiz1 (Anesthesia Department); Gaizka
Hospital General Universitario Gregorio Marañón de Errazti-Olartecoechea, Iratxe Rodeño-Esteban, Tamara
Madrid Moreno-Allende, Oihane Gutierrez-Grijalba, Yanina Katary-
Carmen Benito1,2, Cristina Lisbona, Pilar Benito (Anesthesia niuk-Di-Costanzo, Irene Alvarez-Abad, Patricia Sendino-Cañi-
Department) zares, Patricia Mifsut-Porcel, Aingeru Sarriugarte-Lasarte1,
Hospital General Universitario Santa Lucia Mikel Guerra-Lerma (Surgery Department)
Olga Cecilia Correa-Chacón1,2, Alejandro Alcázar-Urrea, Hospital Universitario de Álava
Ana Belén Fernández-López, Ramiro Betancourt-Bastidas Margarita Logroño-Ejea1,2, Marı́a Del Carmen Iturricastillo-
(Anesthesia Department); Inmaculada Navarro-Garcı́a, Elena Pérez, Marı́a Gastaca-Abasolo
Romera-Barba (Surgery Department) Marı́a José Muñoz-Sanz, Ibai Iriarte-Zaranton, Erika Olea-
Hospital Joan XXIII de Tarragona De-La-Fuente, Ana Mendiguren-Murua (Anesthesia Depart-
Nuria Mira-Jovells1,2, Liz Karime Estevez-Perez, Judit Salu- ment); Lorena Reka-Mediavilla, Alberto Gastón-Moreno,
des-Serra (Anesthesia Department); Carles Olona-Casas2, Jordi Gabriel Jesús Martı́nez-De-Aragón-Remirez-De-Esparza,
Vadillo-Bargalló. Rosa Jorba-Martı́n (Surgery Department) Valentı́n Sierra-Esteban (Surgery Department)
Hospital Juan Ramon Jimenez, Huelva Hospital Universitario de Badajoz
Irene Mojarro1,2, Juan Victor Lorente, Pablo Longo-Guridi, Gema Montero-Mejı́as, Claudia Pardo-Martı́nez, Teresa
Ana Maria Quintero-Moreno, David Soriano-López, Maria de la Valadés-Periañez, Ana Marı́n-Moreno, Juan Ricardo Caro-
Peña Gómez-Dominguez, Cecilia Prieto-Candau, Marisol Her- González, Marı́a José Rodrı́guez- Pérez1,2 (Anesthesia Depart-
nández-Castillo, Irene Jarana, Francisco Garcı́a-Andreu, Jose ment)
González-González, Marı́a Dolores Dı́az-Lara (Anesthesia Hospital Universitario de Basurto
Department) José Carlos Herrero-Herrero1,2, Pablo Renedo-Corcóstegui,
Hospital Lluı́s Alcanyı́s Alejandro Martı́n-Oliva, Ana Isabel Fernández-Herrero, Nerea
Elena Añón-Iranzo, Javier Aguiló-Lucia (Surgery Depart- Andrieu-Estefanı́a (Anesthesia Department)
ment) Hospital Universitario de Cabueñes
Hospital Medina del Campo Javier Albaladejo-Magdalena, Marı́a Álvarez-Rodriguez
Maria Teresa Fernandez-Martin1,2, Yessica Guerra (Anest- (Anesthesia Department); Valentina Sosa-Rodrı́guez, Raquel
hesia Department) Marı́a Fresnedo-Pérez (Surgery Department)
Hospital Nuestra Señora del Prado. Talavera de la Reina Hospital Universitario de Fuenlabrada
Pablo Gimeno-Fernández1,2, Carla Iglesias-Morales, Ana Cristina Gil-Lapetra1,2, Beatriz Bolzoni-Marciel, Maria Isa-
Marı́a Rı́os Villalba (Anesthesia Department) bel Herrera-López, Fernando Setién-Moreno, Ana Zulema
Hospital Povisa, Vigo Castro-Costoya, José Olarra-Nuel (Anesthesia Department);
Paula Nespereira-Garcı́a1,2, Marı́a José Castro-Neira, Marı́a Marta De-Vega-Irañeta (Surgery Department)
Ochoa-Dı́ez (Anesthesia Department) Hospital Universitario de Galdakao
Hospital Sierrallana, Torrelavega Bakarne Ugarte-Sierra1,2, Irune Vicente-Rodrı́guez, Fran-
Silvia Garcı́a-Orallo (Anesthesia Department); Maialen cisco Javier Fernández-Pablos, Rafael Alberto Abad-Alonso,
Mozo-Segurado, Jose Manuel Gutiérrez-Cabezas1,2, Ruben Roberto Maniega-Alba, Francisco Javier Ibáñez-Aguirre (Sur-
Gonzalo-González (Surgery Department) gery Department); Susana Postigo-Morales, Karmelo Intxau-

Please cite this article in press as: Ripollés-Melchor J, et al. Association between use of enhanced recovery after surgery protocols and
postoperative complications after gastric surgery for cancer (POWER 4): a nationwide, prospective multicentre study. Cir Esp. 2023. http://
dx.doi.org/10.1016/j.cireng.2023.04.011
CIRENG 2881 1–13

cir esp. 2023;xx(xx):xxx–xxx 11

rraga-Fernández, Sorkunde Telletxea-Benguria (Anesthesia Miren Jasone Dı́ez-Zapirain1,2, Guillermo Tejón-Pérez1,

Department); Ángela Outón-Guerrero (Nurse) Marı́a Asunción Álvarez-Cebrián, Eva Barrero-Ruiz, Eva
Hospital Universitario de Gran Canaria Dr. Negrı́n Capa-Fuertes, Mariana Carrillo-Rivas, Isabel Hernandez-San-
Marı́a Asunción Acosta-Mérida1,2 (Surgery Department) chez, Valvanuz Monteagudo-Cimiano, Ángela Pascual-
Hospital Universitario de Guadalajara Casado, Jose Luis Rábago-Morillón (Anesthesia Department)
Roberto de la Plaza-Llamas1,2, José Manuel Garcı́a-Gil, Hospital Universitario Miguel Servet de Zaragoza
Ignacio Antonio Gemio-del-Rey (Surgery Department); Merce- Javier Martinez-Ubieto1, Ana Pascual-Bellosta1, Sonia
des Cabellos-Olivares (Anesthesia Department) Ortega-Lucea, Berta Perez-Otal2, Lucia Tardos-Ascaso2 (Anest-
Hospital Universitario de Móstoles hesia Department); Luis Antonio Ligorred-Padilla (Surgery
Raquel Fernández-Garcı́a1,2, Lidia Castro Freitas, Beatriz Department)
Nacarino Alcorta, Marı́a Martı́n Ayuso (Anesthesia Depart- Hospital Universitari Mútua Terrassa
ment); Marı́a Moral González, David Garcı́a Teruel (Surgery Jaume Tur-Martı́nez1,2, Joaquin Rodrı́guez-Santiago, Noelia
Department) Pérez-Romero, Noelia Puértolas-Rico, Laura Hernández-Gimé-
Hospital Universitario de Vic nez (Surgery Department)
Jordi Serrat-Puyol1,2 (Anesthesia Department), Joan Moli- Hospital Universitario Nuestra Señora de Candelaria
nas-Bruguera, Sara Fernández (Surgery Department) Vanessa Concepción-Martı́n1,2 (Surgery Department)
Hospital Universitario Doctor Peset Hospital Universitario Puerta de Hierro, Majadahonda
Nuria Peris-Tomás1,2, Jose Ángel Dı́ez-Ares, Dolores Periá- Viktoria Molnar1,2, Macarena Barbero, Belén San-Antonio
ñez-Gómez, Paula Gonzálvez-Guardiola, Ramón Trullenque- (Anesthesia Department); Alberto Pueyo (Surgery Department)
Juan, Ezequiel Martı́nez-Mas (Surgery Department); Estefanı́a Hospital Universitario Puerta del Mar
Martı́nez, Julia Martı́n, Raquel Higueras, Sara Cuenca (Anest- M de los Angeles Mayo-Ossorio1,2, Ander Bengoechea-
hesia Department) Trujillo, José Manuel Pacheco-Garcia (Surgery Department)
Hospital Universitario Fundación de Alcorcón Hospital Universitario Ramón y Cajal
Beatriz Martı́n-Vaquerizo1, Alma M. Espinosa-Moreno1,2, Yolanda Diez-Remesal1,2, Alba Gonzalo-Millán, Alberto
Miriam Sánchez-Merchante, Rebeca Alcañiz-Sobrino, Gui- Berruezo-Camacho, Azucena Alaez-Cortés, Begoña Ortolá-
llermo Egea-Hita, Santiago Garcı́a-del-Valle-y-Manzano Rocher, Berta Iglesias-Gallego, Eduardo Martı́n-Montero, Gerardo
(Anesthesia Department) Arias-Cuesta, Inés de la Hoz-Polo, Isabel Recuero-Torrijos, Lucia
Hospital Universitari i Politècnic La Fe Pereira-Torres, Maria Cañamas-Catalá, Maria C. Martin-Gonzá-
Virginia Moreno-Blanco1 (Research Nurse); Marcos Bruna- lez, Paloma Zambrana-Garcı́a, Sergio Llorente -Damas
Esteban2, Fernando Mingol-Navarro, Javier Vaqué-Urbaneja Hospital Universitario Rio Hortega
(Surgery Department); Óscar Dı́az-Cambronero (Anesthesia Cesar Aldecoa1,2, Alba Perez-Gonzalez, Clara Bolaño-Perez,
Department); Beatriz Luján-Sandemetrio, Bisila Copariate- Delia Velasco-Andres, Esther Aguado-Saster, Irene Arranz,
Piqueras, Sonia Giménez-Salcedo (OR Nurse) Itziar Mendez-Torrubiano, Laura Vaquero-Perez, Maria Jesus
Hospital Universitario Infanta Leonor Sanz-de-Leon, Pablo Rodicio, Silvia Martin-Alfonso, David
Javier Ripolles-Melchor1, Ane Abad-Motos1,2, Alfredo Abad- Martin-Tappi
Gurumeta, Norma Aracil-Escoda, Elena Saez-Ruiz, Rut Salva- Mario Madrid-Tribano, Rocio Rioja-Garrido, Borja Morales-
chua-Fernandez (Anesthesia Department); Gloria Paseiro- Jaquete (Dept. of Anesthesia)
Crespo, Marı́a Garcı́a-Nebreda (Surgery Department) ; Begoña Hospital Universitario Severo Ochoa
Toribio (OR Nurse) Marta Vicente-Orgaz1,2, Adriana Carolina Orozco-Vinasco,
Hospital Universitario Infanta Sofı́a Gema Fraga-Casais; Any Minerva Miyagi-Yonamine, Raquel
Esther Ferrero-Celemin1,2, Luis Garcı́a-Sancho-Téllez, José Ramos-de-Castro, Rossel Alina Mejı́a-Arnaud, Rubén Saz-
Daniel Sánchez-López, Sara Núñez-O’Sullivan, Mariana Gar- Castro (Anesthesia Department); Patricia Dı́az-Peña (Surgery
cı́a-Virosta, Carmen Rodriguez-Haro, Marı́a Hernández- Department)
O’Reilly (Surgery Department) Hospital Universitario Vall d’Hebrón
Hospital Universitario La Paz Angels Camps-Cervantes1, M Pilar Tormos-Perez, Patricia
Alejandro Suarez-de-la-Rica1,2, Mercedes Lopez-Martinez, Galan-Menendez1,2, Elena Esclapez-Sampere, Laura Villarino-
Bryant Croes, Jaime Mujica, Emilio Maseda (Anesthesia Villa, Yuri Loaiza-Aldeán, Ivette Chocron-Dapratt, Olga Marti-
Department); nez-Silva, Silvia Matarin-Olmo (Surgery Department)
Hospital Universitario La Princesa Hospital Universitario Virgen Macarena
Enrique Alday-Muñoz1,2, Esperanza Mata-Mena (Anesthe- Héctor Berges-Gutiérrez1,2, Macarena Pérez-Serrano, Juan
sia Department); Iñigo Garcı́a-Sanz, Javier Diaz-Castillo, Álvaro Sancho-Muñoz-de-Verger, Jesús
Cristina Marı́n (Surgery Department) Alejandro Villanueva-Mena-Bernal (Anesthesia Department)
Hospital Universitario La Zarzuela Hospital Sant Joan Despi Moises Broggi
Antonio Pedraza Muñoz, Jorge Puertas Dominguez (Anest- Maria Lucia Gil-Gómez1,2, Jesús Fernanz-Anton2, Sandra
hesia Department) Marmaña-Mezquita (Anesthesia Department); Gonzalo Galo-
Hospital Universitario Lucus Augusti fré-Pujol (Surgery Department); Carlos Jericó (Internal Medi-
Rocı́o González-López1,2, Gisela Navarro-Quirós1,2, M. Isa- cine Department.)
bel Pérez-Moreiras, Marı́a Conde-Rodriguez, Manuel Muinelo- Hospital Virgen de los Lirios de Alcoy
Lorenzo (Surgery Department) José Jacob Motos-Micó1,2, Francisco José Orts-Micó1, Carlos
Hospital Universitario Marqués de Valdecilla Serra-Dı́az, Francisco Arlandis-Félix, Nieves Pérez-Climent

Please cite this article in press as: Ripollés-Melchor J, et al. Association between use of enhanced recovery after surgery protocols and
postoperative complications after gastric surgery for cancer (POWER 4): a nationwide, prospective multicentre study. Cir Esp. 2023. http://
dx.doi.org/10.1016/j.cireng.2023.04.011
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Please cite this article in press as: Ripollés-Melchor J, et al. Association between use of enhanced recovery after surgery protocols and
postoperative complications after gastric surgery for cancer (POWER 4): a nationwide, prospective multicentre study. Cir Esp. 2023. http://
dx.doi.org/10.1016/j.cireng.2023.04.011