BACKGROUND: Previous studies have reported the effectiveness of the "enhanced recovery after surgery" program in patients who underwent gastric cancer surgery, mostly based on the 2014 gastrectomy guidelines. Therefore, based on subsequent advancements in perioperative management, this randomized, controlled, open-label, single-center study aimed to assess the impact of a recent evidence-based multimodal enhanced recovery after surgery program on the quality of early recovery after gastric cancer surgery. MATERIALS AND METHODS: This study included adult patients scheduled to undergo elective laparoscopic or robotic distal gastrectomy for gastric cancer. Patients were randomly assigned to the enhanced recovery after surgery or conventional group. The primary outcome was the total Quality of Recovery-15 score assessed 24, 48, and 72 h postoperatively. Differences between both groups were evaluated using a linear mixed-effects model. We hypothesized that an increase of at least 8 points in the Korean version of Quality of Recovery-15 scores would indicate a clinically significant improvement, consistent with the minimal clinically important difference (≥8) for Quality of Recovery-15. Secondary outcomes included pain scores at rest and during coughing, cumulative fentanyl consumption through intravenous patient-controlled analgesia, postoperative nausea/vomiting incidence, and gastrointestinal dysfunction as measured using the I-FEED score - all assessed 24, 48, and 72 h postoperatively. RESULTS: For the 92 patients examined (enhanced recovery after surgery, n = 45
conventional, n = 47), the estimated difference in the postoperative Quality of Recovery-15 total scores between the two groups during the first days was significantly larger than the minimal clinically important difference of Quality of Recovery-15 (mean difference: 16.0, 95% confidence interval: 8.9-23.0, P <
0.001). Therefore, excluding the incidence of postoperative nausea/vomiting, the enhanced recovery after surgery group demonstrated significant improvements in other secondary outcomes. CONCLUSIONS: Our evidence-based multimodal enhanced recovery after surgery program significantly improved the quality of early postoperative recovery after minimally invasive distal gastrectomy.