Enhanced recovery after surgery continuity nursing in elderly gastric cancer patients.

INTRODUCTION
Gastric cancer remains a significant global health challenge, particularly among the elderly population, where the incidence and associated mortality rates are notably high. Approximately 60% of gastric cancer cases occur in patients aged 60 years and above, largely because of age-related physiological changes and the accumulation of risk factors over time. As the demographic shift toward an older population becomes increasingly pronounced, understanding and improving the management of gastric cancer in this cohort become paramount. Surgical resection of gastric cancer is the cornerstone of curative treatment; however, it is often accompanied by significant postoperative complications, prolonged recovery times, and substantial psychological stress[1-3].
In recent years, the enhanced recovery after surgery (ERAS) program has been heralded as a transformative approach to surgical care. Originating in colorectal surgery, the ERAS program is a multimodal, multidisciplinary approach aimed at reducing surgical stress and improving recovery times through optimized perioperative care. Its core principles include preoperative counseling and optimization, minimally invasive surgical techniques, and early postoperative mobilization and nutrition, all designed to harmonize the patients’ physiological state with the demands of surgery. Although the ERAS approach has been widely adopted across various surgical disciplines, its impact on the elderly undergoing gastric cancer surgery remains under investigated[4-6].
Continuity of care, an extension of ERAS, emphasizes sustained engagement between healthcare providers and patients. It carries out tailored interventions that span the preoperative, intraoperative, and postoperative phases. Such continuity is particularly crucial for elderly patients, who often possess unique physiological and psychological needs that can profoundly influence surgical outcomes. Nursing care, particularly within the ERAS framework, assumes an integral role in delivering this continuous support. Nurses serve as pivotal figures in perioperative management by providing not only direct medical care but also emotional support, education, and personalized guidance to encourage compliance with ERAS protocols[7-9].
Despite these promising insights, research exploring the intersection of continuity nursing care and the ERAS framework in elderly gastric cancer patients is sparse. This demographic often presents with compromised functional reserves and multiple comorbidities, which, when compounded with the stress of major abdominal surgery, can lead to heightened postoperative complications and prolonged recovery[10,11]. In response to these gaps, we aim to evaluate the impact of continuity nursing care based on ERAS principles on postoperative satisfaction, inflammation, and stress among elderly patients undergoing gastric cancer resection.

MATERIALS AND METHODS

Case selection
This study is a retrospective cohort analysis involving 322 elderly patients who underwent gastric cancer resection at our institution between January 2020 and January 2022. The patients were divided into two groups: 156 patients who received routine care were placed in the routine group, whereas 166 patients who received continuity of care based on the ERAS principles were placed in the ERAS-control (ERAS-C) group. Data, including demographic information, general clinical details, postoperative complications, inflammation markers, stress responses, patient satisfaction, and quality of life, were collected from the medical records system for both groups.
This study was approved by the Ethics Committee of the Zhoukou First People’s Hospital. Informed consent was waived because the study utilized only de-identified patient data, which presented no risk or impact on patient care. This waiver adheres to the regulatory and ethical guidelines related to retrospective research as approved by our institution’s Institutional Review Board and Ethics Committee.

Inclusion and exclusion criteria

Inclusion criteria: (1) Patients with histologically confirmed gastric carcinoma, classified as resectable gastric cancer at clinical stages I–III based on the eighth edition of the tumor, node, metastasis (TNM) staging classification[12]; (2) Patients aged 60 years or older; and (3) Patients with comprehensive medical records.

Exclusion criteria: (1) Patients with a history of severe allergies or significant cardiovascular disease; (2) Patients with congenital immune dysfunction; (3) Patients undergoing multivisceral resection; and (4) Patients with psychiatric disorders or with language or hearing impairments.

Treatment approach
In the routine group, patients received standard care, which involved the following steps. Before surgery, healthcare providers briefly introduced knowledge about the disease and the surgical procedure, informed patients about surgery-related precautions, and patiently alleviated any negative emotions. Postoperatively, they intensified monitoring of vital signs and recovery status, and rehabilitation activities based on recovery progress were coordinated. Before discharge, patients received reinforced guidance, including education about post discharge diet and exercise, and were followed up with weekly phone calls.
In the ERAS-C group, continuity of care based on the principles of ERAS was implemented through detailed methods discussed in the subsequent sections.

Multidisciplinary perioperative care under the ERAS framework: Healthcare professionals collectively managed patient admissions, gathered medical history, assessed the severity of the illness, and provided detailed information concerning gastric cancer resection.
On the day before surgery, anesthetists assessed the patient’s vital signs to determine the optimal anesthesia plan. They also educated the patient and their family on anesthesia-related knowledge and precautions.
Psychologists, along with medical staff, evaluated the patient’s psychological state, identified causes of negative emotions, and employed techniques such as distraction and relaxation exercises to adjust the psychological status.
Dieticians developed nutritional plans tailored to the patient’s condition and preferences. They emphasized high-quality proteins and vitamin-rich foods while ensuring sufficient daily nutritional intake. They strictly controlled salt and sodium intake to prevent diet-related blood pressure increases.
Postoperatively, rehabilitation therapists actively participated in rehabilitation treatment by creating tailored training regimens based on the patient’s condition and instructing them on training techniques.

Continuity of care: Establishing a health archive: Before discharge, nurses collected personal information, medical history, and treatment plans. These data were entered into electronic health records.
Before discharge, patients’ contact information and home addresses were double-checked. Then, the patients were encouraged to join a WeChat or QQ group. Healthcare providers regularly disseminated recovery knowledge about gastric cancer resection in these groups. Health education was provided to patients and their families to alleviate negative emotions, promote correct disease understanding, and increase recovery confidence. Personalized guidance on medication, diet, and rehabilitation exercises was also offered.

Follow-up care: One week after discharge, patients received weekly phone follow-ups twice a week, along with monthly home visits to assess psychological status, medication adherence, diet, and recovery progress. Patients were advised on correcting any inappropriate behaviors, setting rehabilitation goals, and maintaining a recovery diary. They were also reminded to return for a first-month postoperative check-up.

Data collection
Data on patients, encompassing demographic characteristics, pathological findings, surgical results, hospital courses, and postoperative outcomes, were systematically recorded in our electronic gastric cancer database. The demographic information comprised age, sex, body mass index (BMI), education level, residential status, employment status, history of smoking and alcohol consumption, and preoperative laboratory results. Pathological findings detailed the tumor location, TNM stage, histological classification of the tumor, and the type of gastrectomy performed. Surgical results included operative duration, length of postoperative hospital stay, and complications occurring within the first month after surgery.

Nursing satisfaction
This study evaluated patient satisfaction one month post-surgery using the Chinese version of Ware’s patient satisfaction questionnaire-18 (PSQ-18). PSQ-18 consists of seven dimensions: Overall satisfaction, technical service quality, nurses’ interpersonal communication, nurse–patient communication, service cost-effectiveness, service timeliness, and service accessibility. Each dimension employs forward and reverse questioning techniques. Before statistical analysis, the responses were normalized, with high scores indicating great satisfaction. Each question on the PSQ-18 has a maximum satisfaction score of 5, culminating in a total possible score of 90. The questionnaire demonstrates strong reliability and validity, with a Cronbach’s α coefficient of 0.852, a split-half reliability of 0.813, and a Kaiser-Meyer-Olkin Measure of 0.867[13].

Biochemical indicators
One month post-surgery, fasting venous blood samples were collected from all patients in the morning for biochemical analysis.

Inflammatory markers: Serum interleukin-6 (IL-6) levels were measured using an enzyme-linked immunosorbent assay (ELISA) kit (Ready-Set-Go; eBioscience, San Diego, CA, United States) by following the manufacturer’s instructions. Serum albumin was quantified via the bromocresol green method (AU-ALB, Beckman Coulter Inc., Brea, CA, United States). High-sensitivity C-reactive protein (CRP) levels were determined using the turbidimetric method (AU-CRP, Beckman Coulter Inc., Brea, CA, United States) in accordance with routine laboratory procedures.

Immune parameters: The immune profile was assessed by measuring the total number of leukocytes (μL), lymphocytes (μL), and lymphocyte subsets, including the percentage of natural killer (NK) cells and the cluster of differentiation (CD) 4:CD8 ratio. A minimum of 1 × 106 cells/mL was analyzed using a flow cytometer (FACScan; Becton Dickinson, Mountain View, CA, United States) through the Cell Quest program with Infinicity software. Antibodies (CD4-fluorescein isothiocyanate, CD8-phycoerythrin, CD3 peridinin-chlorophyll-protein complex, CD3-fluorescein isothiocyanate, and CD16-phycoerythrin) were provided by BD Biosciences, and CD56-peridinin-chlorophyll-protein complex was obtained from Beckman Coulter (Schaumburg, IL, United States).

Stress response: Postoperative levels of norepinephrine (NE), aldosterone (ALD), and cortisol (Cor) were quantified using ELISA. NE levels were measured with the NE ELISA kit (ABN-KA1877, Abnova, Taipei, Taiwan). ALD levels were assessed using the ALD ELISA kit (501090, Cayman, Ann Arbor, MI, United States), and serum Cor levels were determined with the Cor Parameter assay kit (KGE008B, Beckman Coulter Inc., Brea, CA, United States) according to the manufacturer’s protocols.

Assessment of quality of life
We utilized the validated version of the European Organization for Research and Treatment of Cancer 22-item Quality of Life Questionnaire specific to gastric cancer (EORTC-QLQ-STO22) to assess the changes in health-related quality of life (HRQOL) one month post-surgery[14]. The EORTC-QLQ-STO22 includes one functional item (body image), five symptom scales (dysphagia, eating restrictions, pain, reflux, and anxiety), and three individual symptom items (dry mouth, taste disturbance, and hair loss). Low scores indicate good HRQOL. The Cronbach’s alpha for this scale was 0.92, demonstrating high reliability[15].

Data cleaning and management
Prior to data analysis, this study implemented a standardized data cleaning process to identify and rectify any inconsistencies, errors, or missing values. This process involved thoroughly examining the dataset, removing duplicate entries, correcting data entry errors, and addressing missing values. Missing data were imputed using the Multivariate Imputation by Chained Equation package in R version 4.3.2. This process also involved initially creating a basic mean imputation and constructing a K-Dimensional Tree (KDTree) using a complete list. Then, the KDTree was used to compute the nearest neighbor points. The weighted average of these points was calculated after the closest K points were identified.
Missing data were kept within 5% to control potential selection bias, and sensitivity analyses were conducted. In these analyses, outcomes for cases lost to follow-up were calculated under worst-case and best-case scenarios. If the conclusions showed no significant differences, then the impact of the missing data on the conclusions was deemed minimal, thereby indicating the reliability of the findings. The final result output included the dataset with imputed missing values.

Statistical analysis
The sample size was calculated using G Power 3.1. Data analysis was conducted using Statistical Package for the Social Sciences (SPSS) version 29.0 (SPSS Inc., Chicago, IL, United States). Categorical data were represented as n (%). The χ2 test was applied to data with a sample size of ≥ 40 and a theoretical frequency (T) of ≥ 5, with the test statistic denoted by χ². When the sample size was ≥ 40 but the theoretical frequency was between 1 and < 5, an adjusted χ2 test was used with a correction formula. Fisher’s exact test was employed when the sample size was < 40 or the theoretical frequency (T) was < 1.
Continuous variables were first evaluated for normal distribution using the Shapiro-Wilk test. For normally distributed continuous data, values were expressed as mean ± SD. Nonnormally distributed data were assessed using the Wilcoxon rank-sum test and were presented as median (25% quantile, 75% quantile). A P value of < 0.05 was considered statistically significant. Correlation analyses were performed using Pearson correlation for continuous variables and Spearman correlation for categorical variables.

RESULTS

Baseline characteristics of participants
In the study comparing the impact of continuity nursing care based on ERAS principles on postoperative outcomes in elderly patients undergoing gastric cancer resection, 322 patients were divided into a routine care group (n = 156) and an ERAS-C group (n = 166) (Table 1). The analysis of demographic and baseline characteristics demonstrated no statistically significant differences between groups in terms of gender distribution [male: (routine) 68.59%, (ERAS-C) 65.66%; χ² = 0.312, P = 0.576], age [(routine) 70.84 ± 10.17 years, (ERAS-C) 69.66 ± 10.12 years; t = 1.043, P = 0.298], and BMI [(routine) 22.12 ± 3.40 kg/m², (ERAS-C) 22.51 ± 3.11 kg/m²; t = 1.070, P = 0.285]. Moreover, no significant variation was found in other factors, including the degree of education, smoking and drinking history, employment status, diabetes, hypertension, residence area, and living situation, all showing P values greater than 0.05. Tumor location and clinical TNM stage distributions did not differ significantly between the groups (χ² = 5.538, P = 0.136; χ² = 0.363, P = 0.834). The comparability of the routine and ERAS-C groups with respect to these baseline characteristics affirms the robustness of our ensuing analyses regarding postoperative satisfaction, inflammation, and stress outcomes.

Operative and pathological stage
Tumor histology, categorized by Lauren classification, showed similar distributions between the two groups [intestinal: (routine) 54.49%, (ERAS-C) 60.24%; diffuse: (routine) 14.10%, (ERAS-C) 19.28%; others: (routine) 31.41%, (ERAS-C) 20.48%; χ² = 5.474, P = 0.065] (Table 2). The type of gastrectomy performed did not significantly differ: Total gastrectomy was conducted in 26.28% and 27.71% of the routine group and the ERAS-C group, respectively, and distal gastrectomy was conducted in 54.49% and 47.59% of the routine group and the ERAS-C group, respectively (χ² = 5.729, P = 0.220). The proportion of patients undergoing an open surgical approach was comparable [(routine) 85.90%, (ERAS-C) 79.52%; χ² = 2.278, P = 0.131]. Operative time did not significantly differ between groups, with the routine group averaging 298.31 ± 40.94 minutes and the ERAS-C group averaging 300.14 ± 45.68 minutes (t = 0.377, P = 0.706). Similarly, the length of postoperative hospital stay was comparable, with the routine group averaging 13.85 ± 3.69 days and the ERAS-C group averaging 14.32 ± 3.11 days (t = 1.245, P = 0.214). Overall, these findings indicate homogeneity between the groups with respect to operative and pathological characteristics.

Inflammatory markers
The neutrophil-to-lymphocyte ratio (NLR) was similar between the groups, with the routine group and the ERAS-C group showing an average of 1.99 ± 0.34 and 1.96 ± 0.41, respectively (t = 0.580, P = 0.562) (Figure 1A-D). Serum albumin levels were also comparable, with averages of 433.02 ± 25.86 and 435.74 ± 26.58 g/L for the routine group and the ERAS-C group, respectively (t = 0.930, P = 0.353). CRP levels were measured at 273.06 ± 6.87 and 274.38 ± 7.73 mg/L in the routine group and the ERAS-C group, respectively, with no significant difference observed (t = 1.622, P = 0.106). IL-6 levels were also not significantly different, with averages of 2.01 ± 0.19 and 2.00 ± 0.21 pg/mL in the routine group and the ERAS-C group, respectively (t = 0.700, P = 0.485). These results indicate that preoperative inflammatory status was equivalent between the two patient groups.
The IL-6 levels in the ERAS-C group (12.97 ± 4.02 pg/mL) were significantly lower than those in the routine group (14.37 ± 3.86 pg/mL). This finding indicates a significant reduction in postoperative inflammation with ERAS-C care (t = 3.182, P = 0.002) (Figure 1E-H). Other inflammatory markers did not exhibit statistically significant differences: The NLR in the ERAS-C group (2.49 ± 0.44) was marginally but not significantly lower than that in the routine group (2.55 ± 0.26) (t = 1.478, P = 0.141). Serum albumin levels, an indicator of nutritional and inflammatory status, were similar between the groups, with the routine group at 287.05 ± 76.88 g/L and the ERAS-C group at 276.14 ± 89.30 g/L (t = 1.171, P = 0.242). CRP levels remained consistent between the routine (285.12 ± 97.14 mg/L) and ERAS-C (284.54 ± 58.33 mg/L) groups (t = 0.065, P = 0.948), suggesting comparable systemic inflammatory response at this postoperative stage. These findings highlight the impact of ERAS-C on lowering IL-6 levels, potentially contributing to improved recovery.

Immune parameters
Leukocyte counts were similar between the groups, with the routine group averaging 7453.72 ± 2325.01 μL and the ERAS-C group averaging 7369.78 ± 2236.14 μL (t = 0.330, P = 0.741) (Figure 2A-D). Lymphocyte counts were also comparable, with the routine group at 1978.45 ± 602.17 μL and the ERAS-C group at 2004.36 ± 624.67 μL (t = 0.378, P = 0.705). The percentage of total lymphocytes classified as NK cells was consistent between groups, with the routine group at 13.65% ± 2.75% and the ERAS-C group at 13.89% ± 2.68% (t = 0.787, P = 0.432). Additionally, the CD4:CD8 ratio showed no significant difference, being 2.23 ± 0.73 and 2.14 ± 0.77 in the routine group and the ERAS-C group, respectively (t = 0.955, P = 0.340). Overall, these findings indicate a uniform preoperative immune status between the two patient groups.
One month postoperatively, the analysis of immune parameters between the routine care group and the ERAS-C group revealed a significant difference in the CD4:CD8 ratio, with the ERAS-C group exhibiting a higher ratio (2.34 ± 0.35) than the routine group (2.13 ± 0.61). This finding indicates a more favorable immune profile in the ERAS-C group than in the routine care (t = 3.748, P < 0.001) (Figure 2E-H). Other immune parameters showed no statistically significant differences. Leukocyte counts remained similar, with the routine group averaging 11983.64 ± 3645.18 μL and the ERAS-C group averaging 11647.15 ± 3254.97 μL (t = 0.875, P = 0.382). Lymphocyte counts were also comparable, with the routine group and the ERAS-C group at 1165.39 ± 307.26 and 1187.64 ± 289.17 μL, respectively (t = 0.669, P = 0.504). The percentage of total lymphocytes classified as NK cells was consistent between groups, with the routine group and the ERAS-C group at 11.98% ± 1.23% and 12.04% ± 2.06%, respectively (t = 0.356, P = 0.722). These results suggest that although most postoperative immune parameters were similar, the ERAS-C care had a beneficial effect on the CD4:CD8 ratio, potentially enhancing postoperative immune response.

Postoperative course in patients undergoing gastrectomy
Within the first postoperative month, complications were reported in 11.54% of the routine group and 5.42% of the ERAS-C group. This finding demonstrates a statistically significant decrease (χ² = 3.917, P = 0.048) (Table 3). Major complications in the ERAS-C group (1.20%) were significantly lower than those in the routine group (5.77%) (χ² = 5.078, P = 0.024). Specific major complications, such as pulmonary embolism, anastomosis leakage, intra-abdominal bleeding, and intra-abdominal abscess, showed numerically lower incidences in the ERAS-C group than in the routine care group, with no pulmonary embolisms or intra-abdominal bleedings reported. Minor complications, including wound infection, ileus, urinary tract infection, and atelectasis, were similar between the groups, with the routine group and the ERAS-C group experiencing 5.77% and 4.22%, respectively (χ² = 0.410, P = 0.522). These findings suggest the significant benefit of ERAS-based continuity nursing care in reducing postoperative complications, particularly major complications, in elderly patients undergoing gastric cancer resection.

Nursing satisfaction
One month postoperatively, the total satisfaction score in the ERAS-C group (80.36 ± 7.24) was markedly higher than that in the routine group (75.23 ± 7.03). This finding reflects an overall enhanced nursing experience for patients under ERAS-C care (t = 6.450, P < 0.001) (Table 4). Specific aspects contributing to this increase included nurses’ interpersonal communication ability [which was rated at 9.24 ± 0.63 and 9.01 ± 0.67 in the ERAS-C group and the routine group, respectively (t = 3.301, P = 0.001)] and the nurse-patient communication level [with scores of 9.57 ± 0.74 vs 9.25 ± 0.58, respectively (t = 4.396, P < 0.001)]. Service timeliness in the ERAS-C group (9.36 ± 1.03) was also significantly better than that in the routine group (8.85 ± 1.20) (t = 4.130, P < 0.001). Furthermore, service accessibility in the ERAS-C group (17.35 ± 1.57) was rated higher than that in the routine group (16.98 ± 1.34) (t = 2.274, P = 0.024). Technical service quality and service economy showed no significant differences between groups, with comparable scores in technical service quality (t = 0.755, P = 0.451) and service economy (t = 0.738, P = 0.461). These data underline the advantages of continuity nursing care based on ERAS principles in enhancing patient satisfaction across multiple dimensions of nursing services.

Stress response indicators
One month postoperatively, the level of NE in the ERAS-C group (209.48 ± 14.48 ng/mL) was significantly reduced than that in the routine group (214.15 ± 23.08 ng/mL), indicating a decreased stress response (t = 2.159, P = 0.032) (Figure 3). Similarly, Cor levels in the ERAS-C group (200.65 ± 20.97 ng/mL) were lower than those in the routine group (207.54 ± 24.19 ng/mL). This finding further suggested reduced stress (t = 2.734, P = 0.007). Additionally, the ALD levels in the ERAS-C group (19.22 ± 4.05 ng/L) were significantly lower than those in the routine group (20.37 ± 3.04 ng/L) (t = 2.891, P = 0.004). These findings highlight the effectiveness of continuity nursing care based on ERAS principles in mitigating postoperative stress responses in elderly patients following gastric cancer resection.

Quality of life
One month postoperatively, dysphagia scores in the ERAS-C group (19.18 ± 2.54) were significantly lower than those in the routine group (20.26 ± 3.77). This finding indicates that the former experienced less difficulty in swallowing than the latter (t = 2.992, P = 0.003) (Table 5). Pain levels in the ERAS-C group (24.74 ± 3.68) were also reduced relative to those in the routine group (25.77 ± 3.49) (t = 2.585, P = 0.010). Participants in the ERAS-C group reported fewer eating restrictions (19.96 ± 1.77) than those in the routine group (22.18 ± 2.85), demonstrating a substantial improvement (t = 8.335, P < 0.001). Anxiety scores, reflecting emotional well-being, in the ERAS-C group (38.67 ± 3.46) were lower than those in the routine group (40.52 ± 6.98) (t = 2.977, P = 0.003). Additionally, dry mouth severity in the ERAS-C group (28.72 ± 2.15) was reduced compared with that in the routine group (30.66 ± 5.43) (t = 4.166, P < 0.001). Body image perceptions also improved, with lower concerns reported in the ERAS-C group (38.96 ± 2.54) than those reported in the routine group (40.03 ± 4.15) (t = 2.760, P = 0.006). These findings underscore the enhanced quality of life experienced by patients receiving ERAS-based continuity nursing care postoperatively.

DISCUSSION
The study explores the impact of continuity nursing care rooted in ERAS principles on postoperative outcomes, particularly satisfaction, inflammation, immune response, stress, and quality of life in elderly gastric cancer patients.
The superior outcomes in the ERAS-C group were due to the core principles of ERAS. These principles focused on multidisciplinary and perioperative care. This comprehensive approach optimizes physiological responses to surgery, reduces stress, and curtails inflammatory cascades, thereby resulting in decreased postoperative complications, improved satisfaction, and enhanced quality of life[9,11,16].
Patient satisfaction, markedly higher in the ERAS-C group than in the routine care group, reflects enhanced communication channels, timely service, and improved accessibility. Central to this outcome was the ERAS protocol’s commitment to active and ongoing patient engagement, which extends beyond the surgical phase into recovery. Stress responses and anxiety levels were mitigated by fostering a patient-centered environment that accommodates emotional and psychological needs, thereby creating a highly favorable perception of care among patients. The psychological support, coupled with nutrition and tailored rehabilitation protocols, plays a critical role in addressing patients’ concerns and anxieties, thereby boosting satisfaction scores. The use of platforms such as WeChat for continued patient education further solidifies the connection between healthcare providers and patients, thereby ensuring that they feel supported throughout their recovery journey[8,17,18].
Postoperative inflammation was intrinsically linked to surgical stress and immune function. In the ERAS-C group, IL-6 levels were much lower, indicating less inflammation. This reduction may be due to better preoperative preparation of patients’ health and mental state. Synchronization of nutritional support, anesthetic care, and early mobilization further attenuates the inflammatory response, as evidenced by controlled CRP levels and stable serum albumin. Nutrition, a pivotal element of ERAS, improves healing capacity and immune function, thereby diminishing inflammatory markers and aiding in a smooth recovery[19,20].
The ERAS protocols’ influence on stress was underscored by the reduced NE, Cor, and ALD levels observed in the ERAS-C group. The ERAS model minimizes the hypothalamic–pituitary–adrenal axis activation, which was responsible for the physiological stress response, by alleviating anxiety through educational initiatives and psychological support. The low stress marker levels signify reduced physiological stress and correlate with improved pain management and decreased pain perception, contributing to improved psychological well-being and patient satisfaction[21-23].
Immune function, vital for postoperative recovery, also appears to be effectively preserved under the ERAS framework. The highly favorable CD4:CD8 ratio in the ERAS-C group indicates enhanced postoperative immunity. This finding can be attributed to reduced surgical stress and inflammation, which foster an immune environment conducive to recovery. Maintaining a balanced immune response minimizes the risk of infection, supports tissue repair, and lowers the incidence of complications[24-26].
The reduction in postoperative complications, particularly major ones, highlights the practical benefits of ERAS principles. ERAS care significantly curtails the risk of adverse postoperative events by fostering early mobilization, employing minimally invasive surgical techniques, and promoting intestinal recovery through dietary optimization. Minimization of complications such as anastomosis leakage and pulmonary embolism illustrates the protocols’ effectiveness in stabilizing physiological functions and improving recovery outcomes. These outcomes translate into clinical advantages and contribute markedly to patient satisfaction and quality of life[27-29].
The improvement in quality of life parameters, such as reduced dysphagia, pain, and anxiety, along with improved results in eating restrictions and body image, conveys the broad impact of ERAS-based care. The ERAS protocols foster a holistic healing process by collectively addressing the physical, psychological, and social dimensions of recovery. Emotional well-being was enhanced through structured communication, whereas physical recovery benefits from intentional interventions tailored to individual patient needs. This scenario results in few dietary limitations, alleviated discomfort, and improved self-perception, collectively boosting patients’ postoperative quality of life[30-33].
Mechanistically, ERAS protocols seem to attenuate the typical stress and inflammatory pathways activated by surgery. The strategic combination of preoperative optimization, including nutrition and mental health preparations, coupled with postoperative care such as pain management, early mobilization, and continuous education, disrupts the traditional trajectory of surgical recovery. This comprehensive care model expedites physiological recovery and mentally equips patients to engage positively with their health outcomes[34,35].
Although this study demonstrates the benefits of continuity nursing care rooted in ERAS principles, several limitations must be acknowledged. First, the study’s sample size was relatively small and drawn from a single institution. Thus, the generalizability of our findings may be limited to broad populations. To address this limitation, future research could adopt a multi-center collaborative approach, pooling data from multiple institutions to enhance the feasibility and prospective validity of the study. Such an approach would allow for a larger and more diverse patient cohort, thereby increasing the robustness of the findings. Additionally, the assessment of patient satisfaction and quality of life relied on self-reported measures, which can be subject to bias. Future studies should consider incorporating objective measures, such as clinical assessments and biomarkers, to complement self-reported data. This dual approach would provide a more comprehensive understanding of patient outcomes. The study also did not account for potential confounding factors, such as comorbidities and varying degrees of surgical complexity, which may influence postoperative outcomes. Future research should include detailed stratification of patients based on these factors to control for potential biases and ensure more accurate comparisons. Additionally, employing statistical techniques such as propensity score matching or multivariate regression analysis could help mitigate the impact of these confounders. The observational design precludes any causal inferences, thereby underscoring the need for future randomized controlled trials (RCTs) to effectively establish the efficacy of ERAS-based continuity nursing care. RCTs would enable researchers to draw stronger conclusions about causality and the effectiveness of ERAS protocols. Furthermore, extending the follow-up period beyond the current duration would allow for a more thorough evaluation of long-term outcomes and the sustainability of the observed benefits. Longitudinal studies with extended follow-up periods are essential to assess the durability of improvements in patient satisfaction, inflammation, stress, and quality of life.
Moreover, the integration of ERAS principles into clinical practice faces unique challenges depending on the local context. For instance, resource constraints, varying levels of staff training, and differences in patient demographics can influence the implementation and effectiveness of ERAS protocols. By analyzing additional clinical practice cases, we can gain deeper insights into how these factors impact the outcomes of ERAS-based care. This approach not only enhances the depth and breadth of our discussion but also provides practical guidance for adapting ERAS principles to meet the specific needs of different institutions and patient groups.

CONCLUSION
The implementation of continuity nursing care based on ERAS principles in elderly gastric cancer patients undergoing surgery has demonstrated significant improvements in various postoperative measures. The ERAS protocol stands out as a superior alternative to conventional care approaches by optimizing inflammation, stress, immune response, and overall patient satisfaction and recovery. Future research should continue exploring specific components of ERAS that yield the greatest benefits to refine and enhance these protocols further. Ultimately, the integration of ERAS-based strategies holds the potential to reform surgical care paradigms, thereby promoting healthy and rapid recoveries and improved long-term outcomes for patients.