Upper GI

Upper gastrointestinal surgery — encompassing oesophagectomy, gastrectomy, and related procedures — involves some of the most technically demanding and physiologically stressful operations in elective surgical oncology. Gastrectomy alone carries an overall morbidity rate of around 30% and a mortality rate approaching 4.5%, making the optimisation of perioperative care a critical priority. Oesophagectomy presents a further layer of complexity, combining major abdominal and thoracic surgery with the challenges of oncological resection, conduit reconstruction, and the risk of serious postoperative complications including anastomotic leak and pulmonary morbidity.

ERAS programmes provide a structured, multidisciplinary framework for perioperative care that has been shown to reliably improve short-term outcomes. For oesophagectomy in particular — a procedure historically associated with high levels of morbidity and mortality — the routine application and audit of ERAS guidelines specifically designed for oesophageal resection has significant potential to improve outcomes at scale.

The ERAS® Society has published dedicated guidelines for both oesophagectomy and gastrectomy, developed through systematic review of the evidence and international expert collaboration. For gastrectomy, an international working group assembled a comprehensive, evidence-based framework for optimal perioperative care, with evidence and recommendations classified according to the GRADE system and agreed through consensus. For oesophagectomy, the guidelines broke new ground — covering 39 sections, including procedure-specific operative and technical elements that were entirely new to ERAS programmes, reflecting the unique thoracic component of the procedure.

While both sets of guidelines are now established, they are yet to be universally adopted. Evidence increasingly highlights the importance of compliance with all pathway elements — the benefits of ERAS appear to arise from the accumulation of incremental gains across the whole pathway, rather than from any single intervention. The ERAS® Society encourages all centres performing upper gastrointestinal surgery to implement, audit, and continually refine their perioperative pathways in line with these recommendations.