Enhanced recovery versus conventional care in gastric cancer surgery: a meta-analysis of randomized and non-randomized controlled trials

Abstract

Introduction Enhanced recovery after surgery (ERAS) protocols have been successfully integrated into peri-operative management of different cancer surgeries such as colorectal cancer. Their value for gastric cancer surgery, however, remains uncertain. Methods A search for randomized and observational studies comparing ERAS versus conventional care in gastric cancer surgery was performed according to PRISMA guidelines. Random-effects meta-analyses with inverse variance weighting were conducted, and quality of included studies was assessed using the Cochrane risk-of-bias tool and Newcastle-Ottawa scale (PROSPERO: CRD42017080888). Results Twenty-three studies involving 2686 patients were included. ERAS was associated with reduced length of hospital stay (WMD-2.47 days, 95% CI − 3.06 to − 1.89, P < 0.00001), time to flatus (WMD-0.70 days, 95% CI − 1.02 to − 0.37, P < 0.0001), and hospitalization costs (WMD-USD$ 4400, 95% CI − USD$ 5580 to − USD$ 3210, P < 0.00001), with consistent results across open and laparoscopic surgery. Postoperative morbidity and 30-day mortality were similar, although a higher rate of readmission was observed in the ERAS group (RR = 1.95, 95% CI 1.03-3.67, P = 0.04). Patients in the ERAS arm had significantly attenuated C-reactive protein levels on days 3/4 and 7, interleukin-6 levels on days 1, and 3/4, and tumor necrosis factor-α levels on days 3/4 postoperatively. Conclusion Compared to conventional care, ERAS reduces hospital stay, costs, surgical stress response and time to return of gut function, without increasing post-operative morbidity in gastric cancer surgery. However, precaution is necessary to reduce the increased risk of hospital readmission when adopting ERAS.

Clinical pathway for enhanced recovery after surgery for gastric cancer: A prospective single‐center phase II clinical trial for safety and efficacy

“…[23][24][25] However, some studies have raised the concern that early discharge could miss complications and lead to a higher readmission rate. 26,27 Complication rates (13.4%) within 30 days after surgery were comparable to previous conventional studies (13.0%-16.6%) 5,6 and our conventional CP group (9.5%, P = 0.338). The readmission rate (6.3%) in this study was also comparable to previous studies that applied conventional management (3.8%-7.5%), [28][29][30] although it was higher than that of our conventional CP group (0.7%).…”

“…The mean length of hospital stay (4.7 ± 1.3 days) was shorter than our historical cohort that had completed a conventional CP (7.2 ± 2.3 days) and the previous time periods reported for gastric cancer ERAS (6.8 − 9.0 days) . However, some studies have raised the concern that early discharge could miss complications and lead to a higher readmission rate …”

Clinical efficacy of enhanced recovery after surgery (ERAS) program in patients undergoing radical prostatectomy: a systematic review and meta-analysis

“…However, the differences of interpretative measures (including operative time and blood loss) and the occurrence of complications (including nausea, intestinal obstruction, urinary tract infection, urinary leakage, and deep venous thrombosis) remained no statistical significance. To date, numerous articles have been performed to explore the efficacy and safety of ERAS program in laparoscopic surgery of various diseases, such as colorectal cancer, gastric cancer, bladder cancer, and hepatocellular cancer [17][18][19][20][21]. Ni et al [17] reported 13 RCTs of ERAS program in laparoscopic colorectal cancer surgery.…”

“…Specifically, IL-6 and CRP levels of patients in ERAS group are proved to be lower. Wee et al [18] reported 23 studies (including 14 RCTs) of ERAS program in gastric cancer surgery in 2018 and demonstrated that ERAS program in gastric cancer surgery can reduce hospital stay, costs, surgical stress response, and time to return of gut function as compared to conventional care. Xiao et al [19] reported 16 trails (including 8 retrospective and 8 prospective trials) of ERAS program in bladder cancer surgery in 2019 and showed that ERAS protocols are associated with a faster return of bowel function, reduced incidence of POI, and shorter LOS when compared to SC in patients undergoing RC.…”

Feasibility of totally laparoscopic pylorus-preserving gastrectomy with intracorporeal gastro-gastrostomy for early gastric cancer: a retrospective cohort study

“…These results may also have been influenced by the clinical pathway of enhanced recovery after surgery (ERAS). The ERAS program reduces the time required for normalization of gut function [18]. With the widespread use of the recent ERAS protocol, fluid and meal intakes were initiated earlier in the latter period of this study.…”