Impact of enhanced recovery after surgery programs on pancreatic surgery: A meta-analysis

Abstract

AIMTo evaluate the impact of enhanced recovery after surgery (ERAS) programs on postoperative complications of pancreatic surgery.METHODSComputer searches were performed in databases (including PubMed, Cochrane Library and Embase) for randomized controlled trials or case-control studies describing ERAS programs in patients undergoing pancreatic surgery published between January 1995 and August 2017. Two researchers independently evaluated the quality of the studies’ extracted data that met the inclusion criteria and performed a meta-analysis using RevMan5.3.5 software. Forest plots, demonstrating the outcomes of the ERAS group vs the control group after pancreatic surgery, and funnel plots were used to evaluate potential publication bias.RESULTSTwenty case-control studies including 3694 patients, published between January 1995 and August 2017, were selected for the meta-analysis. This study included the ERAS group (n = 1886) and the control group (n = 1808), which adopted the traditional perioperative management. Compared to the control group, the ERAS group had lower delayed gastric emptying rates [odds ratio (OR) = 0.58, 95% confidence interval (CI): 0.48-0.72, P < 0.00001], lower postoperative complication rates (OR = 0.57, 95%CI: 0.45-0.72, P < 0.00001), particularly for the mild postoperative complications (Clavien-Dindo I-II) (OR = 0.71, 95%CI: 0.58-0.88, P = 0.002), lower abdominal infection rates (OR = 0.70, 95%CI: 0.54-0.90, P = 0.006), and shorter postoperative length of hospital stay (PLOS) (WMD = -4.45, 95%CI: -5.99 to -2.91, P < 0.00001). However, there were no significant differences in complications, such as, postoperative pancreatic fistulas, moderate to severe complications (Clavien-Dindo III- V), mortality, readmission and unintended reoperation, in both groups.CONCLUSIONThe perioperative implementation of ERAS programs in pancreatic surgery is safe and effective, can decrease postoperative complication rates, and can promote recovery for patients.

Risk factors for post‐pancreaticoduodenectomy delayed gastric emptying in the absence of pancreatic fistula or intra‐abdominal infection

“…Emerging evidence supporting the use of enhanced‐recovery pathways following pancreatic resection has led many clinicians to consider enhanced‐recovery pathways following PD. 33,34 Concerns have been raised about early feeding following PD, at least partially due to the frequency of DGE, despite observed lower rates of DGE with enhanced‐recovery protocols in some studies . The exact cohort in this study (ie, those developing DGE without overt physiologic disturbance due to fistula or infection) may be at particularly risk of adverse events resulting from aggressive early refeeding, as the otherwise smooth postoperative course may make surgeons more comfortable with aggressive dietary advancement.…”

“…Emerging evidence supporting the use of enhancedrecovery pathways following pancreatic resection has led many clinicians to consider enhanced-recovery pathways following PD. 33,34 Concerns have been raised about early feeding following PD, at least partially due to the frequency of DGE, despite observed lower rates of DGE with enhanced-recovery protocols in some studies. 33 The decompression, or TPN) is a more restrictive definition and overlaps with postoperative ileus.…”

“…33,34 Concerns have been raised about early feeding following PD, at least partially due to the frequency of DGE, despite observed lower rates of DGE with enhanced-recovery protocols in some studies. 33 The decompression, or TPN) is a more restrictive definition and overlaps with postoperative ileus. It is our view that the restrictive ACS NSQIP definition of DGE likely makes the definition more reliable by eliminating any differences in oral feeding attributable to local surgeon practices (eg, early feeding vs planned NPO period) and biases result away from spurious findings.…”

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

“…On the other hand, the postoperative complications rate remains controversial among these studies. In this meta-analysis, the difference of postoperative complications rate between ERAS group and TC group has no statistical significance, and several studies shared the same result with us [21,22]. The other four studies [17,19,20,23] shared the result that ERAS group has a lower postoperative complications rate.…”

Postoperative complications are main reason for noncompliance with enhanced recovery after surgery program in patients undergoing hepatectomy and pancreatectomy

“…Recently, multiple publications have demonstrated the feasibility and safety of enhanced recovery after surgery (ERAS) protocols in hepatobiliopancreatic (HPB) surgery. [1][2][3][4] Postulated benefits of ERAS included decrease in length of stay and hospital cost without a negative impact on perioperative mortality and morbidity or readmission rate. [1][2][3][4] There is significant variability in reported outcomes, and the validity of conclusions is usually based on lowquality evidence.…”