Published online Apr 14, 2018. doi: 10.3748/wjg.v24.i14.1562
Peer-review started: February 6, 2018
First decision: February 26, 2018
Revised: March 3, 2018
Accepted: March 7, 2018
Article in press: March 6, 2018
Published online: April 14, 2018
Processing time: 64 Days and 22.9 Hours
Enhanced recovery after surgery (ERAS) has emerged as an optimal perioperative strategy for improving clinical outcomes in elective gastric cancer (GC) surgery. However, numerous controversies exist with regard to ERAS practice after radical gastrectomy.
Accumulating studies highlight that implementation of ERAS protocols reduces overall hospital stay, morbidity and mortality significantly, without compromising patient safety in multiple surgical disciplines. However, the safety and feasibility of applying ERAS in its current form in radical gastrectomy still remains to be proven by performing an updated meta-analysis.
This meta-analysis aims to provide an updated assessment of the safety and efficacy of ERAS protocols in GC surgery.
A comprehensive literature search in PubMed, Medline, EMBASE, World Health Organization International Trial Registry platform, and Cochrane Library until June 2017 was performed independently to identify all available randomized controlled trials (RCTs) comparing the ERAS program with standard perioperative care (SC) in GC surgery. Non-comparative studies, case-controlled trials, cohort studies, retrospective studies, items of ERAS applied being less than four, and no follow-up after discharge were excluded.
Thirteen RCTs, with a total of 1092 participants, were analyzed in this study, of whom 545 underwent ERAS protocols and 547 received SC treatment. ERAS protocols significantly decreased the length of postoperative hospital stay and medical costs, and accelerated bowel function recovery. Moreover, ERAS protocols were associated with a lower level of serum inflammatory response, higher serum albumin, and superior short-term quality of life. There were no significant differences regarding the incidence of total complications, mortality and reoperation following gastrectomy. However, the readmission rate after GC surgery nearly tripled under ERAS.
ERAS results in accelerated convalescence, reduction of surgical stress and medical costs, improved nutritional status, and better quality of life for GC patients, but increased the readmission rate. Furthermore, the significant heterogeneity of some results is a major limitation of this study. ERAS investigators need to proceed with caution as far as ERAS is concerned beyond colorectal cancer surgery.
This study provides an updated assessment of ERAS in GC surgery and is expected to provide guidance and reference for clinical practice, and also to provide high-level evidence for evidence-based medicine. High-quality multicenter RCTs with large samples and long-term follow-up are needed to more precisely evaluate ERAS in radical gastrectomy.