Application of enhanced recovery after gastric cancer surgery: An updated meta-analysis

Table 1 Main characteristics of the included studies

Study	Year	Sample size		Age in yr		Sex, male/female		Approach	Neoadjuvant chemotherapy	Follow-up(d)
		ERAS	SC	ERAS	SC	ERAS	SC
Abdikarim et al[21]	2015	30	31	63 ± 12	62 ± 11	21/9	20/11	Lap	No	30
Bu et al[23]-Adult	2015	64	64	62.4 ± 7.8	63.0 ± 7.4	31/33	35/29	Open	No	30
Bu et al[23]-Elderly	2015	64	64	80.1 ± 4.0	79.6 ± 3.5	37/27	40/24	Open	No	30
Chen Hu et al[34]-Lap	2012	19	22	59 (49-71)	62.5 (45-72)	10/9	10/12	Lap	No	28
Chen Hu et al[34]-Open	2012	21	20	62.5 (45-72)	64.5 (49-75)	9/12	12/8	Open	No	28
Feng et al[33]	2013	59	60	55.0 ± 11.4	55.8 ± 10.1	41/18	44/16	Open	No	28
Kim et al[35]	2012	22	22	52.6 ± 11.6	57.5 ± 14.5	13/9	15/7	Lap	-	14
Liu et al[36]	2010	33	30	60.7 ± 9.7	61.9 ± 8.3	18/15	16/14	Open	No	30
Liu et al[24]-Lap	2016	21	21	69.2 ± 5.1	70.3 ± 5.8	10/11	12/9	Lap	No	30
Liu et al[24]-Open	2016	21	21	67.8 ± 3.9	68.6 ± 4.9	9/12	11/10	Open	No	30
Mingjie et al[22]	2017	73	76	61 (40-75)	63 (35-75)	48/25	50/26	Lap	No	30
Tanaka et al[30]	2017	73	69	68 (29-85)	67 (44-85)	49/24	49/20	Lap/Open	No	30
Wang et al[37]	2010	45	47	58.8 ± 9.7	56.9 ± 9.1	32/13	29/18	Open	No	28

ERAS: Enhanced recovery after surgery; Lap: laparoscopic surgery; Open: Open surgery; SC: Standard care.

Table 2 Elements of enhanced recovery after surgery protocol applied in the included studies

Study	Year	No bowel preparation	Carbohydrate loading	No routine use of abdominal drainage	Fluid restriction	Pain management	Early mobilization	Early feeding	Others	No. of ERAS elements
Abdikarim et al[21]	2015	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	11
Bu et al[23]	2015	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	14
Chen Hu et al[34]	2012	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	13
Feng et al[33]	2013	-	Yes	Yes	Yes	Yes	Yes	Yes	Yes	9
Kim et al[35]	2012	Yes	Yes	-	-	Yes	Yes	Yes	Yes	10
Liu et al[36]	2010	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	12
Liu et al[24]	2016	Yes	Yes	-	Yes	Yes	Yes	Yes	Yes	11
Mingjie et al[22]	2017	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	13
Tanaka et al[30]	2017	Yes	Yes	Yes	-	Yes	Yes	Yes	Yes	22
Wang et al[37]	2010	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	14

ERAS: Enhanced recovery after surgery.

Table 3 Evaluation of the complications or outcomes in enhanced recovery after surgery vs standard care groups in the included studies

Subgroup	Studies, n	Participants, n	Statistical method	Effect estimate	Heterogeneity
					I2	P value
Total complications	13	1092	Risk ratio (M-H, random, 95%CI)	1.03 [0.73, 1.44]	75%	< 0.00001
Anastomotic leak	10	964	Risk ratio (M-H, random, 95%CI)	1.36 [0.54, 3.45]	0	0.50
Ileus	12	1048	Risk ratio (M-H, random, 95%CI)	1.62 [0.75, 3.52]	0	0.57
Incision infection	11	1007	Risk ratio (M-H, random, 95%CI)	0.79 [0.39, 1.60]	0	0.87
Urinary tract infection	9	699	Risk ratio (M-H, random, 95%CI)	0.53 [0.26, 1.08]	0	0.99
Pulmonary infection	9	775	Risk ratio (M-H, random, 95%CI)	0.52 [0.28, 0.94]	0	0.99
Postoperative hospital stay	13	1092	Mean difference (IV, random, 95%CI)	-1.65 [-2.09, -1.21]	89%	< 0.00001
Duration of first flatus	11	882	Mean difference (IV, random, 95%CI)	-12.70 [-19.71, -5.69]	92%	< 0.00001
Duration of first defecation	4	471	Mean difference (IV, random, 95%CI)	-28.07 [-41.48, -14.67]	90%	< 0.00001
Medical costs	10	819	Mean difference (IV, random, 95%CI)	-0.50 [-0.69, -0.30]	85%	< 0.00001
CRP
POD1	8	514	Mean difference (IV, random, 95%CI)	-14.81 [-21.42, -8.21]	72%	0.0007
POD4	6	378	Mean difference (IV, random, 95%CI)	-19.81 [-29.64, -9.98]	64%	0.02
POD7	5	258	Mean difference (IV, random, 95%CI)	-21.36 [-28.81, -13.91]	74%	0.004
IL-6
POD1	4	239	Mean difference (IV, random, 95%CI)	-61.22 [-114.58, -7.86]	99%	< 0.00001
POD4	3	147	Mean difference (IV, random, 95%CI)	-31.50 [-55.63, -7.38]	96%	< 0.00001
POD7	3	176	Mean difference (IV, random, 95%CI)	-26.62 [-34.23, -19.01]	89%	0.0001
ALB
POD1	2	84	Mean difference (IV, random, 95%CI)	0.24 [-0.89, 1.36]	0	0.79
POD4	4	166	Mean difference (IV, random, 95%CI)	3.27 [2.24, 4.30]	23%	0.27
POD7	4	166	Mean difference (IV, random, 95%CI)	5.68 [3.31, 8.05]	83%	0.0005
Readmission	8	777	Risk ratio (M-H, Fixed, 95%CI)	2.86 [1.31, 6.24]	0	0.92
Reoperation	3	517	Risk ratio (M-H, Fixed, 95%CI)	0.62 [0.17, 2.35]	33%	0.22
Quality of life	2	136	Std. mean difference (IV, Fixed, 95%CI)	-0.46 [-0.80, -0.12]	36%	0.21

ALB: Serum albumin; CRP: C-reactive protein; IL-6: Interleukin-6; IV: Inverse Variance; M-H: Mantel-Haenszel; POD: Postoperative day.