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

Table 1 The search strategy for the PubMed database¹

Search number	Description	Number of publications
1	Enhanced recovery after surgery [Title/Abstract] OR ERAS [Title/Abstract] OR fast track surgery [Title/Abstract]	3333
2	Clinical pathways [MeSH Terms]	5848
3	1 OR 2	9130
4	Pancreatectomy [MeSH Terms] OR Pancreatectomy* [Title/Abstract] OR Pancreatoduodenectomy [MeSH Terms] OR Pancreatoduodenectom* [Title/Abstract] OR duodenopancreatectomy [MeSH Terms] OR duodenopancreatectom* [Title/Abstract]	21497
5	3 AND 4 NOT (animals[mh] NOT humans[mh])	69
6	5 limited to English	68

¹Date of search: August 1, 2017.

Table 2 Study Characteristics and Quality Assessment.

Study	Year	Country	Study design	Sample size		ERAS programs1	MINORS Score
				ERAS group	Control group
Kennedy et al[14]	2007	United States	Case-control	91	44	e, f, g, h	16/24
Vanounou et al[15]	2007	United States	Case-control	145	64	c, d, g, h	15/24
Balzano et al[16]	2008	Italy	Case-control	252	252	d, e, f, g, h	13/24
Kennedy et al[17]	2009	United States	Case-control	71	40	d, e, f, g, h	11/24
Abu Hilal et al[18]	2013	Britain	Case-control	20	24	b, e, f, g, h	15/24
Braga et al[19]	2014	Italy	Case-control	115	115	a, b, c, d, e, f, g, h	17/24
Pillai et al[20]	2014	India	Case-control	20	20	c, d, e, f, g, h	17/24
Coolsen et al[21]	2014	Holland	Case-control	86	97	b, c, d, e, f, g, h	12/24
Nussbaum et al[22]	2014	United States	Case-control	100	142	c, e, f, g, h	11/24
Yui et al[23]	2014	Japan	Case-control	57	52	e, g, h	13/24
Nussbaum et al[24]	2014	United States	Case-control	50	100	c, e, f, g, h	16/24
Kobayashi et al[25]	2014	Japan	Case-control	100	90	a, e, g, h	13/24
Shao et al[26]	2015	China	Case-control	325	310	d, e, f, g, h	15/24
Joliat et al[27]	2015	Switzerland	Case-control	74	87	a, b, c, d, e, f, g, h	15/24
Partelli et al[28]	2015	Italy	Case-control	22	66	a, c, d, e, f, g, h	13/24
Williamsson et al[29]	2015	Sweden	Case-control	50	50	c, d, e, f, g, h	17/24
Morales Soriano et al[30]	2015	Spain	Case-control	41	44	a, b, c, d, e, f, g, h	17/24
Bai et al[31]	2016	China	Case-control	124	63	a, d, e, f, g, h	15/24
Zouros et al[32]	2016	Greece	Case-control	75	50	a, b, c, d, e, f, g, h	16/24
Dai et al[33]	2017	China	Case-control	68	98	a, b, c, e, f, g, h	15/24

¹ERAS programs: a: No bowel preparation in the preoperative period; b: Clear fluids until 2-3 h before surgery; c: Restrictive policy of intravenous fluids in the intra-operative period; d: Multimodal analgesia of the postoperative period; e: Clear fluids or food intakes in the early period; f: Enhanced mobilization in the early period; g: Removal of the drainage tube; h: Others. ERAS: enhanced recovery after surgery; MINORS score: Methodological Index for Non-Randomized Studies checklist.

Table 3 Results of Subgroup Analysis

Outcomes of interest	Studies	Patients	OR/WMD	95%CI	P-value	Heterogeneity P-value	I2, %
Studies with cases ≥ 100
POPF	14	3067	0.87	0.73-1.03	0.11	0.02	48
DGE	14	3117	0.58	0.47-0.71	< 0.00001	0.07	39
Overall complications	14	3045	0.57	0.45-0.72	< 0.00001	0.006	55
Mild complications	9	1470	0.74	0.59-0.93	0.009	0.06	46
Abdominal infection	10	2087	0.67	0.51-0.87	0.003	0.07	42
PLOS	10	2394	-4.64	-6.37 to -2.91	< 0.00001	0.009	65
Mortality	15	2802	0.83	0.51-1.37	0.47	1	0
Readmission	12	2877	1.05	0.83-1.33	0.68	0.23	22
Unintended reoperation	9	1955	0.85	0.60-1.21	0.38	0.96	0
MINORS score > 12
POPF	15	2784	0.84	0.70-1.00	0.05	0.13	30
DGE	16	2949	0.52	0.42-0.64	< 0.00001	0.12	31
Overall complications	16	3008	0.56	0.44-0.71	< 0.00001	0.01	51
Mild complications	11	1504	0.67	0.54-0.83	0.0003	0.24	21
Abdominal infection	10	1791	0.63	0.46-0.85	0.002	0.05	46
PLOS	11	2272	-4.35	-5.97 to -2.72	< 0.00001	0.003	66
Mortality	16	2523	0.96	0.56-1.65	0.89	0.99	0
Readmission	13	2598	1.09	0.84-1.43	0.52	0.82	0
Unintended reoperation	11	1787	0.96	0.65-1.41	0.83	0.94	0

CI: Confidence interval; DGE: Delayed gastric emptying; MINORS score: Methodological Index for Non-Randomized Studies checklist; OR: Odds ratio; PLOS: Postoperative length of hospital stay; POPF: Postoperative pancreatic fistula; WMD: Weighted mean difference.

Table 4 Results of sensitivity analysis by omitting one study in each turn

Studies	OR	95%CI	P-value
Omitting Vanounou et al[15]	0.56	0.44-0.72	< 0.00001
Omitting Kennedy et al[14]	0.56	0.44-0.71	< 0.00001
Omitting Balzano et al[16]	0.56	0.43-0.73	< 0.0001
Omitting Kennedy et al[17]	0.58	0.46-0.74	< 0.00001
Omitting Abu Hilal et al[18]	0.58	0.45-0.73	< 0.00001
Omitting Yui et al[23]	0.56	0.44-0.72	< 0.00001
Omitting Kobayashi et al[25]	0.58	0.45-0.74	< 0.00001
Omitting Coolsen et al[21]	0.54	0.43-0.69	< 0.00001
Omitting Braga et al[19]	0.55	0.43-0.71	< 0.00001
Omitting Pillai et al[20]	0.57	0.45-0.73	< 0.00001
Omitting Joliat et al[27]	0.57	0.45-0.73	< 0.0001
Omitting Partelli et al[28]	0.55	0.44-0.68	< 0.00001
Omitting Williamsson et al[29]	0.56	0.44-0.71	< 0.00001
Omitting Morales Soriano et al[30]	0.58	0.46-0.74	< 0.00001
Omitting Shao et al[26]	0.57	0.44-0.74	< 0.0001
Omitting Zouros et al[32]	0.57	0.44-0.73	< 0.00001
Omitting Bai et al[31]	0.56	0.44-0.71	< 0.00001
Omitting Dai et al[33]	0.62	0.52-0.71	< 0.00001
Overall effect	0.57	0.45-0.72	< 0.00001

CI: Confidence interval; OR: Odds ratio.