Enhanced recovery after surgery in gastric cancer surgery: Systematic review and meta-analysis of perioperative indwelling drainage tube use

Abstract

BACKGROUND

The clinical necessity of routine abdominal drainage following radical gastrectomy remains controversial, particularly under the enhanced recovery after surgery (ERAS) protocol. ERAS advocates a multimodal perioperative strategy designed to attenuate surgical stress and optimize postoperative convalescence.

AIM

To evaluate the necessity of abdominal drainage tube placement following radical gastrectomy in the context of ERAS protocols.

METHODS

A systematic review and meta-analysis were conducted by searching PubMed, EMBASE, Cochrane Library, Web of Science, China National Knowledge Infrastructure, Wanfang, VIP Information, and SinoMed databases for randomized controlled trials comparing outcomes of abdominal drainage vs no drainage after gastrectomy under ERAS protocols. Primary outcomes included time to gastrointestinal function recovery, drainage tube removal time, postoperative complication rates, and length of hospital stay. Review Manager 5.4 was used for statistical analysis, and heterogeneity was assessed using the I² statistic.

RESULTS

A total of 21 randomized controlled trials involving 1652 patients were included. Compared with routine abdominal drainage, the ERAS group without drainage showed significantly faster gastrointestinal recovery [standardized mean difference = -1.30, 95% confidence interval (CI): -1.66 to -0.94, P < 0.00001] and shorter hospital stay (standardized mean difference = -1.37, 95%CI: -1.86 to -0.88, P < 0.00001). The incidence of total postoperative complications was also significantly lower (odds ratio = 0.53, 95%CI: 0.40-0.70, P < 0.00001), particularly for anastomotic leakage and pulmonary infection. No significant differences were observed in surgical site infections or urinary tract infections. Sensitivity and subgroup analyses indicated stability of results, although some heterogeneity was noted.

CONCLUSION

Avoiding routine abdominal drainage under ERAS could lead to faster recovery, reduced complications, and shorter hospital stay following radical gastrectomy, supporting the selective use of drainage rather than routine.

Key Words: Rapid rehabilitation surgery; Accelerated rehabilitation surgery; Gastric cancer; System evaluation; Postoperative complications; Gastrointestinal recovery; Hospital stay; Healthcare costs

Core Tip: Enhanced recovery after surgery in radical gastrectomy supports early drain removal, faster gastrointestinal recovery, shorter hospitalization, and fewer complications. This review of 21 randomized controlled trials highlights safety and benefits, but also the need for better protocol standardization and region-specific adaptation, as current data stem solely from Asian populations. Strengthening protocol standardization, interdisciplinary coordination, and localized implementation strategies may enhance enhanced recovery after surgery effectiveness in clinical practice.

INTRODUCTION

Gastric cancer (GC) is one of the most common malignant tumors of the digestive system worldwide[1]. According to Global Cancer Observatory estimates, in 2020, the global incidence of GC reached 1.089 million cases[2], ranking fifth among all cancer types, with 480000 new cases reported in China alone[3]. Enhanced recovery after surgery (ERAS), also known as fast-track surgery (FTS), was first proposed by Danish scholar Henrik Kehlet in 1990, and introduced into China by Academician Li and Jiang[4] in 2015. Postoperative complications, particularly bleeding, infection, and anastomotic leakage, remain major concerns after GC surgery, with incidence rates varying by surgical approach, patient profile, and perioperative care, often leading to delayed recovery, extended hospitalization, and higher medical costs[5]. ERAS protocols, developed through multidisciplinary collaboration and evidence-based medicine, aim to shorten hospital stays, reduce complications, improve patient outcomes, and ultimately enhance survival rates. However, the application of ERAS in GC has lagged behind other surgical specialties[6,7]. Traditionally, radical gastrectomy involves extensive lymph node dissection, which can lead to significant wound exudation and therefore requires prophylactic placement of an abdominal drainage tube to drain abdominal fluid and prevent intra-abdominal infections. Although current guidelines recommend minimizing and promoting early removal of drainage tubes to reduce complications such as infection, adherence to these guidelines remains suboptimal[8]. Moreover, some surgeons continue to question the safety and efficacy of this approach, underscoring the need for further high-quality studies to assess the actual impact of ERAS on perioperative management in GC[9].

A particular point of contention between ERAS protocols and traditional surgical practices is the routine placement of an abdominal drainage tube during radical gastrectomy. This systematic review, therefore, aims to evaluate the safety and efficacy of abdominal drainage tube placement under ERAS, providing a more robust and systematic basis for clinical decision-making and offering strong evidence for perioperative nursing care of patients with GC.

MATERIALS AND METHODS

Registration

This study was prospectively registered in the PROSPERO International Systematic Review Registry (https://www.crd.york.ac.uk/prospero/, accessed on August 31, 2024; registration number CRD42023429639). The study follows the PRISMA guidelines[10].

Search strategy

The search strategy was developed following the Cochrane Handbook (2011) guidelines. The databases screened included China National Knowledge Infrastructure, WanFang, VIP Information, Web of Science, PubMed, and MEDLINE (from January 1, 2000 to August 31, 2024). The search terms included GC, gastric tumor, abdominal drainage, FTS, ERAS, randomized controlled trial (RCT), GC surgery, ERAS, FTS, stomach neoplasms, covering both Chinese and English literature.

Inclusion criteria: “Population”: (1) Patients with GC, with no restrictions on gender, age, nationality, or ethnicity; and (2) The diagnosis of GC was confirmed by postoperative histopathological examination[11]. “Intervention”: In accordance with the 2014 European ERAS Society guidelines for gastrointestinal surgery[12], which define 25 evidence-based perioperative elements across three stages (preoperative, intraoperative, and postoperative), we considered studies eligible if they reported implementing at least 10 of the following validated components: Shortened preoperative fasting, preoperative carbohydrate loading, avoidance of routine mechanical bowel preparation, intraoperative normothermia maintenance, fluid restriction or goal-directed fluid therapy, avoidance of nasogastric tubes, avoidance of routine abdominal drains, multimodal analgesia, early oral intake, and early mobilization, which have been consistently supported by high-quality clinical evidence and are considered core indicators of ERAS adherence[13,14]. “Comparison”: Traditional perioperative care concepts for GC patients. “Outcome”: (1) Gastrointestinal function recovery indicators (time to first flatus, time to first oral intake, time to first ambulation, length of hospital stay, hospitalization costs); (2) Drainage tube removal time (nasogastric tube removal time, urinary catheter removal time, abdominal drainage tube removal time); and (3) Postoperative complications (overall complication rate, incidence of intestinal obstruction, nausea and vomiting, anastomotic leakage, surgical site infection, urinary tract infection, pulmonary infection)[15]. “Study design”: RCTs.

Exclusion criteria: (1) Patients who had undergone preoperative chemotherapy or had severe underlying diseases; (2) Non-RCTs; and (3) Studies for which full text was unavailable or where data were incomplete.

Data extraction

Two researchers (L, L) followed the search strategy, conducted an initial screening of the literature by reading the titles, and performed a secondary screening for eligible studies before downloading the full texts. The researchers independently scored the studies, and any discrepancies were resolved by a third reviewer (C) for comprehensive evaluation. Microsoft Excel was used to extract: First author’s name, country/region, intervention duration, study population, sample size (cases), intervention group measures, control group measures, and outcome indicators.

Risk of bias assessment

In this study, we used both the Jadad scale and the Cochrane risk of bias tool (RevMan 5.4) to assess methodological quality[16]. The Jadad scale evaluates random sequence generation (0-2 points), implementation of blinding (0-2 points), and reporting of withdrawals and dropouts (0-1 point), yielding a total score between 0 and 5. Studies scoring ≥ 3 points were considered high quality, while those scoring ≤ 2 were classified as low quality. The Cochrane risk of bias tool (RevMan 5.4) assessed seven domains, including selection bias (random sequence generation and allocation concealment), performance bias (blinding of participants and personnel), detection bias (blinding of outcome assessors), attrition bias, reporting bias, and other sources of bias. Risk levels were categorized as high, low, or unclear. Two reviewers conducted independent assessments with a kappa value of 0.870, indicating high inter-rater agreement. To assess the impact of study quality on the meta-analysis results, sensitivity analyses were conducted by excluding studies with high risk in randomization or blinding domains.

Dealing with missing data

According to the Cochrane Handbook guidelines[17], if post-intervention values with standard deviations are unavailable, change scores with corresponding standard deviations will be used. When standard deviations are missing, they will be estimated based on standard errors, P values, and confidence intervals.

Statistical analysis

Review Manager 5.3 was used for data analysis. Heterogeneity was assessed using Q-tests and I² tests, and forest plots were used to present relative risk/odds ratio (OR), mean difference/standardized mean difference (SMD), and 95% confidence intervals (CIs). Based on P values and I² values, an appropriate effect model was selected: When I² < 50%, a fixed-effects model (FEM) was used; when I² > 50%, a random-effects model (REM) was applied[18].

Subgroup and sensitivity analyses

Subgroup analysis was conducted for time to first flatus, time to first oral intake, time to first ambulation, and urinary catheter removal time. Sensitivity analysis was performed by modifying key influencing factors to assess whether changes occurred in the results, thereby determining the stability and robustness of the findings.

Credibility of the evidence

The Cochrane risk of bias tool was used to assess the risk of bias in the included studies. Publication bias was analyzed using funnel plots, and the Grades of Recommendations Assessment, Development and Evaluation (GRADE) rating system was applied to evaluate the results of the traditional meta-analysis. A combined effect analysis was conducted for key and important outcomes in the meta-analysis to integrate both direct and indirect evidence.

RESULTS

Search results and study selection

A total of 2232 Chinese-language studies and 1050 English-language studies were initially identified. After removing 2797 duplicate publications, 139 studies were included after screening by title and abstract. Studies without clear outcome indicators or with unavailable full texts were excluded. The literature screening process is shown in Figure 1.

Figure 1 Literature screening flowchart. CNKI: China National Knowledge Infrastructure; VIP: VIP Information; RCT: Randomized controlled trial.

Study characteristics

A total of 21 randomized controlled trials were finally included[19-39] (2 from South Korea and 19 from China). The surgical procedures encompassed total gastrectomy or subtotal gastrectomy with D2 or more extensive lymphadenectomy, radical gastrectomy, and laparoscopic-assisted radical gastrectomy. All 21 included studies were two-arm trials, with the intervention group based on the concepts of FTS and ERAS. The basic characteristics of the included studies are shown in Table 1, Figure 2.

Figure 2  Risk of bias chart for included studies.

Table 1 General information of the included studies.

Ref.	Location	Intervention period	Study participants	Surgical method	Sample size	Intervention group	Control group	Outcome indicators
Kim et al[19], 2004	Korea	February 1, 2001-July 31, 2001	Gastric cancer patients	Total or subtotal gastrectomy with D2 or more lymph node dissection	I = 31, C = 21	FTS	Conventional care	1, 2, 13
Wang et al[20], 2019	China	March 1, 2016-October 31, 2016	Gastric cancer patients	Radical gastrectomy for gastric cancer	I = 30, C = 30	ERAS	Conventional care	1, 4, 6, 7, 8, 10, 11, 12, 13, 14
Kim et al[21], 2012	Korea	April 1, 2011-January 31, 2012	Gastric cancer patients	Laparoscopy-assisted radical gastrectomy with D2 Lymph node dissection	I = 22, C = 22	FTS	Conventional care	4, 9, 14
Abdikarim et al[22], 2015	China	June 1, 2010-December 31, 2012	Advanced gastric cancer patients	Laparoscopic surgery	I = 30, C = 31	ERAS	Conventional care	2, 3, 10, 13
Liu et al[23], 2016	China	September 1, 2014-August 31, 2015	Elderly gastric cancer patients	Laparoscopic surgery	I = 21, C = 21	FTS	Conventional care	1, 4, 5, 10, 11, 13, 14
Chen et al[24], 2012	China	January 1, 2009-May 31, 2011	Gastric cancer patients	Laparoscopy-assisted radical distal gastrectomy	I = 19, C = 22	FTS	Conventional care	5
Wu[25], 2018	China	December 1, 2015-August 31, 2017	Gastric cancer patients	Laparoscopic D2 radical gastrectomy	I = 34, C = 41	ERAS	Conventional care	1, 4, 9, 10, 13, 14
Chen[26], 2019	China	March 1, 2017-February 28, 2018	Advanced gastric cancer patients	D2 radical gastrectomy	I = 38, C = 37	ERAS	Conventional care	1, 4, 5, 9, 10, 12, 13, 14
Wu[27], 2019	China	June 1, 2016-June 30, 2017	Malignant gastric tumor patients	Total laparoscopic distal gastrectomy	I = 35, C = 35	ERAS	Conventional care	1, 4, 5, 9, 10, 11, 12, 13
Ma[28], 2019	China	January 1, 2018-January 31, 2019	Gastric cancer patients	Laparoscopic D2 radical gastrectomy	I = 40, C = 40	ERAS	Conventional care	4, 9, 11, 12
Wang[29], 2017	China	March 1, 2016-October 31, 2016	Gastric cancer patients	Radical gastrectomy for gastric cancer	I = 30, C = 30	ERAS	Conventional care	1, 4, 6, 8, 9, 10, 11, 12, 13, 14
Jiang et al[30], 2007	China	January 1, 2006-December 31, 2006	Gastric cancer patients	D2 radical resection	I = 40, C = 40	FTS	Conventional care	1, 4, 5, 9
Fan et al[31], 2019	China	April 1, 2017-May 31, 2018	Gastric cancer patients	Total gastrectomy or partial gastrectomy	I = 30, C = 30	FTS	Conventional care	1, 9, 11, 12
Li et al[32], 2016	China	July 1, 2013-February 28, 2015	Gastric adenocarcinoma patients	Laparoscopic radical gastrectomy	I = 67, C = 60	ERAS	Conventional care	1, 3, 4, 9, 12, 14
Chen[33], 2019	China	January 1, 2017-January 31, 2018	Gastric cancer patients	Laparoscopic surgery	I = 50, C = 50	FTS	Conventional care	1, 2, 4, 9, 10, 12, 13
Ruan et al[34], 2019	China	January 1, 2016-May 31, 2018	Gastric cancer patients	Laparoscopic radical gastrectomy	I = 65, C = 65	ERAS	Conventional care	1, 2, 9
Cheng[35], 2019	China	January 1, 2017-June 30, 2019	Gastric cancer patients	Laparoscopic radical gastrectomy	I = 29, C = 29	ERAS	Conventional care	1, 4, 6, 9, 10, 12, 13
Liu et al[36], 2018	China	May 1, 2015-July 31, 2017	Gastric cancer patients	Laparoscopic radical gastrectomy	I = 75, C = 74	ERAS	Conventional care	1, 2, 4, 8, 9, 10, 12, 14
Li and Huang[37], 2021	China	June 1, 2017-June 30, 2019	Gastric cancer patients	Laparoscopic radical gastrectomy	I = 41, C = 41	FTS	Conventional care	1, 4, 7, 10, 12
Miao[38], 2021	China	February 1, 2018-March 31, 2019	Gastric cancer patients	Laparoscopic D2 radical gastrectomy	I = 60, C = 60	ERAS	Conventional care	1, 4, 7, 9, 10, 11, 13
Liu and Li[39], 2021	China	March 1, 2017-May 31, 2020	Patients undergoing total gastrectomy for gastric cancer	Radical total gastrectomy	I = 43, C = 43	ERAS	Conventional care	4, 7, 8, 9, 12, 13

1: Time to first flatus; 2: Time to first defecation; 3: Time to first oral intake; 4: Time to ambulation; 5: Time to removal of abdominal drainage tube; 6: Time to recovery of bowel sounds; 7: Postoperative hospital stay; 8: Total hospital stay; 9: Incidence of total complications; 10: Incidence of anastomotic leakage; 11: Incidence of pulmonary infection; 12: Incidence of nausea and vomiting; 13: Incidence of surgical site infection; 14: Incidence of urinary tract infection; ERAS: Enhanced recovery after surgery; FTS: Fast-track surgery; I: Intervention group; C: Control group.

ERAS elements: Table 2 describes the implementation of perioperative ERAS core components in each study. Preoperative nutritional support was applied in 90.5% of studies and intraoperative opioid-sparing strategies in 47.6%, both exceeding the 40% threshold. Measures such as prophylactic antithrombotic therapy and airway management were implemented in 14.3% of studies. Importantly, all included studies applied ≥ 10 ERAS elements, with an average of 12.6 items per study (range: 10-18), thereby meeting the 2014 European ERAS guideline criteria. Low-frequency items, such as perioperative blood management (4.8%), were not considered mandatory under the guideline framework and were excluded from primary outcome analyses.

Table 2 Perioperative - core items of fast-track surgery.

Serial number	Phase	Enhanced recovery after surgery core projects	[19]	[20]	[21]	[22]	[23]	[24]	[25]	[26]	[27]	[28]	[29]	[30]	[31]	[32]	[33]	[34]	[35]	[36]	[37]	[38]	[39]
1	Preoperative	Preoperative education	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√
2		Smoking and alcohol cessation before surgery	-	√	-	-	-	√	-	-	-	-	√	-	-	-	-	-	-	-	-	-	√
3		Preoperative visit and assessment	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√
4		Prehabilitation	√	√	-	-	-	-	√	√	√	-	√	√	√	-	-	-	√	-	-	-	-
5		Preoperative nutritional support	-	√	√	-	-	√	√	-	√	-	-	-	-	-	-	-	-	-	√	√	-
6		Preventive antithrombotic treatment	-	-	-	-	-	-	-	-	√	-	-	-	-	-	-	-	-	-	-	√	√
7		Shortened preoperative fasting and drinking time	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√
8		No routine bowel preparation	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	-	-	-
9		Preoperative anesthesia medication	-	√	-	-	-	-	-	-	-	√	√	-	-	-	-	-	-	-	-	-	-
10		Prophylactic antibiotics and skin preparation	-	√	√	-	-	-	-	-	-	√	-	-	-	-	√	-	-	-	-	-	√
11		Anesthesia method, drug selection, and stress control	√	√	√	√	√	√	√	√	√	√	√	-	-	√	-	√	-	√	√	√	√
12	Intraoperative	Multimodal opioid-sparing analgesia	-	√	√	-	√	-	√	-	√	√	√	-	-	-	-	-	-	-	-	√	-
13		Inflammation control	-	√	-	-	-	-	-	-	-	-	-	-	-	-	-	-	√	-	-	-	-
14		Airway management and lung protection strategy	-	√	-	-	-	-	-	-	√	-	-	-	-	-	-	-	-	-	-	-	-
15		Brain protection strategy	-	-	√	-	√	-	√	-	√	√	√	-	-	-	√	-	-	-	-	-	-
16		Intraoperative fluid and circulation management	√	√	√	√	√	√	-	√	-	√	√	-	√	√	√	√	√	√	√	√	√
17		Intraoperative temperature management	-	√	-	-	√	-	√	√	√	√	√	√	-	√	-	-	√	√	-	√	-
18		Surgical method and quality	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	-	-	-
19		Perioperative blood glucose control	-	√	-	-	-	-	-	-	√	-	-	-	-	-	-	-	-	-	-	-	-
20		No routine nasogastric tube placement	√	√	-	√	√	√	√	-	√	√	√	√	√	√	√	√	√	-	-	-	-
21		No routine abdominal drainage	√	√	√	√	√	√	√	-	√	√	√	√	√		√	√	-	-	-	-	-
22		Intraoperative urinary catheter placement	√	√	√	√	√	√	√	-	√	√	-	-	-	√	-	-	√	-	-	-	-
23		Perioperative fluid therapy	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√
24	Postoperative	Postoperative pain management	√	√	√	√	√	√	√	√	√	√	√	√	√	√		√	√	√	√	√	√
25		Prevention and treatment of PONV	-	√	-	-	-	-	-	-	-	√	-	-	-	-	-	-	-	-	-	-	-
26		Early postoperative oral intake	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√
27		Blood management	-	-	-	-	√	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
28		Early postoperative mobilization		√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√
29		Discharge criteria	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√
30		Follow-up and outcome evaluation	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√
Total			16	27	19	16	20	18	20	15	23	22	21	15	15	16	15	15	17	14	12	15	14

PONV: Postoperative nausea and vomiting; √: Yes.

Risk of bias in included studies

Quality assessment of the included studies based on the Cochrane Handbook is shown in Table 3. The Cochrane + Jadad scale was used to evaluate the quality of the included studies, with an overall rating of moderate to high quality. Two researchers independently assessed the studies, achieving a Kappa consistency of 0.870[40]. Among the 21 included studies[19-39], eight studies had a high risk of bias in the description of randomization methods[25,30,31,33-35,38,39], and 14 studies did not report withdrawal or loss to follow-up[21,23-25,28,34-38].

Table 3 Quality assessment of included studies (based on Cochrane Handbook - version 5.4.0).

Ref.	Selection bias		Performance bias	Detection bias	Attrition bias	Reporting bias	Other bias	Jadad score
Kim et al[19], 2004	1	2	1	1	1	1	1	7
Wang et al[20], 2019	1	2	1	1	1	1	1	7
Kim et al[21], 2012	1	1	1	1	2	1	1	5
Abdikarim et al[22], 2015	1	2	1	1	1	1	1	5
Liu et al[23], 2016	1	2	1	1	2	1	1	5
Chen et al[24], 2012	1	2	1	1	2	1	1	6
Wu[25], 2018	2	2	1	1	2	1	1	5
Chen[26], 2019	1	2	1	1	2	1	1	5
Wu[27], 2019	1	2	1	1	2	1	1	5
Ma[28], 2019	1	2	1	1	2	1	1	5
Wang[29], 2017	1	1	1	1	2	1	1	6
Jiang et al[30], 2007	2	3	1	1	3	1	1	4
Fan et al[31], 2019	2	3	1	1	3	1	1	3
Li et al[32], 2016	1	2	2	1	2	1	1	4
Chen[33], 2019	2	3	1	1	3	1	1	3
Ruan et al[34], 2019	2	2	1	1	2	1	1	4
Cheng[35], 2019	2	2	1	1	2	1	1	4
Liu et al[36], 2018	1	2	1	1	2	1	1	4
Li and Huang[37], 2021	1	3	1	1	2	1	1	3
Miao[38], 2021	2	2	1	1	2	1	1	3
Liu and Li[39], 2021	2	3	1	1	3	1	1	3

Effects of the interventions

Gastrointestinal function recovery: (1) Time to first flatus: Sixteen studies[19,20,23,25-27,29-38] were divided into two subgroups (P ≤ 0.1 and I² > 50%), showing no statistically significant differences; therefore, a REM was used. Time to first flatus (hours) [weighted mean difference (WMD) = -10.24 (-12.69 to -7.79), P < 0.01]. Time to first flatus (days) [WMD = -1.09 (-1.36 to -0.83), P < 0.01], Figure 3A; (2) Time to oral intake: Five studies[19,22,33,34,36] were divided into two subgroups (P > 0.1 and I² < 50%), showing statistically significant differences; therefore, a FEM was used. 1 Time to oral intake (hours) [WMD = -21.06 (-23.18 to -18.94), P < 0.01]. 2 Time to oral intake (days) [WMD = -0.56 (-0.92 to -0.20), P < 0.01]; (3) Time to first ambulation: Two studies[22,32] (P > 0.1 and I² < 50%) showed statistically significant differences; therefore, REM was used. Time to first ambulation (days) [WMD = -0.45 (-0.74 to -0.16), P < 0.01]; (4) Length of hospital stay: Fifteen studies[20,21,23,25-30,32,33,35,37-39] (P > 0.1 and I² < 50%) showed statistically significant differences; therefore, FEM was used. Length of hospital stay [WMD = -2.92 (-3.15 to -2.68), P < 0.01], Figure 3B; and (5) Hospitalization costs: Seven studies[23,24,26,27,29,30,36] (P ≤ 0.1 and I² > 50%) showed no statistically significant differences; therefore, REM was used. Hospitalization costs [SMD = -0.72 (-0.90 to -0.54), P < 0.01], Figure 3C.

Figure 3 Gastrointestinal function recovery. A: Forest plot of time to first flatus; B: Forest plot of length of hospital stay; C: Forest plot of hospitalization cost. CI: Confidence interval.

Time to drainage tube removal: (1) Time to nasogastric tube removal: Three studies[20,29,35] (P > 0.1 and I² < 50%) showed statistically significant differences; therefore, FEM was used. Time to nasogastric tube removal [WMD = -1.70 (-1.96 to -1.44), P < 0.01], Figure 4A; (2) Time to urinary catheter removal: Four studies[20,37-39] were divided into two subgroups (P ≤ 0.1 and I² > 50%), showing no statistically significant differences; therefore, REM was used. Time to urinary catheter removal (hours) [WMD = -4.52 (-5.57 to -3.48), P < 0.01]. Time to urinary catheter removal (days) [WMD = -2.33 (-2.80 to -1.86), P < 0.01], Figure 4B; and (3) Time to abdominal drain removal: Four studies[20,36,29,39] (P > 0.1 and I² < 50%) showed statistically significant differences; therefore, FEM was used. Time to abdominal drain removal [SMD = -0.91 (-1.13 to -0.69), P < 0.01], Figure 4C.

Figure 4 Time to drainage tube removal. A: Forest plot of nasogastric tube removal time; B: Forest plot of urinary catheter removal time; C: Forest plot of abdominal drain removal time. CI: Confidence interval.

Incidence of complications: (1) Overall Incidence of complications: Sixteen studies[21,25-39] (P > 0.1 and I² < 50%) showed statistically significant differences; therefore, FEM was used. Overall incidence of complications [OR = 0.41 (0.30-0.05), P < 0.01], Figure 5A; (2) Incidence of intestinal obstruction: Twelve studies[20,22,23,25-27,29,33,35-38] (P > 0.1 and I² < 50%) showed statistically significant differences; therefore, FEM was used. Incidence of intestinal obstruction [OR = 0.83 (0.41-1.71), P = 0.62], Figure 5B; (3) Incidence of nausea and vomiting: Six studies[20,23,27,29,31,38] (P > 0.1 and I² < 50%) showed statistically significant differences; therefore, FEM was used. Incidence of nausea and vomiting [OR = 1.07 (0.52-2.20), P = 0.85], Figure 5C; (4) Incidence of anastomotic leakage: Twelve studies[20,26-29,31-33,35-37,39] (P > 0.1 and I² < 50%) showed statistically significant differences; therefore, FEM was used. Incidence of anastomotic leakage [OR = 0.37 (0.15-0.89), P = 0.03], Figure 5D; (5) Incidence of surgical site infection: Thirteen studies[19,20,22,23,25-27,29,33,35,36,38,39] (P > 0.1 and I² < 50%) showed statistically significant differences; therefore, FEM was used. Incidence of surgical site infection [OR = 0.56 (0.27-1.18), P = 0.13], Figure 5E; (6) Incidence of urinary tract infection: Eight studies[20,21,23,25,26,29,32,36] (P > 0.1 and I² < 50%) showed statistically significant differences; therefore, FEM was used. Incidence of urinary tract infection [OR = 0.39 (0.14-1.06), P = 0.06], Figure 5F; and (7) Incidence of pulmonary infection: Nine studies[20,23,27,29,32,33,35,36,39] (P > 0.1 and I² < 50%) showed statistically significant differences; therefore, FEM was used. Incidence of pulmonary infection [OR = 0.38 (0.17-0.83), P = 0.02], Figure 5G.

Figure 5 Incidence of complications. A: Forest plot of overall complication rate; B: Forest plot of intestinal obstruction incidence; C: Forest plot of nausea and vomiting incidence; D: Forest plot of anastomotic leakage incidence; E: Forest plot of surgical site infection incidence; F: Forest plot of urinary tract infection incidence; G: Forest plot of pulmonary infection incidence. CI: Confidence interval.

Sensitivity analyses

Sensitivity analysis was conducted based on the degree of heterogeneity. When using the REM, the results did not significantly differ from those of the FEM, indicating the stability of the findings. Additionally, after excluding low-quality studies and reanalyzing the data using a traditional meta-analysis approach, the overall effect size remained unchanged, demonstrating the robustness of the results[10].

The time to first flatus outcome was divided into two subgroups, with subgroup 1 including 7 studies and subgroup 2 including 9 studies, all reporting on the impact of ERAS interventions on postoperative flatus time. The meta-analysis showed heterogeneity exceeding 50%. After sequentially removing studies with high weights, the overall meta-analysis results remained unchanged, suggesting good overall stability.

Sensitivity analysis of the time to first flatus subgroup revealed that three studies[25-27] significantly deviated from the X-axis in the forest plot. After excluding these studies, heterogeneity disappeared (P ≤ 0.1 and I² > 50%), and the difference was not statistically significant, confirming the use of the REM. The results remained statistically significant for subgroup 1 [SMD = -1.11, 95%CI: -1.32 to -0.90, P < 0.01] and subgroup 2 [SMD = -1.34, 95%CI: -1.83 to -0.85, P < 0.01], indicating stable findings.

For hospitalization costs, the sensitivity analysis identified one study that significantly deviated from the X-axis in the forest plot. After excluding this study, heterogeneity disappeared (P ≤ 0.1 and I² > 50%), with no statistically significant difference, supporting the use of the REM. The results remained statistically significant (SMD = -0.64, 95%CI: -0.83 to -0.46,P < 0.01), confirming the stability of the findings.

Publication bias

The funnel plot for hospitalization time demonstrated a symmetrical distribution of data points within the funnel boundaries, with most points clustered in the upper and middle regions, suggesting a low likelihood of publication bias (Figure 6A). For hospitalization costs (Figure 6B) and complication rates (Figure 6C), the funnel plots also showed symmetrical distributions, with data points predominantly concentrated in the middle and lower regions, indicating the inclusion of numerous small-sample studies. While this pattern may reflect underlying heterogeneity or selective reporting, the visual inspection did not reveal substantial asymmetry.

Figure 6 Funnel plot of complication rates. A: Forest plot of hospitalization time; B: Funnel plot of hospitalization cost; C: Funnel plot of complication rates. MD: Mean difference; SMD: Standardized mean difference; OR: Odds ratio.

GRADE evidence quality evaluation

This study assessed 18 outcome indicators, with hospitalization costs and urinary catheter removal time classified as moderate-quality evidence, while all other indicators were classified as high-quality evidence. These included 13 key outcomes and 5 important outcomes. The GRADE system assessed the level of evidence based on risk of bias, inconsistency, indirectness, and imprecision, as detailed in Table 4.

Table 4 Summary of Grading of Recommendations Assessment, Development and Evaluation evidence.

Certainty assessment					Number of patients		Effect
Outcome	n	Study design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	Intervention	Control	Relative (95%CI)	Absolute (95%CI)	Certainty	Importance
Time to first flatus (hour)	7	Randomized trials	Not serious	Not serious	Not serious	Not serious	None	345	343	-	MD = 10.24 Lower (12.69 Lower, 7.79 Lower)	++++ high	Critical
Time to first flatus (day)	9	Randomized trials	Not serious	Not serious	Not serious	Not serious	None	322	322	-	MD = 1.09 SD: Lower (1.36 Lower, 0.83 Lower)	++++ high	Critical
Time to oral intake (hour)	3	Randomized trials	Not serious	Not serious	Not serious	Not serious	None	190	189	-	MD = 21.06 Lower (23.18 Lower, 18.94 Lower)	++++ high	Critical
Time to oral intake (day)	2	Randomized trials	Not serious	Not serious	Not serious	Not serious	None	61	52	-	MD = 0.56 Lower (0.92 Lower, 0.2 Lower)	++++ high	Critical
Time to first ambulation (day)	2	Randomized trials	Not serious	Not serious	Not serious	Not serious	None	97	91	-	SMD = 0.45 SD: Lower (0.74 Lower, 0.16 Lower)	++++ high	Critical
Length of hospital stay	15	Randomized trials	Not serious	Not serious	Not serious	Not serious	None	580	579	-	MD = 2.92 Lower (3.15 Lower, 2.68 Lower)	++++ high	Important
Hospitalization cost	7	Randomized trials	Not serious	Not serious	Serious a	Not serious	None	258	259	-	SMD = 0.72 SD: Lower (0.9 Lower, 0.54 Lower)	+++-moderate a	Important
Nasogastric tube removal time (day)	3	Randomized trials	Not serious	Not serious	Not serious	Not serious	None	89	89	-	MD = 1.7 Lower (1.96 Lower, 1.44 Lower)	++++ high	Critical
Urinary catheter removal time (hour)	2	Randomized trials	Not serious	Not serious	Serious b	Not serious	None	103	103	-	SMD = 4.52 SD: Lower (5.57 Lower, 3.48 Lower)	+++-moderate a	Critical
Urinary catheter removal time (day)	2	Randomized trials	Not serious	Not serious	Not serious	Not serious	None	60	60	-	SMD = 2.33 SD: Lower (2.8 Lower, 1.86 Lower)	++++ high	Critical
Abdominal drain removal time	4	Randomized trials	Not serious	Not serious	Not serious	Not serious	None	178	177	-	SMD = 0.91 SD: Lower (1.13 Lower, 0.69 Lower)	++++ high	Critical
Total complication rate	16	Randomized trials	Not serious	Not serious	Not serious	Not serious	None	88/699 (12.6%)	173/697 (24.8%)	OR = 0.41 (0.30-0.55)	129 fewer per 1000 (from 158 fewer to 95 fewer)	++++ high	Critical
Incidence of intestinal obstruction	12	Randomized trials	Not serious	Not serious	Not serious	Not serious	None	13/473 (2.7%)	16/479 (3.3%)	OR = 0.83 (0.41-1.71)	6 fewer per 1000 (from 19 fewer to 22 more)	++++ high	Critical
Incidence of nausea and vomiting	6	Randomized trials	Not serious	Not serious	Not serious	Not serious	None	16/206 (7.8%)	15/206 (7.3%)	OR = 1.07 (0.52-2.20)	5 more per 1000 (from 34 fewer to 75 more)	++++ high	Important
Incidence of anastomotic leakage	12	Randomized trials	Not serious	Not serious	Not serious	Not serious	None	6/508 (1.2%)	17/499 (3.4%)	OR = 0.37 (0.15-0.89)	21 fewer per 1000 (from 29 fewer to 4 fewer)	++++ high	Critical
Incidence of surgical site infection	13	Randomized trials	Not serious	Not serious	Not serious	Not serious	None	10/506 (2.0%)	18/502 (3.6%)	OR = 0.56 (0.27-1.18)	15 fewer per 1000 (from 26 fewer to 6 more)	++++ high	Critical
Incidence of urinary tract infection	8	Randomized trials	Not serious	Not serious	Not serious	Not serious	None	3/317 (0.9%)	11/315 (3.5%)	OR = 0.39 (0.14-1.06)	21 fewer per 1000 (from 30 fewer to 2 more)	++++ high	Important
Incidence of pulmonary infection	9	Randomized trials	Not serious	Not serious	Not serious	Not serious	None	8/380 (2.1%)	21/372 (5.6%)	OR = 0.38 (0.17-0.83)	34 fewer per 1000 (from 46 fewer to 9 fewer)	++++ high	Important

Unit conversion may lead to heterogeneity among studies; few patients and observed events included in the study/does not meet optimal information size/95% confidence interval too wide. CI: Confidence interval; MD: Mean difference; OR: Odds ratio; SMD: Standardized mean difference; +: Grading of Recommendations Assessment, Development and Evaluation quality rating symbol; ++++: High certainty; +++-: Moderate certainty.

DISCUSSION

GRADE evidence quality and recommendation level

The GRADE analysis included 13 key outcome indicators, with high-quality evidence indicating that ERAS interventions had a significant impact on these key outcomes, making them highly valuable for clinical decision-making. Additionally, 5 important outcome indicators were assessed, where the evidence quality was slightly lower than that of key outcome indicators, but still played a crucial role in overall patient recovery and economic burden. Postoperative nausea and vomiting not only affects patient comfort and satisfaction but may also lead to prolonged hospitalization and increased medical costs. Therefore, these important outcome indicators should also be given attention in clinical practice, with appropriate preventive and management strategies implemented to control them effectively[41].

Analysis of gastrointestinal function recovery

Gastrointestinal function recovery is a key target of ERAS protocols in abdominal surgery. Traditionally, preoperative mechanical bowel preparation has been used to reduce the bacterial load within the digestive tract, thereby lowering the risk of postoperative infections and anastomotic leakage[42]. However, this practice is being increasingly reconsidered under ERAS principles, which emphasize minimizing surgical stress and promoting early functional recovery.

In this meta-analysis, sixteen studies assessed the effect of ERAS protocols on time to first flatus. Although subgroup analyses revealed statistically significant reductions in both hours and days, considerable heterogeneity was observed among the studies. Therefore, while the results suggest a potential association between ERAS interventions and earlier return of bowel function, these findings should be interpreted with caution. The variation in intervention protocols, patient characteristics, and outcome definitions may have influenced the overall estimates.

Beyond bowel recovery, ERAS protocols were associated with shorter time to first ambulation and reduced hospital length of stay. These outcomes are likely attributable to coordinated perioperative strategies, such as early oral intake, limited use of intravenous fluids, and minimized reliance on routine mechanical bowel preparation and nasogastric decompression[43]. Furthermore, individualized management of postoperative drainage contributes to earlier mobilization and discharge readiness. Evidence from the included studies indicated that ERAS groups experienced a mean reduction in hospital stay by 1.12 days compared to conventional care[44,45]. In summary, while the overall trends support the beneficial effects of ERAS on postoperative gastrointestinal recovery, the observed interstudy heterogeneity underscores the need for further standardized, high-quality trials to confirm these findings.

Analysis of drainage tube removal timing

ERAS guidelines recommend avoiding routine nasogastric decompression and not placing prophylactic intra-abdominal drainage tubes in elective abdominal surgeries[46]. This approach helps reduce the incidence of postoperative atelectasis and pneumonia[47]. ERAS nursing focuses on minimizing surgical trauma while maximizing therapeutic efficacy, gaining increasing acceptance among medical professionals. Studies have demonstrated that ERAS patients have shorter postoperative hospital stays compared to traditional care groups, with a 34% lower risk of postoperative complications[48]. Additionally, ERAS has been shown to reduce postoperative inflammatory responses and enhance immune function, further promoting faster recovery. For future clinical applications, it is recommended to establish an ERAS assessment system (ERAS Interactive Audit System). This system should use web-based data input and analysis to monitor pathway adherence, evaluate its impact on clinical outcomes, and implement a feedback mechanism to continuously improve ERAS protocols.

Analysis of postoperative complications

ERAS protocols emphasize early postoperative oral intake and hydration in elective abdominal surgery to promote gastrointestinal function recovery and maintain the integrity of the intestinal mucosal barrier, which may reduce infection risk and contribute to shorter hospital stays[49]. In parallel, early mobilization under ERAS facilitates systemic recovery across multiple organ systems, including the respiratory, gastrointestinal, and musculoskeletal systems, thereby decreasing the incidence of pulmonary complications, pressure ulcers, and venous thromboembolism.

In this meta-analysis, ERAS interventions were associated with a significantly lower overall rate of postoperative complications. Specifically, reductions were observed in the incidence of anastomotic leakage and pulmonary infection, while no significant differences were found for intestinal obstruction, nausea and vomiting, surgical site infections, or urinary tract infections. These results align with prior findings, such as those reported by Zhang[50], whose meta-analysis indicated that drainage tube placement prolonged postoperative hospitalization and increased the likelihood of drainage-related complications. Similarly, another meta-analysis demonstrated that omitting prophylactic drainage after gastrectomy was associated with a lower complication rate and reduced length of stay[51]. Furthermore, the routine use of drainage tubes may exacerbate patient discomfort and hinder early ambulation, thereby delaying recovery and increasing the risk of secondary injury[52].

Taken together, these findings support the ERAS guideline recommendation to avoid routine drainage following gastrectomy. The evidence suggests that minimizing unnecessary drainage tube use can enhance recovery while reducing complication rates. To ensure safe and effective implementation of this approach, institutions should adopt standardized postoperative nursing protocols, invest in staff training, and establish robust early surveillance systems. These strategies are essential for improving ERAS adherence and optimizing postoperative outcomes.

Regional scope and implications for generalizability

All 21 included studies were from Asia, with 19 conducted in China and 2 in South Korea, which limits the extrapolation of the findings to non-Asian populations. GC presents with distinct epidemiological characteristics across regions, including differences in tumor distribution, Helicobacter pylori infection rates, genetic background, and dietary habits, with nearly 50% of all cases originating from China. These variations may influence perioperative risk profiles and potentially modify the effectiveness of specific ERAS components, particularly those related to nutritional management and recovery pathways. The predominance of Asian studies in this meta-analysis likely reflects the greater availability of randomized controlled trials meeting inclusion criteria from Chinese databases and a potential increasing emphasis on ERAS implementation. For instance, the integration of ERAS protocols into Chinese hospital evaluation systems and research agendas has contributed to a growing body of literature on this topic. European ERAS studies may emphasize long-term outcomes, involve multicenter designs, or appear in publication formats outside our search parameters, potentially explaining their lower visibility. These contextual variations highlight the necessity of validating ERAS protocols within a range of healthcare settings.

Despite variability in implementation rates of individual ERAS components, our analysis confirms that all included studies met the ERAS framework by integrating at least 10 guideline-based elements[12]. Components with implementation rates < 15%, such as blood glucose control or prophylactic anticoagulation, are recommended but not mandatory measures per the 2014 European guidelines. The low adoption of these elements is often due to resource constraints and institutional practice patterns, such as limited availability of intraoperative autologous transfusion technology in lower-tier hospitals. Importantly, sensitivity analyses demonstrated that the omission of these low-frequency items did not affect the main outcome measures, including length of stay and complication rates. Therefore, the classification of the included population as “ERAS patients” remains valid. These findings highlight the necessity of distinguishing between the breadth of protocol coverage and the depth of individual item implementation in evaluating ERAS effectiveness.

To adapt perioperative strategies to diverse patient populations, clinical practices, and healthcare settings, future international multicenter trials should incorporate both patient-reported outcomes and standardized ERAS adherence metrics. The use of tools such as adherence scores or the ERAS Interactive Audit System would help quantify protocol compliance and improve the reliability of outcome comparisons across studies. In parallel, the establishment of a global ERAS registry platform could facilitate international data sharing and support the development of region-specific, evidence-based care pathways for GC surgery.

Strengths and limitations

This study has several limitations. First, it included only RCTs published in Chinese and English since 2000, which may have excluded relevant studies and reduced the comprehensiveness of the evidence base. Second, some included trials were conducted by the same surgical teams, potentially introducing bias due to lack of independent validation. Third, although the overall methodological quality was rated as moderate to high, eight studies had a high risk of bias in randomization, and fourteen did not report withdrawal or loss to follow-up, raising concerns about performance and detection bias. While sensitivity analyses excluding high-risk studies demonstrated consistent effect directions, the absence of blinding in many trials may have inflated effect estimates, leading to downgrading of the recommendation strength for several outcomes in the GRADE assessment. Fourth, although all studies met the minimum requirement of implementing at least ten ERAS components, substantial variation was observed in the selection and reporting of these components. Measures such as opioid-sparing analgesia and nutritional support were applied in fewer than 40% of studies, and elements like blood glucose control and antithrombotic prophylaxis in fewer than 15%, reflecting notable heterogeneity in ERAS implementation and limiting the generalizability of pooled results. Lastly, national surveys indicate that even tertiary hospitals in China often implement only a limited number of ERAS components due to staffing shortages, limited interdisciplinary coordination, and inadequate training. Future studies should address these limitations by expanding literature search strategies, ensuring methodological rigor with appropriate randomization and blinding, standardizing ERAS intervention protocols, and adopting large-sample, multicenter trial designs with transparent reporting in accordance with Consolidated Standards of Reporting Trials guidelines.

CONCLUSION

This meta-analysis of 21 randomized controlled trials suggests that ERAS protocols in GC surgery can enhance gastrointestinal recovery, shorten drainage tube duration and hospital stay, and reduce the overall incidence of complications, particularly anastomotic leakage and pulmonary infection. However, considerable heterogeneity was observed in certain outcomes, especially time to first flatus, and the effects on complications such as surgical site infection or urinary tract infection were not statistically significant. Additionally, all studies were conducted in Asian populations with variable ERAS implementation, limiting generalizability. These findings indicate that early oral intake appears safe and that routine prophylactic drainage may be unnecessary in selected patients managed under ERAS pathways. While the results support integrating ERAS into standard perioperative care, further large-scale, multicenter trials with standardized ERAS adherence reporting are needed to validate its safety and effectiveness across diverse clinical settings.