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

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.

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.

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

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.