The efficacy and safety of enhanced recovery after surgery (ERAS) Program in laparoscopic distal gastrectomy: a systematic review and meta-analysis of randomized controlled trials

Figures & data

Figure 1. PRISMA flowchart of literature selection.

Figure 2. The reporting results of ERAS items in the included RCTs.

(The ERAS items: 1, Preoperative nutrition; 2, Wound catheters and transversus abdominis plane block; 3, Avoid nasogastric/nasojejunal decompression; 4, Avoiding the use of abdominal drains; 5, Early postoperative diet and artificial nutrition; 6, Preoperative counselling; 7, Preoperative smoking and alcohol consumption; 8, Avoid preoperative bowel preparation; 9, Preoperative fasting and preoperative treatment with carbohydrates; 10, No Preanesthetic Medication; 11, Antithrombotic prophylaxis; 12, Antimicrobial prophylaxis and skin preparation; 13, Epidural analgesia; 14, Intravenous analgesia; 15, Anaesthetic management; 16, Prevention of nausea and vomiting; 17, Avoiding hypothermia; 18, Postoperative glycaemic control; 19, Fluid balance; 20, Early urinary drainage tube removal; 21, Stimulation of bowel movement; 22, Early and scheduled mobilization)

Figure 2 showed the ERAS items reported in both the ERAS and TC groups during different time periods: (A) all, (B) before 2015, (C) after 2015.

Table 1. Basic characteristics of the included RCTs.

Study	Year	Country	Sample (n)		Age (years)		Sex (male/female)		BMI (kg/m^2)		Follow-up (days)	Outcomes
			ERAS	TC	ERAS	TC	ERAS	TC	ERAS	TC
Song, XC [43]	2020	China	42	33	≤60(18), >60(24)	≤60(16), >60(17)	22/20	20/13	NA	NA	NA	1,2,4,5,7,9.
Wu, HF [41]	2019	China	35	35	61.53 ± 10.30	63.53 ± 11.57	25/10	28/7	22.65 ± 2.3	22.31 ± 2.1	28	1,2,3,4,5,6,7,9,10,16,17,18,20.
Xu, X [35]	2017	China	30	30	60.20 ± 8.10	60.12 ± 8.14	12/18	16/14	22.41 ± 2.02	22.68 ± 2.38	30	1,2,4,5,7,9,10,16,19,20.
Yang, Y [36]	2017	China	21	21	60.5 ± 7.7	61.0 ± 7.5	15/6	13/8	NA	NA	NA	1,2,3,4,5,6,7,9,10,11,12,14,15,16,19,20.
Kang, JR [38]	2017	China	40	40	61.12 ± 4.56	62.24 ± 4.71	22/18	24/16	22.33 ± 2.09	22.91 ± 2.14	NA	1,2,3,4,5,7,9,11,12,14,15,16,17,19,20.
Zhang, ZB [32]	2013	China	30	30	53.8 ± 9.5	54.2 ± 9.0	17/13	16/14	22.5 ± 2.3	23.0 ± 2.5	30	1,2,3,4,5,7,9,10,16,19,20.
Jin, ZJ [42]	2019	China	30	30	NA	NA	NA	NA	NA	NA	NA	4,5,7,11,12,13,21,22,23.
Zheng, H [39]	2018	China	30	30	52.4 ± 15.5	55.4 ± 17.5	21/9	19/11	NA	NA	180	1,4,5,7,8,9,11,12,13.
Zhu, XC [37]	2017	China	15	15	NA	NA	NA	NA	NA	NA	NA	4,5,7,9,10,16,18.
Ren, K [34]	2017	China	50	50	53.43 ± 4.22	54.12 ± 5.03	36/14	35/15	NA	NA	NA	4,5,7,9,10,21.
Zhu, CL [33]	2016	China	79	78	57.51 ± 7.99	55.81 ± 7.89	52/27	49/29	22.56 ± 2.21	22.37 ± 2.54	28	1,2,4,5,7,8,9,10,16.
Li, L [46]	2015	China	40	36	39-66	39-66	NA	NA	NA	NA	NA	11,12,13,21,22,23.
Han, SL [45]	2010	China	23	23	59.35 ± 10.14	61.35 ± 7.90	15/8	13/10	24.83 ± 2.19	25.57 ± 1.59	NA	1,2,11,12,13,21,22,23.
Tian, YL [44]	2022	China	186	184	58.3 ± 10.5	58.6 ± 10.9	129/57	124/60	23.6 ± 3.2	23.7 ± 3.3	1080	1,4,5,6,7,9,10.
Kang, SH [40]	2018	Korea	46	51	56.3 ± 10.4	54.5 ± 12.6	33/13	38/13	23.4 ± 2.7	24.3 ± 2.5	90	1,4,5,6,7,9.
Kim, JW [31]	2012	Korea	22	22	52.64 ± 11.57	57.45 ± 14.54	13/9	15/7	23.40 ± 3.17	23.77 ± 3.54	14	1,2,3,4,5,6,7,9,10,12,13.
Hu, JC [30]	2012	China	19	22	59(49-71)	62.5(45-72)	10/9	10/12	22.94 ± 2.23	22.99 ± 2.24	28	1,2,3,4,7,9,10,11,12,14,15,16,19,20.

ERAS: enhanced recovery after surgery, TC: traditional care, BMI: body mass index, NA: not applicable; Outcomes: 1, Operative time; 2, Intraoperative bleeding volume; 3, Number of lymph node dissections; 4, The overall postoperative complication rate; 5, The individual postoperative complication rate; 6, Readmission; 7, Time to first postoperative flatus; 8, Time to first postoperative defecation; 9, Postoperative hospital stay; 10, Hospitalization costs; 11, CRP-preoperation; 12, CRP-POD1; 13, CRP-POD3; 14, CRP-POD4; 15, CRP-POD7; 16, ALB-preoperation; 17, ALB-POD1; 18, ALB-POD3; 19, ALB-POD4; 20, ALB-POD7; 21, IL-6-preoperation; 22, IL-6-POD1; 23, IL-6-POD3.

Table 2. Number of ERAS items adopted in the included RCTs.

Study	Arm	N	Enhanced Recovery After Surgery Interventions																						Total items
			1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16	17	18	19	20	21	22
Song, XC 2020 [43]	E	42		√	√		√	√		√	√					√	√		√		√	√	√	√	13
	T	33						√																√	2
Wu, HF 2019 [41]	E	35	√	√	√	√	√	√		√	√		√			√	√		√	√	√	√		√	16
	T	35																							0
Xu, X 2017 [35]	E	30		√	√	√	√	√		√	√					√			√		√	√		√	12
	T	30														√									1
Yang, Y 2017 [36]	E	21	√			√	√	√		√	√					√			√	√	√		√	√	12
	T	21						√																	1
Kang, JR 2017 [38]	E	40	√		√	√	√	√		√	√				√	√		√	√		√	√	√	√	15
	T	40														√									1
Zhang, ZB 2013 [32]	E	30			√	√		√		√	√			√		√			√		√	√		√	11
	T	30														√									1
Jin, ZJ 2019 [42]	E	30	√				√	√			√			√		√			√		√		√	√	10
	T	30	√											√		√									3
Zheng, H 2018 [39]	E	30	√		√	√	√	√	√	√	√			√	√	√	√		√		√	√		√	16
	T	30					√		√					√		√									4
Zhu, XC 2017 [37]	E	15			√	√					√								√		√	√		√	7
	T	15																							0
Ren, K 2017 [34]	E	50			√					√	√					√			√		√			√	7
	T	50																							0
Zhu, CL 2016 [33]	E	79			√	√	√				√			√		√			√		√	√		√	10
	T	78												√		√					√				3
Li, L 2015 [46]	E	40			√		√	√		√	√			√		√	√		√		√			√	11
	T	36						√						√											2
Han, SL 2010 [45]	E	23		√	√	√	√			√	√		√	√	√				√		√	√		√	13
	T	23												√								√			2
Tian, YL 2022 [44]	E	186	√		√	√	√	√			√		√	√	√	√	√		√		√	√		√	15
	T	184						√					√	√					√						4
Kang, SH 2018 [40]	E	46			√		√	√		√	√		√		√		√	√			√	√		√	12
	T	51			√			√		√			√									√			5
Kim, JW 2012 [31]	E	22		√	√		√	√		√	√	√					√	√	√		√	√		√	13
	T	22		√	√					√							√					√			5
Hu, JC 2012 [30]	E	19	√		√	√	√	√		√	√					√					√	√	√	√	12
	T	22																							0

E/ERAS: enhanced recovery after surgery, T/TC: traditional care, NA: not applicable; The ERAS items: 1, Preoperative nutrition; 2, Wound catheters and transversus abdominis plane block; 3, Avoid nasogastric/nasojejunal decompression; 4, Avoiding the use of abdominal drains; 5, Early postoperative diet and artificial nutrition; 6, Preoperative counselling; 7, Preoperative smoking and alcohol consumption; 8, Avoid preoperative bowel preparation; 9, Preoperative fasting and preoperative treatment with carbohydrates; 10, No Preanesthetic Medication; 11, Antithrombotic prophylaxis; 12, Antimicrobial prophylaxis and skin preparation; 13, Epidural analgesia; 14, Intravenous analgesia; 15, Anaesthetic management; 16, Prevention of nausea and vomiting; 17, Avoiding hypothermia; 18, Postoperative glycaemic control; 19, Fluid balance; 20, Early urinary drainage tube removal; 21, Stimulation of bowel movement; 22, Early and scheduled mobilization.

Figure 3. The risk of bias graph and risk of bias summary.

Table 3. Results of the meta-analysis comparing the efficacy between the ERAS group and TC group.

Efficacy Outcomes	Studies	Sample size		Statistical results		Heterogeneity		Effect model
		ERAS	TC	Effect estimate (95% CI)	P value	P value	I^2(%)
Time to first postoperative flatus	15	675	671	SMD −1.29 (-1.68 to −0.90)	<0.001	<0.001	90	random
Time to first postoperative defecation	2	109	108	SMD −1.26 (-1.90 to −0.61)	<0.001	0.04	75	random
Postoperative hospital stay	14	645	641	SMD −0.99 (-1.34 to −0.63)	<0.001	<0.001	88	random
Hospitalization costs	10	487	487	SMD −1.17 (-1.86 to −0.48)	<0.001	<0.001	95	random
CRP
CRP-preoperation	7	203	202	SMD −0.22 (-0.60 to 0.17)	0.27	0.001	72	random
CRP-POD1	8	225	224	SMD −0.58 (-1.02 to −0.14)	0.01	<0.001	80	random
CRP-POD3/4	8	225	224	SMD −1.34 (-2.04 to −0.63)	<0.001	<0.001	91	random
CRP-POD7	3	80	80	SMD −0.82 (-1.40 to −0.24)	0.005	0.05	67	random
ALB
ALB-preoperation	8	269	271	SMD 0.17 (-0.00 to 0.34)	0.05	0.48	0	fixed
ALB-POD1	2	75	75	SMD 1.68 (-0.12 to 3.48)	0.07	<0.001	95	random
ALB-POD3/4	7	190	193	SMD 1.09 (0.72 to 1.45)	<0.001	0.01	63	random
ALB-POD7	6	175	178	SMD 1.55 (0.75 to 2.36)	<0.001	<0.001	91	random
IL-6
IL-6-preoperation	3	93	89	SMD −0.19 (-0.91 to 0.53)	0.61	0.003	83	random
IL-6-POD1	3	93	89	SMD −1.08 (-1.54 to −0.62)	<0.001	0.13	52	random
IL-6-POD3	3	93	89	SMD −1.57 (-2.52 to −0.63)	0.001	<0.001	87	random

ERAS: enhanced recovery after surgery, TC: traditional care, SMD: standardized mean difference, CI: confidence interval, CRP: C-reactive protein, ALB: albumin, IL-6: interleukin-6, POD1: first postoperative day, POD3/4: third or fourth postoperative day, POD7: seventh postoperative day.

Table 4. Results of the meta-analysis comparing the safety between the ERAS group and TC group.

Safety Outcomes	Studies	Sample size		Statistical results		Heterogeneity		Effect model
		ERAS	TC	Effect estimate (95% CI)	P value	P value	I^2 (%)
Operative time	13	603	599	SMD −0.06 (-0.18 to 0.05)	0.27	0.64	0	fixed
Intraoperative bleeding volume	10	341	334	SMD −0.01 (-0.16 to 0.15)	0.95	0.63	0	fixed
Number of lymph node dissection	6	167	170	SMD −0.06 (-0.28 to 0.15)	0.57	0.76	0	fixed
Readmission	5	310	313	RR 1.22 (0.51 to 2.96)	0.65	0.55	0	fixed
The overall postoperative complication rate	15	675	671	RR 0.76 (0.60 to 0.97)	0.03	0.17	27	fixed
Anastomotic leakage	11	565	553	RR 0.48 (0.19 to 1.21)	0.12	0.92	0	fixed
Incision infection or liquefaction	9	481	478	RR 0.72 (0.33 to 1.57)	0.41	0.99	0	fixed
Intestinal obstruction	10	543	531	RR 0.48 (0.17 to 1.30)	0.15	0.72	0	fixed
Deep vein thrombosis	6	342	340	RR 0.33 (0.04 to 3.11)	0.33	1.00	0	fixed
Urinary tract infection	5	182	181	RR 1.24 (0.34 to 4.55)	0.74	0.77	0	fixed
Pulmonary complications	8	394	392	RR 0.51 (0.25 to 1.06)	0.07	0.99	0	fixed
Lung infection	6	342	340	RR 0.46 (0.21 to 1.01)	0.05	0.98	0	fixed

ERAS: enhanced recovery after surgery, TC: traditional care, SMD: standardized mean difference, RR: risk ratio, CI: confidence interval.

Figure 4. Summary of the Doi plots for each outcome.

Figure 4 showed that publication bias was assessed by Doi plots for each outcome, and asymmetry was indicated using the LFK index for eight outcomes: (a) Operative time, (b) Intraoperative bleeding volume, (c) The overall postoperative complication rate, (d) Time to first postoperative flatus, (e) Postoperative hospital stay, (f) Hospitalization costs, (g) Anastomotic leakage, (h) Intestinal obstruction.

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Data availability statement

Authors of included studies should be contacted individually for further details.