Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Apr 14, 2018; 24(14): 1562-1578
Published online Apr 14, 2018. doi: 10.3748/wjg.v24.i14.1562
Application of enhanced recovery after gastric cancer surgery: An updated meta-analysis
Liu-Hua Wang, Ren-Fei Zhu, Cheng Gao, Shou-Lin Wang, Li-Zong Shen
Liu-Hua Wang, Ren-Fei Zhu, Cheng Gao, Li-Zong Shen, Division of Gastrointestinal Surgery, Department of General Surgery, First Affiliated Hospital, Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
Liu-Hua Wang, Department of General Surgery, Yizheng People’s Hospital, Yangzhou 211400, Jiangsu Province, China
Shou-Lin Wang, School of Public Health, Nanjing Medical University, Nanjing 211166, Jiangsu Province, China
Author contributions: Wang LH, Zhu RF and Gao C contributed equally to this work; Wang LH and Shen LZ conceived and designed the updated meta-analysis; Wang LH, Zhu RF and Gao C carried out the literature search, data extraction and statistical analysis, and drafted this manuscript; Wang SL and Shen LZ were responsible for retrieval strategy and assessment of the risk of bias, and provided critical supervision and revision of this article; all authors conducted detailed review and revision for the data and approved the final version of the manuscript.
Supported by the National Natural Science Foundation of China, No. 81272711 to Shen LZ; the Priority Academic Program Development of Jiangsu Higher Education Institutions, No. JX10231801 to Shen LZ; and the Key Medical Talents Program of Jiangsu Province, No. ZDRCA2016014 to Shen LZ.
Conflict-of-interest statement: The authors declare that they have no conflicts of interest.
PRISMA 2009 Checklist statement: All authors have read the PRISMA 2009 Checklist, and the manuscript was carefully prepared and revised based on the PRISMA 2009 Checklist.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Li-Zong Shen, MD, PhD, Chief Doctor, Professor, Division of Gastrointestinal Surgery, Department of General Surgery, First Affiliated Hospital, Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, Jiangsu Province, China.
Telephone: +86-25-83724440
Received: February 5, 2018
Peer-review started: February 6, 2018
First decision: February 26, 2018
Revised: March 3, 2018
Accepted: March 7, 2018
Article in press: March 6, 2018
Published online: April 14, 2018
Research background

Enhanced recovery after surgery (ERAS) has emerged as an optimal perioperative strategy for improving clinical outcomes in elective gastric cancer (GC) surgery. However, numerous controversies exist with regard to ERAS practice after radical gastrectomy.

Research motivation

Accumulating studies highlight that implementation of ERAS protocols reduces overall hospital stay, morbidity and mortality significantly, without compromising patient safety in multiple surgical disciplines. However, the safety and feasibility of applying ERAS in its current form in radical gastrectomy still remains to be proven by performing an updated meta-analysis.

Research objectives

This meta-analysis aims to provide an updated assessment of the safety and efficacy of ERAS protocols in GC surgery.

Research methods

A comprehensive literature search in PubMed, Medline, EMBASE, World Health Organization International Trial Registry platform, and Cochrane Library until June 2017 was performed independently to identify all available randomized controlled trials (RCTs) comparing the ERAS program with standard perioperative care (SC) in GC surgery. Non-comparative studies, case-controlled trials, cohort studies, retrospective studies, items of ERAS applied being less than four, and no follow-up after discharge were excluded.

Research results

Thirteen RCTs, with a total of 1092 participants, were analyzed in this study, of whom 545 underwent ERAS protocols and 547 received SC treatment. ERAS protocols significantly decreased the length of postoperative hospital stay and medical costs, and accelerated bowel function recovery. Moreover, ERAS protocols were associated with a lower level of serum inflammatory response, higher serum albumin, and superior short-term quality of life. There were no significant differences regarding the incidence of total complications, mortality and reoperation following gastrectomy. However, the readmission rate after GC surgery nearly tripled under ERAS.

Research conclusions

ERAS results in accelerated convalescence, reduction of surgical stress and medical costs, improved nutritional status, and better quality of life for GC patients, but increased the readmission rate. Furthermore, the significant heterogeneity of some results is a major limitation of this study. ERAS investigators need to proceed with caution as far as ERAS is concerned beyond colorectal cancer surgery.

Research perspectives

This study provides an updated assessment of ERAS in GC surgery and is expected to provide guidance and reference for clinical practice, and also to provide high-level evidence for evidence-based medicine. High-quality multicenter RCTs with large samples and long-term follow-up are needed to more precisely evaluate ERAS in radical gastrectomy.