Published online Apr 21, 2018. doi: 10.3748/wjg.v24.i15.1666
Peer-review started: February 6, 2018
First decision: February 24, 2018
Revised: March 8, 2018
Accepted: March 18, 2018
Article in press: March 18, 2018
Published online: April 21, 2018
Enhanced recovery after surgery (ERAS) is a multidisciplinary and evidence-based framework, developed to decrease perioperative surgical stress, accelerate postoperative recovery and significantly reduce the postoperative length of hospital stay (PLOS). ERAS programs have been launched in a variety of other fields of surgery, such as colorectal, orthopedics, urology, esophageal, and gynecology, and have demonstrated favorable outcomes. The implementation of ERAS programs has lagged surrounding pancreatic surgeries because of the anatomical location of the pancreas and the high rate of postoperative complications (30%-60%). It is very important to promote the postoperative recovery for this high-risk abdominal surgery via implementing ERAS programs during the perioperational period.
ERAS requires surgical, nursing, anesthesia and other specialties to work together and uses a series of optimal or evidence-based management measures to lessen perioperative surgical stress while promoting the recovery of organ function in the early postoperative period. The implementation of ERAS programs may play a very important role in the perioperational period for pancreatic surgery.
This study evaluated the impact of ERAS programs on postoperative complications and PLOS of pancreatic surgery.
Computer searches were performed in databases (including PubMed, Cochrane Library, and Embase) for randomized controlled trials or case-control studies describing ERAS programs in patients undergoing pancreatic surgery published between January 1995 and August 2017. Two researchers independently evaluated the quality of the studies’ extracted data that met inclusion criteria and performed a meta-analysis using RevMan5.3.5 software. Forest plots, demonstrating the outcomes of the ERAS group versus the control group after pancreatic surgery, and funnel plots were used to evaluate potential publication bias.
Twenty case-control studies, published between January 1995 and August 2017, including 3694 patients, were selected for the meta-analysis. They included the ERAS group (n = 1886) and control group (n = 1808), which adopted the traditional perioperative management. Compared to the control group, the ERAS group had lower delayed gastric emptying (DGE) rates (odds ratio (OR) = 0.58, 95% confidence interval (CI): 0.48-0.72, P < 0.00001), lower postoperative complication rates (OR = 0.57, 95%CI: 0.45-0.72, P < 0.00001), particularly for mild postoperative complications (Clavien-Dindo I- II) (OR = 0.71, 95%CI: 0.58-0.88, P = 0.002), lower abdominal infection rates (OR = 0.70, 95%CI: 0.54-0.90, P = 0.006) and shorter PLOS (weighted mean difference (WMD) = -4.45, 95%CI: -5.99 to -2.91, P < 0.00001). However, there were no significant differences in postoperative pancreatic fistulas (POPF), moderate to severe complications (Clavien-Dindo III- IV), mortality, readmission and unintended reoperation in both groups.
The results from our present study demonstrate that the implementation of ERAS programs could reduce overall complication rates, especially of mild complications, DGE, rate of abdominal infection and PLOS, while not affecting the rates of POPF, reoperation, readmission and mortality during the perioperative period for pancreatic surgery. The perioperative period for pancreatic surgery is safe and effective to implement ERAS programs that can decrease postoperative complication rates and promote recovery
We need to include more high-quality and strict prospective studies to assess the contributions of individual program components, such as clear fluids or food intakes in the early period, and removal of the drainage tube.