Enhanced recovery versus conventional care in gastric cancer surgery: a meta-analysis of randomized and non-randomized controlled trials
Enhanced recovery after surgery (ERAS) protocols have been successfully integrated into peri-operative management of different cancer surgeries such as colorectal cancer. Their value for gastric cancer surgery, however, remains uncertain.
A search for randomized and observational studies comparing ERAS versus conventional care in gastric cancer surgery was performed according to PRISMA guidelines. Random-effects meta-analyses with inverse variance weighting were conducted, and quality of included studies was assessed using the Cochrane risk-of-bias tool and Newcastle-Ottawa scale (PROSPERO: CRD42017080888).
Twenty-three studies involving 2686 patients were included. ERAS was associated with reduced length of hospital stay (WMD—2.47 days, 95% CI − 3.06 to − 1.89, P < 0.00001), time to flatus (WMD—0.70 days, 95% CI − 1.02 to − 0.37, P < 0.0001), and hospitalization costs (WMD—USD$ 4400, 95% CI − USD$ 5580 to − USD$ 3210, P < 0.00001), with consistent results across open and laparoscopic surgery. Postoperative morbidity and 30-day mortality were similar, although a higher rate of readmission was observed in the ERAS group (RR = 1.95, 95% CI 1.03–3.67, P = 0.04). Patients in the ERAS arm had significantly attenuated C-reactive protein levels on days 3/4 and 7, interleukin-6 levels on days 1, and 3/4, and tumor necrosis factor-α levels on days 3/4 postoperatively.
Compared to conventional care, ERAS reduces hospital stay, costs, surgical stress response and time to return of gut function, without increasing post-operative morbidity in gastric cancer surgery. However, precaution is necessary to reduce the increased risk of hospital readmission when adopting ERAS.
KeywordsERAS Enhanced recovery after surgery Gastric surgery Gastric cancer
NLS and IW are supported by Wong Hock Boon Society funds from the Yong Loo Lin School of Medicine, National University of Singapore.
Compliance with ethical standards
Conflict of interest
All authors declare no conflicts of interest.
- 8.Jiang ZW, Li JS, Wang ZM, Li N, Liu XX, Li WY, et al. The safety and efficiency of fast track surgery in gastric cancer patients undergoing D2 gastrectomy. Zhonghua wai ke za zhi (Chin J Surg). 2007;45(19):1314–7.Google Scholar
- 9.Wang DS, Zhou YB, Kong Y, Wang QG, Wang H. Observation of fast track surgery in patients with gastric cancer. Zhonghua wei chang wai ke za zhi (Chin J Gastrointest Surg). 2009;12(5):462–6.Google Scholar
- 10.He ZG, Tang Y, Wu HG, Wei B, Chen L, Li R. Benefits of perioperative fast-track surgery program on clinical outcome in patients with gastric cancer. Chin J Clin Nutr. 2010;18(1):29–32.Google Scholar
- 13.Tang YWX, Wei B. Clinical application of perioperative fast-track and nutrition support program in elderly patients with gastric cancer. China J Clin Nutr. 2010;18:137–40.Google Scholar
- 19.Wang G, Yang Y, Zhou B, Chen Y, Jin C, Wang Z, et al. Promotion of postoperative recovery with fast track surgery for gastric cancer patients undergoing gastrectomy: a prospective randomized controlled study. Zhonghua wei chang wai ke za zhi (Chin J Gastrointest Surg). 2014;17(5):489–91.Google Scholar
- 23.Liu G, Jian F, Wang X, Chen L. Fast-track surgery protocol in elderly patients undergoing laparoscopic radical gastrectomy for gastric cancer: a randomized controlled trial. OncoTargets Ther. 2016;9:3345–51.Google Scholar
- 25.GS HJ. Cochrane handbook for systematic reviews of interventions. Chichester: The Cochrane Collaboration and John Wiley & Sons Ltd; 2008.Google Scholar
- 28.Wells G, Shea B, O’Connell J, Robertson J, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analysis. 2011. http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp.
- 31.Kang SH, Lee Y, Min SH, Park YS, Ahn SH, Park DJ, et al. Multimodal enhanced recovery after surgery (ERAS) program is the optimal perioperative care in patients undergoing totally laparoscopic distal gastrectomy for gastric cancer: a prospective, randomized, clinical trial. Ann Surg Oncol. 2018;25(11):3231–8.CrossRefGoogle Scholar
- 33.Li Y, Qiu J, Cao H. Application of enhanced recovery after surgery for patients with laparoscopic radical gastrectomy. Zhonghua wei chang wai ke za zhi (Chin J Gastrointest Surg). 2016;19(3):269–73.Google Scholar
- 34.Meng C, Cao S. Clinical efficacy of enhanced recovery after surgery in the radical gastrectomy for gastric cancer: a prospective study. Surg Endosc Other Interv Tech. 2016;30:485.Google Scholar
- 43.Siotos C, Stergios K, Naska A, Frountzas M, Pergialiotis V, Perrea DN, et al. The impact of fast track protocols in upper gastrointestinal surgery: a meta-analysis of observational studies. Surg J R Coll Surg Edinb Irel. 2018;16(3):183–92.Google Scholar
- 55.Hu JCJL, Cai L. Preliminary experience of fast-track surgery combined with laparoscopy-assisted radical distal gastrectomy for gastric cancer. J Gastrointest Surg. 2012;16:1,830-1,9..Google Scholar
- 56.Hosoda K, Azuma M, Katada C, Moriya H, Mieno H, Ishido K, et al. A phase II study of neoadjuvant chemotherapy with docetaxel, cisplatin, and S-1, followed by gastrectomy with D2 lymph node dissection for high-risk advanced gastric cancer: results of the KDOG1001 trial. Gastric Cancer. 2018. https://doi.org/10.1007/s10120-018-0884-0.Google Scholar
- 58.Fava BEC, da Costa WL Jr, Medeiros MLL, Sonagli M, de Castro Ribeiro HS, Diniz AL, et al. Neoadjuvant intraperitoneal chemotherapy followed by radical surgery and HIPEC in patients with very advanced gastric cancer and peritoneal metastases: report of an initial experience in a western single center. World J Surg Oncol. 2018;16(1):62.CrossRefGoogle Scholar
- 60.Kim W, Kim HH, Han SU, Kim MC, Hyung WJ, Ryu SW, et al. Decreased morbidity of laparoscopic distal gastrectomy compared with open distal gastrectomy for stage i gastric cancer: short-term outcomes from a multicenter randomized controlled trial (KLASS-01). Ann Surg. 2016;263(1):28–35.CrossRefGoogle Scholar