Meta-Analysis
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Aug 14, 2015; 21(30): 9209-9216
Published online Aug 14, 2015. doi: 10.3748/wjg.v21.i30.9209
Enhanced recovery after surgery programs in patients undergoing hepatectomy: A meta-analysis
Tian-Gen Ni, Han-Teng Yang, Hao Zhang, Hai-Peng Meng, Bo Li
Tian-Gen Ni, Han-Teng Yang, Hao Zhang, Hai-Peng Meng, Bo Li, Department of Liver Surgery, Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
Author contributions: Ni TG and Li B conceived the study; Yang HT and Zhang H collected the data and performed the data analysis; Ni TG, Yang HT, Zhang H and Meng HP designed the study and participated in writing the paper; Ni TG and Li B submitted the final manuscript; all authors read and approved the final manuscript.
Conflict-of-interest statement: The authors declare no conflict of interest.
Data sharing statement: Technical appendix, statistical code, and datasets are available from the corresponding author at libo14@126.com.
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: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Bo Li, MD, Professor, Department of Liver Surgery, Liver Transplantation Center, West China Hospital of Sichuan University, 37 Guo Xue Road, Chengdu 610041, Sichuan Province, China. libo14@126.com
Telephone: +86-28-85422476 Fax: +86-28-85423724
Received: March 20, 2015
Peer-review started: March 22, 2015
First decision: April 23, 2015
Revised: May 19, 2015
Accepted: June 9, 2015
Article in press: June 10, 2015
Published online: August 14, 2015
Processing time: 149 Days and 12.4 Hours
Abstract

AIM: To evaluate the impact of enhanced recovery after surgery (ERAS) programs in comparison with traditional care on liver surgery outcomes.

METHODS: The PubMed, EMBASE, CNKI and Cochrane Central Register of Controlled Trials databases were searched for randomized controlled trials (RCTs) comparing the ERAS program with traditional care in patients undergoing liver surgery. Studies selected for the meta-analysis met all of the following inclusion criteria: (1) evaluation of ERAS in comparison to traditional care in adult patients undergoing elective open or laparoscopic liver surgery; (2) outcome measures including complications, recovery of bowel function, and hospital length of stay; and (3) RCTs. The following exclusion criteria were applied: (1) the study was not an RCT; (2) the study did not compare ERAS with traditional care; (3) the study reported on emergency, non-elective or transplantation surgery; and (4) the study consisted of unpublished studies with only the abstract presented at a national or international meeting. The primary outcomes were complications. Secondary outcomes were length of hospital stay and time to first flatus.

RESULTS: Five RCTs containing 723 patients were included in the meta-analysis. In 10/723 cases, patients presented with benign diseases, while the remaining 713 cases had liver cancer. Of the five studies, three were published in English and two were published in Chinese. Three hundred and fifty-four patients were in the ERAS group, while 369 patients were in the traditional care group. Compared with traditional care, ERAS programs were associated with significantly decreased overall complications (RR = 0.66; 95%CI: 0.49-0.88; P = 0.005), grade I complications (RR = 0.51; 95%CI: 0.33-0.79; P = 0.003), and hospital length of stay [WMD = -2.77 d, 95%CI: -3.87-(-1.66); P < 0.00001]. Similarly, ERAS programs were associated with decreased time to first flatus [WMD = -19.69 h, 95%CI: -34.63-(-4.74); P < 0.0001]. There was no statistically significant difference in grade II-V complications between the two groups.

CONCLUSION: ERAS is a safe and effective program in liver surgery. Future studies should define the active elements to optimize postoperative outcomes for liver surgery.

Keywords: Enhanced recovery after surgery; Liver surgery; Complications; Hospital length of stay; Meta-analysis

Core tip: To the best of our knowledge, this is the first meta-analysis of randomized controlled trails that have investigated the impact of enhanced recovery after surgery (ERAS) programs on surgical outcomes in liver surgery patients. The implementation of ERAS programs is safe and effective for liver surgery. However, we found some problems, which involved inconsistent outcome measures and ERAS criteria that were not specific to liver surgery. Future research in this field should develop liver surgery-specific ERAS programs.