The Safety and Feasibility of Enhanced Recovery after Surgery in Patients Undergoing Pancreaticoduodenectomy: An Updated Meta-Analysis

Abstract

Background: Enhanced recovery after surgery (ERAS) is a multimodal, multidisciplinary, evidence-based approach to care for surgical patients and aims at optimizing the perioperative management and outcomes. The ERAS approach was first implemented in colorectal surgery patients; however, the reported applications in pancreatoduodenectomy patients are limited. In recent years, studies on ERAS for patients undergoing pancreaticoduodenectomy have been published. The accumulation of new randomized controlled trials and high-quality case-control studies stimulated us to update the analysis. Our study comprehensively collected data to provide the best evidence summary for the clinic.

Aim: To evaluate the safety and feasibility of enhanced recovery after surgery in the perioperative management of pancreatoduodenectomy patients.

Methods: A systematic literature search of PubMed, Embase, and the Cochrane Library was performed up to July 2019. All randomized controlled trials and case-control studies that applied ERAS for patients undergoing pancreaticoduodenectomy were considered for inclusion in this study. The patients were divided into two groups: patients who received the ERAS perioperative management approach were defined as the ERAS group and patients who received the traditional perioperative management approach were defined as the control group. All statistical analyses were conducted using the Revman5.3 software, and the outcomes were calculated as odds ratios or weighted mean differences with their corresponding 95% confidence intervals. A funnel plot was created to assess publication bias. Subgroup and sensitivity analyses were performed to explore the sources of heterogeneity.

Results: A total of 20 studies involving 3613 patients (1914 patients in the ERAS group vs. 1699 patients in the control group) were included in this study. Among the 20 studies, 4 were randomized controlled trials, and 16 were case-control studies. The overall postoperative complication rate was significantly lower in the ERAS group (OR = 0.62, 95% CI: 0.53-0.74, P < 0.00001) than in the control group. In addition, the minor complication rate (Clavien-Dindo I-II) was also lower in the ERAS group (OR = 0.70, 95% CI: 0.58-0.86, P = 0.0005). The patients in the ERAS group had a lower incidence of delayed gastric emptying (OR = 0.51, 95% CI: 0.42-0.63, P < 0.00001) and shorter length of hospital stay (WMD = -4.27, 95% CI: -4.81~-3.73, P < 0.00001) than in the control group. The rates of pancreatic fistula (regardless of Grade A/B/C), wound infections, abdominal abscesses, readmission, reoperation, and morbidity were not significantly different between the two groups.

Conclusion: The ERAS approach is safe and effective in the perioperative management of patients undergoing pancreaticoduodenectomy and helps to accelerate the postoperative recovery and improve prognosis.

Figure 1

PRISMA flow diagram of the included studies eligible for meta-analysis.

Figure 2

Forest plots demonstrating the outcomes of overall postoperative complications.

Figure 3

Forest plots demonstrating the outcomes of overall postoperative complications based on the classification of Clavien-Dindo.

Figure 4

Forest plots demonstrating the outcomes of pancreatic fistulas.

Figure 5

Forest plots demonstrating the outcomes of pancreatic fistula according to the definition of International Pancreatic Fistula Study Group.

Figure 6

Forest plots demonstrating the outcomes of delayed gastric emptying.

Figure 7

Forest plots demonstrating the outcomes of length of hospital stay.

Figure 8

Forest plots demonstrating the outcomes of wound infection.

Figure 9

Forest plots demonstrating the outcomes of abdominal abscesses.

Figure 10

Forest plots demonstrating the outcomes of readmission.

Figure 11

Forest plots demonstrating the outcomes of reoperation.

Figure 12

Forest plots demonstrating the outcomes of morbidity.

Figure 13

Funnel plot of overall postoperative complications (a), pancreatic fistula (b), delayed gastric emptying (c), and morbidity (d) in all included studies. SE: standard deviation; OR: odds ratio.