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. 2025 Mar 28;17(1):15-29.
doi: 10.52054/FVVO.2024.13599.

Impact of Enhanced Recovery After Surgery (ERAS) guidelines implementation in deep infiltrating endometriosis surgery. A systematic review and meta-analysis

Athanasios Douligeris  1 , Nikolaos Kathopoulis  1 , Christina Karasmani  1 , Konstantinos Kypriotis  1 , Dimitrios Zacharakis  2 , Anastasia Mortaki  1 , Anastasia Prodromidou  2 , Ioannis K Chatzipapas  1 , Themos Grigoriadis  2 , Athanasios Protopapas  1
Affiliations

Impact of Enhanced Recovery After Surgery (ERAS) guidelines implementation in deep infiltrating endometriosis surgery. A systematic review and meta-analysis

Athanasios Douligeris et al. Facts Views Vis Obgyn. .

Abstract

Background: The complexity of surgical management in women with deep infiltrating endometriosis (DIE) demands the optimisation of perioperative care protocols to ensure optimal postoperative outcomes.

Objectives: This meta-analysis evaluates the effectiveness of Enhanced Recovery After Surgery (ERAS) protocols compared to conventional perioperative care in patients undergoing surgery for DIE.

Methods: A systematic literature search was conducted in Medline, Scopus, Google Scholar, Cochrane CENTRAL, and ClinicalTrials.gov databases from inception till August 2024. Meta-analysis was performed with RevMan 5.4 software (Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2020), with mean differences (MDs), pooled risk ratios (RR) and random-effects model. Quality assessment was performed using the Risk of Bias in Non-randomised Studies of Interventions and Risk of Bias tools.

Main outcome measures: Primary outcomes assessed were postoperative length of hospital stay and readmission rates. Secondary outcomes included Clavien-Dindo grade I-II and grade III or higher complication rates.

Results: Four comparative studies were included, encompassing a total of 1,662 patients. ERAS protocols significantly reduced the mean length of hospital stay [MD: -2.88 days; 95% confidence interval (CI): -5.34 to -0.41; P=0.02] without increasing readmission rates (RR: 1.13; 95% CI: 0.75-1.73; P=0.55). No significant differences were observed in Clavien-Dindo grade I-II complications (RR: 0.75; 95% CI: 0.49-1.16; P=0.20) or grade III or higher complications rates (RR: 0.60; 95% CI: 0.27-1.33; P=0.21).

Conclusions: ERAS protocols appear to reduce the length of hospital stay without increasing complications or readmissions in DIE surgery. However, further large-scale randomised studies still needed to be conducted to confirm these findings.

What is new?: The application of ERAS protocols is associated with better postoperative outcomes in patients undergoing major surgeries for DIE.

Keywords: ERAS; Endometriosis; Enhanced Recovery After Surgery; deep infiltrating endometriosis; perioperative care; postoperative outcomes.

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Conflict of interest statement

Conflict of Interest: No conflict of interest was declared by the authors.

Figures

Figure 1
Figure 1
Flow diagram of the detailed process of selection of articles for inclusion in the systematic review and meta-analysis.
Figure 4
Figure 4
Trial sequential analysis for primary and secondary outcomes. a) Length of hospital stay, b) readmission rate, c) Clavien-Dindo grade III or higher complication rate, d) Clavien-Dindo grade I-II complication rate.
Figure 3
Figure 3
Forest plots describing the contrast between the ERAS group and conventional perioperative care group. a) Clavien-Dindo grade III or higher complication rate, b) Clavien-Dindo grade I-II complication rate (vertical line = “no difference” point between the two groups. Blue squares = risk ratios; diamonds = pooled risk ratios and 95% confidence intervals for all studies; horizontal lines = 95% confidence interval).
Figure 2
Figure 2
Forest plots describing the contrast between the ERAS group and conventional perioperative care group. a) length of hospital stay, b) readmission rate (Vertical line = “no difference” point between the two groups. Blue squares = risk ratios; Green squares = mean differences; Diamonds = pooled mean differences/risk ratios and 95% confidence intervals for all studies; Horizontal lines = 95% confidence interval).
See this image and copyright information in PMC

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