Recent advance in enhanced recovery after esophagectomy: A systematic review and meta-analysis

Abstract

Background: Many studies have shown that enhanced rehabilitation after surgery (ERAS) protocol can be closely linked to the reduced hospital stay and better outcomes of cancer patients, including those with esophageal carcinoma. However, not all studies have generated encouraging results. Therefore, a systematic review and meta-analysis of recent advance evidence to evaluate the significance of ERAS following esophagectomy was conducted. Methods: A literature search was performed in Medline, Embase, Pubmed, CINAHL, and the Cochrane library for articles describing an enhanced rehabilitation after surgery protocol in esophagectomy for esophageal cancer published between January 2010 and December 2016. The primary outcome measure was postoperative cardiac or pulmonary complication rates. Secondary outcome measures were postoperative length of stay, readmissions, and mortality. Statistical analysis was carried out using Comprehensive Meta Analysis 2.0. Results: The literature search identified 118 potentially relevant papers. 12 papers met the inclusion criteria for the review: 7 case-control studies, 3 retrospective studies, and 2 prospective randomized controlled study, describing a total of 1,895 patients. Metaanalysis of six studies focusing on pulmonary complications showed that there was a significant difference in favor of the ERAS group (OR=0.625, 95% confidence interval (CI) 0.479-0.815, p=0.001; I2=0%). Implementation of an ERAS protocol led to a significant decrease in cardiac complications (OR=0.656, 95% confidence interval (CI) 0.474-0.907, p=0.011; I2=12.905%). Postoperative length of hospital stay was significantly shorter in ERAS group [standard mean difference=-2.058d, 95%confidence interval (CI) -3.202 to-0.913, P=0.000; P for heterogeneity =0.000, I2=96.109%]. Introduction of an ERAS protocol did not result in an increase in anastomotic leak, chyle leak, mortality or readmissions. There was no significant difference in ICU stay and hospital cost. Conclusions: ERAS protocol as compared with conventional procesure may reduce postoperative hospital stay and cardiac or pulmonary complication rates in patients undergoing esophagectomy for esophageal cancer.