Enhanced Recovery After Surgery for Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: A Systematic Review and Meta-Analysis

Abstract

Background: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is a promising approach for the management of peritoneal carcinomatosis, but is associated with significant morbidity and prolonged hospital stay. Herein, we review the impact of Enhanced recovery after surgery (ERAS) protocol on length of stay (LOS) and early complications in patients undergoing CRS and HIPEC for peritoneal carcinomatosis.Methods: PubMed and Embase were searched for studies comparing ERAS protocol with control for CRS + HIPEC. Mean difference (MD) and risk ratios (RR) were calculated for LOS and complications respectively.Results: Six retrospective studies were included. Meta-analysis indicated statistically significant reduction in LOS with ERAS (MD: −2.82 95% CI: −3.79, −1.85 I2 = 29% p < 0.00001). Our results demonstrated significantly reduced risk of Calvien Dindo grade III/IV complications with the use of ERAS protocol as compared to the control group (RR: 0.60 95% CI: 0.41, 0.87 I2 = 0% p = 0.007). Pooled analysis of limited studies demonstrated no statistically significant difference in the risk of reoperation (RR: 1.04 95% CI: 0.54, 2.03 I2 = 50% p = 0.90) readmission (RR: 0.55 95% CI: 0.21, 1.49 I2 = 0% p = 0.24), acute kidney injury (RR: 0.55 95% CI: 0.28, 1.10 I2 = 0% p = 0.09) or mortality (RR: 0.62 95% CI: 0.17, 2.26 I2 = 0% p = 0.46) between the study groups.Conclusion: For CRS + HIPEC, ERAS is associated with significantly reduced LOS along with lower incidence of complications. Limited data suggest that use of ERAS protocol is not associated with increased readmission, reoperation, and mortality rates in these patients. There is a need for randomized controlled trials to corroborate the current evidence.

Implementation of an enhanced recovery program for complete cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in a referral center: a case control prospective study

“…The major morbidity rate reported in our study (22.7%) is comparable to the most recent literature [ 37 , 38 ].…”

“…Finally, a recent review of the impact of ERP, including six retrospective studies, showed that implementing an ERP after CCRS with HIPEC is feasible and may decrease the HLS (MD: −2.82 95% CI: −3.79, −1.85 I2=29% p<0.00001) as well as the major morbidity rates of Clavien‒Dindo III/IV (RR: 0.60 95% CI: 0.41, 0.87 I2=0% p=0.007) compared to the control group [ 38 ]. However, the findings only suggest that ERP after CCRS with HIPEC is not associated with increased readmission, reoperation, or mortality rates.…”

Which preoperative assessment modalities best identify patients who are suitable for enhanced recovery after liver transplantation? A systematic review of the literature and expert panel recommendations

“…Enhanced Recovery After Surgery (ERAS) protocols are effective at improving outcomes after surgery (1)(2)(3)(4) , but no standardized ERAS protocols exist in liver transplantation (LT) (5,6) . In addition, LT has some peculiarities with respect to other surgical procedures, given that per the intrinsic features of therapy, a large proportion of patients will be in poor condition (relative to elective surgery) at the moment of surgery.…”

Principles of enhanced recovery in gastrointestinal surgery

“…There was also a significant reduction in time to first flatus of 0.8 days. Further meta-analysis revealed similar results for emergency laparotomy [40] and for pancreatoduodenectomy [41] with an associated reduction of delayed gastric emptying, as well as for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy [42], liver resection [43], and even for liver transplantion [44] where a 55% reduction in intensive care unit was associated with the application of ERAS concept. A summary of all most recent meta-analysis for each surgical specialty is provided on Table 1.…”