title: Efficiency and Safety Effects of Applying ERAS Protocols to Bariatric Surgery: a Systematic Review with Meta-Analysis and Trial Sequential Analysis of Evidence.
abstract: Application of the enhanced recovery after surgery (ERAS) to the bariatric surgical procedures is at its early stages with little consolidated evidence. This meta-analysis evaluates present literature and indicates pathways for development of evidence-based standardized ERAS protocols for bariatric surgery. Comparative trials between ERAS and conventional bariatric surgery published till June 2016 were searched in the medical database. Comparisons were made for length of stay (LOS), readmission, complications (major/minor), and reoperation rates. Trial sequential analysis (TSA) for the strength of meta-analysis was performed for the primary outcome LOS. Five subgroups with a total of 394 and 471 patients in ERAS and conventional group respectively were included. LOS was shorter in ERAS group by 1.56 ± 0.18 days (random-effects, p < 0.001, I2= 93.07 %). The sample size in ERAS was well past the "information size" variable which was calculated to be 189 as per the TSA for power 85%. MH odds ratio [1.41 (95% CI 1.13 to1.76)] was higher for minor complications in the ERAS group (fixed effects, I2= 0, p < 0.001). Superiority/inferiority of ERAS could not be established for major or overall complications, readmission, and anastomotic leak rates. No publication bias was found in the included trials (Egger's test, X-intercept = 6.14, p = 0.66). Evaluation based on Cochrane collaboration recommendations suggested that all the five included trials had a high risk of methodological bias. ERAS protocols for bariatric procedures allow faster return to home for patients. The present bariatric ERAS protocols have high heterogeneity and would benefit from standardization. Minor complication rates increase with implementation of ERAS, however without any significant effect on overall patient morbidity. Further randomized trials comparing ERAS with conventional care are required to consolidate these findings.
authors.affiliation: Department of Anesthesia, All India Institute of Medical Sciences, New Delhi, 110029, India. Preetrajpal@gmail.com.
authors.forename: Preet Mohinder
authors.initials: PM
authors.lastname: Singh
authors.affiliation: Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, 110029, India.
authors.forename: Rajesh
authors.initials: R
authors.lastname: Panwar
authors.affiliation: Department of Anesthesia, All India Institute of Medical Sciences, New Delhi, 110029, India.
authors.forename: Anuradha
authors.initials: A
authors.lastname: Borle
authors.affiliation: Hospital of the University of Pennsylvania and Perleman School of Medicine, Philadelphia, PA, USA.
authors.forename: Basavana
authors.initials: B
authors.lastname: Goudra
authors.affiliation: Department of Anesthesia, All India Institute of Medical Sciences, New Delhi, 110029, India.
authors.forename: Anjan
authors.initials: A
authors.lastname: Trikha
authors.affiliation: Department of Surgery, OLVG West, Amsterdam, The Netherlands.
authors.forename: Bart A
authors.initials: BA
authors.lastname: van Wagensveld
authors.affiliation: Anesthesiology and Perioperative, Medicine, Drexel University College of Medicine, 245 N. 15th Street; MS 310, Philadelphia, PA, 19102, USA.
authors.forename: Ashish
authors.initials: A
authors.lastname: Sinha
mesh_terms: D050110:Bariatric Surgery / Q000379:methods* / Q000706:statistics & numerical data*; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D009767:Obesity, Morbid / Q000453:epidemiology* / Q000601:surgery*; D011183:Postoperative Complications / Q000453:epidemiology; D012086:Reoperation / Q000706:statistics & numerical data; D013997:Time Factors
keywords: Bariatric surgery; ERAS; ERAS bariatric surgery; Enhanced recovery after surgery for bariatric procedures; Length of stay bariatric surgery; Meta-analysis; Trial sequential analysis