Systematic review and meta-analysis for laparoscopic versus open colon surgery with or without an ERAS programme

W R Spanjersberg, J D P van Sambeeck, A Bremers, C Rosman, C J H M van Laarhoven, W R Spanjersberg, J D P van Sambeeck, A Bremers, C Rosman, C J H M van Laarhoven

Abstract

Background: In recent years, conventional colorectal resection and its aftercare have increasingly become replaced by laparoscopic surgery and enhanced recovery after surgery (ERAS) pathways, respectively.

Objective: To ascertain whether combining laparoscopy and ERAS have additional value within colorectal surgery.

Methods: A systematic review with meta-analysis was performed with two primary research questions; does laparoscopy offer an advantage when all patients receive ERAS perioperative care and does ERAS offer advantages in a laparoscopically operated patient population. All randomised and controlled clinical trials were identified using MEDLINE, EMBASE and Cochrane databases.

Results: Primary search resulted in 319 hits. After inclusion criteria were applied, three RCTs and six CCTs were included in the meta-analysis. For laparoscopically operated patients with/without ERAS, no differences in morbidity were found and postoperative hospital stay favoured ERAS (MD -2.34 [-3.77, -0.91], Z = 3.20, p = 0.001). When comparing laparoscopy and open surgery within ERAS, major morbidity was significantly reduced in the laparoscopic group (OR 0.42 [0.26, 0.66], Z = 3.73, p = 0.006). Other outcome parameters showed no differences. Quality of included studies was considered moderate to poor overall with small sample sizes.

Conclusion: When laparoscopy and ERAS are combined, major morbidity and hospital stay are reduced. The reduction in morbidity seems to be due to laparoscopy rather than ERAS, so laparoscopy by itself offers independent advantages beyond ERAS care. Quality of included studies was moderate to poor, so conclusions should be regarded with some reservations.

Keywords: Colon surgery; ERAS; Laparoscopic surgery; Meta-analysis; Systematic review.

Figures

Fig. 1
Fig. 1
Search strategy
Fig. 2
Fig. 2
ERAS items used in included studies
Fig. 3
Fig. 3
Risk of bias table according to grade
Fig. 4
Fig. 4
Bias items per study according to grade
Fig. 5
Fig. 5
Forest plot of comparison: laparoscopic versus open surgery within ERAS, outcome: complications, major
Fig. 6
Fig. 6
Forest plot of comparison: laparoscopy ± ERAS, outcome: postoperative hospital stay

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