Enhanced recovery after gastrectomy: updated Meta-analysis of 27 randomized trials (2018-2025)

Enhanced recovery after surgery (ERAS) programs are increasingly applied in upper-GI surgery, yet evidence in gastrectomy remains evolving with minimally invasive and robotic techniques. We updated the randomized evidence base to re-estimate effects on recovery, complications, and costs.

We systematically searched PubMed, Embase, Web of Science, and Cochrane CENTRAL (2018-2025) for parallel-group randomized controlled trials comparing full-pathway ERAS programs versus conventional care in adult patients undergoing gastrectomy for gastric cancer, in accordance with PRISMA for Abstracts guidance. Length of stay was the primary endpoint; secondary outcomes included time to gastrointestinal recovery, postoperative complications, readmission, mortality, and hospital costs. Random-effects meta-analysis was performed, and certainty of evidence was evaluated using GRADE.

Twenty-seven trials (n = 3,274 patients) met eligibility criteria. ERAS significantly shortened length of stay and accelerated gastrointestinal recovery. Overall postoperative complications were numerically lower under ERAS and became statistically significant in prespecified sensitivity analyses excluding high-risk-of-bias or overlapping trials (risk ratio [RR] 0.73, 95% CI 0.56-0.96). Individual complications (pneumonia, surgical-site infection, anastomotic leak) and 30-day readmission did not show clear evidence of a difference. Mortality was rare in both groups. Certainty of evidence was generally low to moderate.

ERAS in gastrectomy for gastric cancer may accelerate postoperative recovery and reduce costs without increasing complications or readmission. Standardized protocols and reporting are needed to enhance reliability and facilitate wider adoption.