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Effectiveness of enhanced recovery after surgery among cancer patients: A meta-analysis of randomized controlled
Linna Li1, Min Hu2, Qianwen Yan1
1School of Nursing, West China Hospital, Sichuan University, P. R. China.
Background:
Enhanced recovery after surgery has been implemented in diverse operations. However, existing research lacks evidence to support the impact of enhanced recovery after surgery on physiological indicators, perioperative and survival outcomes in different cancer patients.
Objectives:
To determine efficacy and safety of enhanced recovery after surgery compared with conventional perioperative care on physiological indicators, patient-reported outcomes, perioperative and survival outcomes, rehabilitation and healthcare resource utilization among perioperative cancer patients, evaluating the effect of enhanced recovery after surgery through subgroup analysis based on countries with different income levels, and targeted patients with various cancer types and ages.
Design:
A meta-analysis of randomized controlled trials.
Methods:
PubMed, the Cochrane Central Register of Controlled Trials, Embase, and Cumulative Index to Nursing and Allied Health Literature were searched from inception to 31 December 2025. Risk of bias was assessed using the revised Cochrane risk-of-bias tool. The Grading of Recommendations, Assessment, Development, and Evaluation framework was used to check the certainty of evidence. The outcomes were C-reaction protein and Interleukin-6, albumin, pre-albumin and transferrin, Immunoglobulin, T lymphocyte, forced vital capacity, forced expiratory volume in 1 s, quality of life, postoperative pain, postoperative complications, mortality, overall survival, disease-free survival, cancer-specific survival, length of hospital stay/length of postoperative hospital stay, 30-day readmission and hospitalization fees. Subgroup analysis was performed for different cancer types, younger and older cancer patients, and high-income countries and low- and middle-income countries. Additionally, sensitivity analyses and publication bias assessments (funnel plots, Egger's test, and the trim-and-fill method) were conducted.
Results:
Sixty-seven studies were included. Cancer patients receiving enhanced recovery after surgery had lower level of inflammatory markers, higher level of nutritional, immune and pulmonary indicators than those receiving conventional perioperative care. Enhanced recovery after surgery alleviated pain on the first [SMD = -1.00 (-1.45, -0.56)] and third [SMD = -0.83 (-1.31, -0.35)] postoperative day, enhancing quality of life [SMD = 0.69 (0.39, 0.98)] compared with conventional perioperative care. Moreover, enhanced recovery after surgery allowed lower incidence of postoperative complications [RR = 0.60 (0.52, 0.68)], mortality [RR = 0.33 (0.11, 0.98)], better overall survival [HR = 0.68 (0.47, 0.98)] and disease-free survival [HR = 0.63 (0.43, 0.93)]. We also found shorter length of hospital stay [WMD = -2.72 (-3.56, -1.87)] and length of postoperative hospital stay [WMD = -2.07 (-2.68, -1.45)], and reduced hospitalization fees [SMD = -0.60 (-0.79, -0.41)] for cancer patients in ERAS group. However, length of postoperative hospital stay in high-income countries and length of hospital stay in older cancer patients were not significantly reduced.
Conclusions:
Enhanced recovery after surgery was related to favorable physiological indicators, perioperative and survival outcomes, and resource utilization among cancer patients of various cancer types and ages. Different outcomes between high-income and low- and middle-income countries may reflect variations in healthcare infrastructure, implementation fidelity, and resource availability. Given the predominance of studies from China, conducting well-designed research tailored to different healthcare contexts is essential to enhance perioperative care quality and economic efficiency.
