Transvaginal versus transabdominal specimen extraction in minimally invasive surgery: a systematic review and meta-analysis.

AIM: Natural orifice specimen extraction (NOSE) is an alternative to conventional transabdominal retrieval. We aimed to compare outcomes following transvaginal specimen extraction (TVSE) and transabdominal specimen extraction (TASE) in minimally invasive abdominal surgery. METHODS: An electronic database search of PubMed, Embase and CENTRAL was performed from inception until March 2023. Comparative studies evaluating TVSE versus TASE in adult female patients were included. Studies involving transanal NOSE, endoluminal surgery, or TVSE with concomitant hysterectomy were excluded. Weighted mean differences (WMD) and odds ratio were estimated for continuous and dichotomous outcomes respectively. Primary outcomes were postoperative day 1 (POD1) pain and length of stay (LOS). Secondary outcomes were operative time, rescue analgesia, morbidity, and cosmesis. A review of sexual, oncological, and technical outcomes was performed. RESULTS: Thirteen studies (2 randomised trials, 11 retrospective cohort studies), involving 1094 patients (TASE 583, TVSE 511), were included in the analysis. Seven studies involved colorectal disease and six assessed gynaecological conditions. TVSE resulted in significantly decreased POD1 pain (WMD 1.08, 95% CI: 0.49, 1.68) and shorter LOS (WMD 1.18 days, 95% CI: 0.14, 2.22), compared to TASE. Operative time was similar between both groups, with fewer patients requiring postoperative rescue analgesia with TVSE. Overall morbidity rates, as well as both wound-related and non-wound related complication rates were better with TVSE, while anastomotic morbidity rates were comparable. Cosmetic scores were higher with TVSE. TVSE did not result in worse sexual or oncological outcomes. CONCLUSION: TVSE may be feasible and beneficial compared to TASE when performed by proficient laparoscopic operators, using appropriate selection criteria. Continued evaluation with prospective studies is warranted.

Postoperative outcomes after prehabilitation for colorectal cancer patients undergoing surgery: a systematic review and meta-analysis of randomized and nonrandomized studies.

PURPOSE: Prehabilitation (PH) is purported to improve patients' preoperative functional status. This systematic review and meta-analysis sought to compare short-term postoperative outcomes between patients who underwent a protocolized PH program and the existing standard of care among colorectal cancer patients awaiting surgery. METHODS: A search in MEDLINE/PubMed, the Cochrane Library, Embase, Scopus, and CINAHL was conducted to identify relevant articles. Repetitive and exhaustive combinations of MeSH search terms ("prehabilitation," "colorectal cancer," "colon cancer," and "rectal cancer") were used to identify randomized and nonrandomized studies comparing PH versus standard of care for colorectal cancer patients awaiting surgery. The primary outcomes included postoperative morbidity, length of hospital stay, and readmission rates. RESULTS: Seven studies including 1,042 colorectal cancer patients (PH, 382) were included. No significant differences were found in intraoperative outcomes. The postoperative complication rates were comparable between groups (Clavien-Dindo grades I and II: risk ratio, 0.82; 95% confidence interval, 0.62-1.07; P=0.15; Clavien-Dindo grades ≥III: risk ratio, 1.02; 95% confidence interval, 0.72-1.44; P=0.92). There were also no significant differences in length of hospital stay (P=0.21) or the risk of 30-day readmission (P=0.68). CONCLUSION: Although PH does not appear to improve short-term postoperative outcomes following colorectal cancer surgery, the quality of evidence is impaired by the limited trials and heterogeneity. Thus, further large-scale trials are warranted to draw definitive conclusions and establish the long-term effects of PH.

Transanal Total Mesorectal Excision With Delayed Coloanal Anastomosis (TaTME-DCAA) Versus Laparoscopic Total Mesorectal Excision (LTME) and Robotic Total Mesorectal Excision (RTME) for Low Rectal Cancer: A Propensity Score-Matched Analysis of Short-term Outcomes, Bowel Function, and Cost.

INTRODUCTION: Total mesorectal excision (TME) with delayed coloanal anastomosis (DCAA) is surgical option for low rectal cancer, replacing conventional immediate coloanal anastomosis (ICAA) with bowel diversion. This study aimed to assess the outcomes of transanal TME (TaTME) with DCAA versus laparoscopic TME (LTME) with ICAA versus robotic TME (RTME) with ICAA. METHODS: This was a retrospective propensity score-matched analysis of patients who underwent elective TaTME-DCAA between November 2021 and June 2022. Patients were propensity-score matched in a ratio of 1:3 to patients who underwent LTME-ICAA and RTME-ICAA from January 2019 to December 2020. Outcome measures were histopathologic results, postoperative morbidity, function, and inpatient costs. RESULTS: Twelve patients in the TaTME-DCAA group were compared with 36 patients in the LTME-ICAA and RTME-ICAA groups each after propensity score matching. Histopathologic results and postoperative morbidity rates were statistically similar. Overall stoma-related complication rates in the ICAA groups were 11%. Median total length of hospital stays for TME plus stoma reversal surgery was similar across all techniques (10 vs. 10 vs. 9 days; P =0.532). Despite a significantly shorter duration of follow-up, bowel function after TaTME-DCAA was comparable to that of LTME-ICAA and RTME-ICAA. Overall median inpatient costs of TaTME-DCAA were comparable to LTME-ICAA and significantly cheaper than RTME-ICAA ($31,087 vs. $29,927 vs. $36,750; P =0.002). CONCLUSIONS: TaTME with DCAA is a feasible and safe technique compared with other minimally invasive methods of TME, while avoiding bowel diversion and stoma-related complications, as well as comparing favorably in terms of overall hospitalization costs.

Efficacy and safety of front-line treatment regimens for Waldenstrom macroglobulinaemia: a systematic review and meta-analysis.

Rituximab-based chemo-immunotherapy is currently the standard first-line treatment for Waldenstrom macroglobulinaemia (WM), while ibrutinib has emerged as an alternative. In the absence of randomised trials (RCTs) comparing these regimens, the optimal first-line treatment for WM remains uncertain. In this systematic review and meta-analysis, we sought to assess the efficacy and safety of first-line treatment regimens for WM. We searched key databases from January 2007 to March 2023, including phase II and III trials, including treatment-naïve WM patients treated with rituximab-based regimens or ibrutinib. Response rates, progression-free survival (PFS), overall survival (OS), and toxicities were evaluated. Four phase III and seven phase II trials were included among 736 unique records. Pooled response rates from all comparative and non-comparative trials were 46%, 33% and 26% for bendamustine rituximab (BR), bortezomib-dexamethasone, cyclophosphamide, rituximab (BDRC) and ibrutinib rituximab (IR), respectively. Two-year pooled PFS was 89%, 81% and 82% with BR, BDRC and IR, respectively. Neuropathy was more frequent with bortezomib, while haematologic and cardiac toxicities were more common with chemo-immunotherapy and ibrutinib-based regimens respectively. Our findings suggest that BR yields higher response rates than bortezomib or ibrutinib-based combinations. RCTs comparing BR against emerging therapies, including novel Bruton Tyrosine Kinase Inhibitors, are warranted.

Transvaginal Natural Orifice Specimen Extraction (NOSE) in Laparoscopic Colorectal Cancer Surgery With New Insights on Technique and Patient Selection.

BACKGROUND: Following laparoscopic colorectal surgery, transabdominal specimen extraction requires a mini-laparotomy or Pfannenstiel incision, associated with increased postoperative pain and wound complications. The vagina has several unique properties that make natural orifice specimen extraction (NOSE) ideal. We report our experience with transvaginal NOSE for colorectal cancer surgery. MATERIALS AND METHODS: A transvaginal sizer allows the posterior vagina to be incised under tension. A transverse or cruciate incision is made, followed by the insertion of a double-ring wound protector. The external ring is opened against the perineum to shorten the length of the conduit for specimen delivery. Vaginotomy closure is performed via laparoscopy using a barbed suture. RESULTS: Seventeen consecutive female patients underwent elective colorectal cancer surgery with attempted transvaginal NOSE. Median age and body mass index was 67 (range: 50 to 82) years and 26.5 (range: 19.7 to 35.8) kg/m 2 , respectively. Fourteen patients (82%) underwent left-sided resections and 3 (18%) underwent right-sided resections. Median operating time, blood loss, and length of hospital stay was 245 (range: 155 to 360) minutes, 30 (range: 10 to 500) mL, and 3 (range: 2 to 9) days, respectively. Transvaginal extraction was unsuccessful in 1 (6%) patient. Two (12%) patients experienced early postoperative morbidity, neither attributable to the extraction procedure. Median tumor circumferential diameter was 3.3 (range: 2.2 to 7.0) cm. Median follow-up duration was 17 (range: 8 to 27) months. There was no instance of sexual dysfunction. CONCLUSIONS: Transvaginal NOSE for colorectal cancer surgery is feasible and safe in selected patients. Overall specimen diameter, inclusive of tumor and mesentery, relative to pelvic outlet and conduit diameter is the most important consideration for transvaginal NOSE.

Effect of preoperative oral antibiotics and mechanical bowel preparation on the prevention of surgical site infection in elective colorectal surgery, and does oral antibiotic regime matter? a bayesian network meta-analysis.

PURPOSE: Surgical site infection (SSI) impacts 5-20% of patients after elective colorectal surgery. There are varying reports on the effectiveness of oral antibiotics (OAB) with preoperative mechanical bowel preparation (MBP) in preventing SSI. We aim to determine the role of OAB and MBP in preventing SSI after elective colorectal surgery. We also determine if a specific OAB regimen will be more effective than others. METHODS: This study investigated the impact of OAB and MBP in patients undergoing elective colorectal surgery. PubMed, MEDLINE, Ovid, Cochrane Central Register of Controlled Trials, ACP Journal Club, and Embase databases were searched for randomized clinical trials (RCTs) published by June 2022. All RCTs comparing various preoperative bowel preparation regimens, including pairwise or multi-intervention comparisons, were included. To establish the role of OAB and MBP in preventing SSI, we conducted a Bayesian network meta-analysis on all RCTs. We further performed subgroup analysis to determine the most effective OAB regimen. RESULTS: Among included 46 studies with a total of 12690 patients, patients in the MBP + OAB group were less likely to have SSI than those having MBP-only (OR 0.55, 95% CrI 0.39-0.76), and without MBP and OAB (OR 0.52, 95% CrI 0.32-0.84). OAB regimen C (kanamycin + metronidazole) and A (neomycin + metronidazole) demonstrated a significantly reduced incidence of SSI, compared to regimen B (neomycin + erythromycin) with OR 0.24 (95% CrI 0.07-0.79) and 0.26 (95% CrI 0.07-0.99) respectively. CONCLUSIONS: OAB with MBP reduces the risk of SSI after elective colorectal surgery. Providing adequate aerobic and anaerobic coverage with OAB may confer better protection against SSI.

Laser hemorrhoidoplasty versus conventional hemorrhoidectomy for grade II/III hemorrhoids: a systematic review and meta-analysis.

PURPOSE: This study compared the short- and long-term clinical outcomes of laser hemorrhoidoplasty (LH) vs. conventional hemorrhoidectomy (CH) in patients with grade II/III hemorrhoids. METHODS: PubMed/Medline and the Cochrane Library were searched for randomized and nonrandomized studies comparing LH against CH in grade II/III hemorrhoids. The primary outcomes included postoperative use of analgesia, postoperative morbidity (bleeding, urinary retention, pain, thrombosis), and time of return to work/daily activities. RESULTS: Nine studies totaling 661 patients (LH, 336 and CH, 325) were included. The LH group had shorter operative time (P<0.001) and less intraoperative blood loss (P<0.001). Postoperative pain was lower in the LH group, with lower postoperative day 1 (mean difference [MD], -2.09; 95% confidence interval [CI], -3.44 to -0.75; P=0.002) and postoperative day 7 (MD, -3.94; 95% CI, -6.36 to -1.52; P=0.001) visual analogue scores and use of analgesia (risk ratio [RR], 0.59; 95% CI, 0.42-0.81; P=0.001). The risk of postoperative bleeding was also lower in the LH group (RR, 0.18; 95% CI, 0.12- 0.28; P<0.001), with a quicker return to work or daily activities (P=0.002). The 12-month risks of bleeding (P>0.999) and prolapse (P=0.240), and the likelihood of complete resolution at 12 months, were similar (P=0.240). CONCLUSION: LH offers more favorable short-term clinical outcomes than CH, with reduced morbidity and pain and earlier return to work or daily activities. Medium-term symptom recurrence at 12 months was similar. Our results should be verified in future well-designed trials with larger samples.

Survival outcomes of salvage surgery in the watch-and-wait approach for rectal cancer with clinical complete response after neoadjuvant chemoradiotherapy: a systematic review and meta-analysis.

PURPOSE: This systematic review and meta-analysis compared the outcomes of the watch-and-wait (WW) approach versus radical surgery (RS) in rectal cancers with clinical complete response (cCR) after neoadjuvant chemoradiotherapy. METHODS: This study followed the PRISMA guidelines. Major databases were searched to identify relevant articles. WW and RS were compared through meta-analyses of pooled proportions. Primary outcomes included overall survival (OS), disease-free survival (DFS), local recurrence, and distant metastasis rates. Pooled salvage surgery rates and outcomes were also collected. The Newcastle-Ottawa scale was employed to assess the risk of bias. RESULTS: Eleven studies including 1,112 rectal cancer patients showing cCR after neoadjuvant chemoradiation were included. Of these patients, 378 were treated nonoperatively with WW, 663 underwent RS, and 71 underwent local excision. The 2-year OS (risk ratio [RR], 0.95; P = 0.94), 5-year OS (RR, 2.59; P = 0.25), and distant metastasis rates (RR, 1.05; P = 0.80) showed no significant differences between WW and RS. Local recurrence was more frequent in the WW group (RR, 6.93; P < 0.001), and 78.4% of patients later underwent salvage surgery (R0 resection rate, 97.5%). The 2-year DFS (RR, 1.58; P = 0.05) and 5-year DFS (RR, 2.07; P = 0.02) were higher among RS cases. However, after adjustment for R0 salvage surgery, DFS showed no significant between-group difference (RR, 0.82; P = 0.41). CONCLUSION: Local recurrence rates are higher for WW than RS, but complete salvage surgery is often possible with similar long-term outcomes. WW is a viable strategy for rectal cancer with cCR after neoadjuvant chemoradiation, but further research is required to improve patient selection.

Computer-Navigated versus Conventional Total Knee Arthroplasty: A Meta-Analysis of Functional Outcomes from Level I and II Randomized Controlled Trials.

The main purpose of this article is to provide an up-to-date systematic review and meta-analysis comparing functional outcomes of total knee arthroplasty using either computer navigation (NAV-TKA) or conventional methods (CON-TKA) from the latest assemblage of evidence. This study was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-Analysis of Observational Studies in Epidemiology guidelines. All Level I and II randomized controlled trials (RCTs) in PubMed, EMBASE, and Cochrane that compared functional outcomes after NAV- and CON-TKA were included in the review. Selected end points for random effects, pairwise meta-analysis included Knee Society Knee Score (KSKS), KS Function Score (KSFS), KS Total Score (KSTS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and range of motion at three arbitrary follow-up times. A total of 24 prospective RCTs comprising 3,778 knees were included from the initial search. At long-term follow-up (>5 years), NAV-TKA exhibited significantly better raw KSKS (p = 0.001) (low-quality evidence), contrary to CON-TKA, which reflected significantly better raw KSTS (p = 0.004) (high-quality evidence). While change scores (KSKS, WOMAC) from preoperative values favor CON-TKA at short-term (<6 months) and medium-term follow-up (6-60 months), long-term follow-up change scores in KSKS suggest the superiority of NAV-TKA over CON-TKA (p = 0.02) (very low-quality evidence). Overall, sizeable dispersion of nonstatistically significant functional outcomes in the medium term was observed to eventually converge in the long term, with less differences in functional outcome scores between the two treatment methods in short- and long-term follow-up. While raw functional outcome scores reflect no differences between NAV and CON-TKA, long-term follow-up change scores in KSKS suggest superiority of NAV-TKA over its conventional counterpart. Prospective studies with larger power are required to support the pattern of diminishing differences in functional outcome scores from medium- to long-term follow-up between the two modalities.

Urological and sexual function after robotic and laparoscopic surgery for rectal cancer: A systematic review, meta-analysis and meta-regression.

BACKGROUND: This systematic review sought to compare the urogenital functions after laparoscopic (LAP) and robotic (ROB) surgery for rectal cancer. METHODS: This study conformed to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS: Twenty-six studies (n = 2709 for ROB, n = 2720 for LAP) were included. There was a lower risk of 30-day urinary retention in the ROB group (risk ratios 0.78, 95% confidence interval [CI] 0.61-0.99), but the long-term risk was comparable (p = 0.460). Meta-regression showed a small, positive relationship between age and risk of 30-day urinary retention in both the ROB (p = 0.034) and LAP groups (p = 0.004). The International Prostate Symptom Score was better in the ROB group at 3 months (mean difference [MD] -1.58, 95% CI -3.10 to -0.05). The International Index of Erectile Function score was better in the ROB group at 6 months (MD 4.06, 95% CI 2.38 - 5.74). CONCLUSION: While robotics may improve urogenital function after rectal surgery, the quality of evidence is low based on the Grading of Recommendations, Assessment, Development and Evaluation approach.

Use of Paclitaxel Coated Drug Eluting Technology to Improve Central Vein Patency for Haemodialysis Access Circuits: Any Benefit?

PURPOSE: Central venous stenosis is a recurring problem affecting dialysis access patency. Increasing evidence suggests that the use of drug-coated balloons (DCBs) improves target lesion primary patency (TLPP) in dialysis access. However, few studies have investigated the use of DCBs specifically in central venous stenosis. Thus, this study presents our initial experience with DCBs in the central vein of a dialysis access circuit. MATERIALS AND METHODS: This is a retrospective cohort study of all hemodialysis patients who underwent central vein angioplasty with DCB between February 2017 and March 2018 at Singapore General Hospital. We compared the primary patency post DCB angioplasty to the primary patency of the patient's previous plain old balloon angioplasty (POBA). RESULTS: We observed a 100% anatomic and procedural success rate with no complications. The median follow-up period was 151 days (interquartile range, 85.5-234 days) and no patients were lost to follow-up. The 30- and 90-day TLPPs after DCB were 93.3% and 75.7%, respectively. The mean primary patency in our study group post-DCB during the follow-up period was 164 days (vs. 140 days in the POBA group). However, no statistically significant difference was detected. CONCLUSION: DCB showed a similar TLPP to that for POBA in treating central venous stenosis with a trend toward a longer re-intervention-free period for DCB. However, there were numerous confounding factors and a well-designed randomized controlled trial is warranted to assess the true utility of DCB in treating central venous stenosis.

A systematic review of the true benefit of robotic surgery: Ergonomics.

BACKGROUND: Ergonomics, as defined by the optimization of one's physical environment to enhance work performance, is an important consideration in surgery. While there have been reviews on the ergonomics of laparoscopy, this has not been the case for robotic surgery despite the rising number of publications. METHODS: This study was performed in accordance to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. A search was performed on main databases to identify relevant articles. RESULTS: Twenty-nine articles were included, comprising 3074 participants. Studies employing objective measurement tools showed that robotics conferred superior ergonomic benefits and reduced work load compared to laparoscopy, for both surgeons and trainees. Survey studies also demonstrated that self-reported discomfort was lower in robotic procedures compared to laparoscopy and open surgery. Compared to other subspecialities, gynecological procedures seem to be associated with greater surgeon-reported strain. CONCLUSION: Robotic surgery is ergonomically superior to open and laparoscopic surgery. However, rates of physical strain remain significant and should be addressed by formal ergonomic training and adequate console familiarization.

The risk of nodal disease in patients with pathological complete responses after neoadjuvant chemoradiation for rectal cancer: a systematic review, meta-analysis, and meta-regression.

BACKGROUND: This systematic review and meta-analysis seek to evaluate the prevalence of nodal disease in rectal cancer patients with pathological complete responses (pCR) after neoadjuvant chemoradiotherapy (ypT0N+). METHODS: This study conformed to the PRISMA guidelines. A search was performed on major databases to identify relevant articles. Meta-analyses of pooled proportions were performed on rectal cancer with pCR and ypT0N+. Meta-regression was undertaken to identify sources of heterogeneity, and the Newcastle-Ottawa Scale (NOS) was employed to assess the risk of bias. RESULTS: A total of 18 studies were included, totaling 7568 patients. The overall risk of bias was low, since all studies scored 6 and above out of 9 on the NOS. Preoperatively, the pooled proportions of patients with T3/T4 tumors and clinically positive nodal disease were 84.08% (95% CI 74.19 to 91.99%) and 52.14% (95% CI 35.02 to 69.00%) respectively. The prevalence of pCR in the whole pool was 18.52% (95% CI 13.31 to 24.35%; I2 = 93.85%; P = 0.00), and meta-regression showed a significantly negative relationship with patient age (ß = - 0.03, 95% CI - 0.03 to - 0.02; P = 0.00). The pooled prevalence of ypT0N+ was 4.61% (95% CI 2.41 to 7.28%; I2 = 52.27%; P = 0.01), and meta-regression demonstrated a significantly positive relationship with male gender (ß = 1.06, 95% CI 1.00 to 1.12; P = 0.04). CONCLUSION: There is a small risk of ypN+ in patients with pCR after neoadjuvant CRT and surgery for rectal cancer. However, further research is warranted to establish these findings and to identify predictive factors for this specific group of patients.

The impact of robotic colorectal surgery in obese patients: a systematic review, meta-analysis, and meta-regression.

BACKGROUND: Robotic surgery (RS) may overcome the limitations of laparoscopic colorectal surgeries (LS) in obese patients, but remains less well studied. This systematic review and meta-analysis aims to evaluate the outcomes of obese patients who have undergone robotic colorectal surgery. METHODS: This study was performed according to the PRISMA guidelines. A search was performed on Medline, EMBASE, and the Cochrane Library to identify relevant articles. Dichotomous and continuous outcomes were analyzed as risk ratio (RR) and mean difference (MD), respectively. All post-operative outcomes were within 30 days after surgery. The quality of studies was assessed using the Newcastle-Ottawa Scale. Meta-regression analysis was conducted to identify sources of heterogeneity. RESULTS: Three studies totaling 262 subjects compared LS (45.0%) against RS (55.0%) in obese patients. The RS group had a significantly reduced length of hospital stay (LOS) (MD - 2.55 days, 95%CI - 3.13 to - 1.97 days, P < 0.00001, I2 = 26%) and lower risk of re-admission (RR 0.42, 95%CI 0.19-0.92, P = 0.030, I2 = 0%), however, the length of operative time was longer (MD 40.54 min, 95%CI 32.72-48.36 min, P < 0.00001, I2 = 37%). Six studies totaling 761 subjects compared obese (40.5%) against non-obese (59.5%) patients who underwent RS. An increased operative time (MD 20.72 min, 95%CI 7.39-34.04 min, P = 0.002, I2 = 0%) and risk of wound infection (RR 2.59, 95%CI 1.12-6.02, P = 0.030, I2 = 0%) were noted in the former, with no differences in other intra- and post-operative outcomes. Meta-regression revealed that the pathology (rectal, colon, both) (P = 0.255), age (P = 0.530), gender (P = 0.279), and continent that the study originated from (P = 0.583) were not significant sources of heterogeneity for the risk of wound infection. CONCLUSION: Compared to laparoscopy, robotic surgery provides earlier recovery with shorter LOS and reduced re-admission rates for obese patients, without compromising on other operative outcomes. Among patients undergoing robotic colorectal surgery, obesity is associated with a longer operative duration and greater risk of wound infection.

Enhanced recovery versus conventional care in gastric cancer surgery: a meta-analysis of randomized and non-randomized controlled trials.

INTRODUCTION: Enhanced recovery after surgery (ERAS) protocols have been successfully integrated into peri-operative management of different cancer surgeries such as colorectal cancer. Their value for gastric cancer surgery, however, remains uncertain. METHODS: A search for randomized and observational studies comparing ERAS versus conventional care in gastric cancer surgery was performed according to PRISMA guidelines. Random-effects meta-analyses with inverse variance weighting were conducted, and quality of included studies was assessed using the Cochrane risk-of-bias tool and Newcastle-Ottawa scale (PROSPERO: CRD42017080888). RESULTS: Twenty-three studies involving 2686 patients were included. ERAS was associated with reduced length of hospital stay (WMD-2.47 days, 95% CI - 3.06 to - 1.89, P < 0.00001), time to flatus (WMD-0.70 days, 95% CI - 1.02 to - 0.37, P < 0.0001), and hospitalization costs (WMD-USD$ 4400, 95% CI - USD$ 5580 to - USD$ 3210, P < 0.00001), with consistent results across open and laparoscopic surgery. Postoperative morbidity and 30-day mortality were similar, although a higher rate of readmission was observed in the ERAS group (RR = 1.95, 95% CI 1.03-3.67, P = 0.04). Patients in the ERAS arm had significantly attenuated C-reactive protein levels on days 3/4 and 7, interleukin-6 levels on days 1, and 3/4, and tumor necrosis factor-α levels on days 3/4 postoperatively. CONCLUSION: Compared to conventional care, ERAS reduces hospital stay, costs, surgical stress response and time to return of gut function, without increasing post-operative morbidity in gastric cancer surgery. However, precaution is necessary to reduce the increased risk of hospital readmission when adopting ERAS.