The application of enhanced recovery after surgery (ERAS) in chronic rhinosinusitis patients undergoing endoscopic sinus surgery: A systematic review and meta-analysis

OBJECTIVES: Enhanced recovery after surgery (ERAS) has become extensively practiced and has shown encouraging benefits. Within recent years, ERAS has also been increasingly performed in chronic rhinosinusitis (CRS) patients undergoing endoscopic sinus surgery (ESS). However, the actual efficacy of ERAS in CRS patients undergoing ESS is not completely clear, and the related evidence remains weak. This systematic review and meta-analysis aimed to evaluate the effectiveness and safety of ERAS in the perioperative management of CRS patients receiving ESS. METHODS: We searched randomized controlled trials in PubMed, Web of Science, EMBASE, Cochrane CENTRAL, Ovid, China National Knowledge Infrastructure, Chinese BioMedical Literature Database, Wanfang, and VIP Database up to February 2023, to analyze the effectiveness and safety of ERAS in ESS perioperative management of CRS patients. We appraised the methodological quality in the included RCTs using the Cochrane Collaboration tool and assessed the quality of evidence with the Recommendations Assessment, Development and Evaluation (GRADE) tool. Meta-analysis, subgroup analysis, and sensitivity analysis were carried out with the the software Review Manager 5.3 and Stata 12.0. In addition, potential publication bias was detected by Begg’s test, Egger’s test, and funnel plot test. RESULTS: Twenty-eight studies involving 2636 patients were included within this study. In comparison with the standard care (SC) group, the ERAS group had the advantages in the following aspects: length of stay (MD = -2.50, 95%CI: -3.04 to -1.97), pain scores (MD = -1.07, 95%CI: -1.46 to -0.67), anxiety score (SMD = -2.13, 95%CI: -2.83 to -1.44), depression score (SMD = -2.42, 95%CI: -3.13 to -1.71), hospitalization expenses, and quality of life. At the same time, the ERAS group presented a markedly lower incidence of adverse events in comparison to the SC group, such as overall complications (RR = 0.28, 95%CI:0.20 to 0.41), postoperative nausea and vomiting (RR = 0.33, 95%CI:0.21 to 0.50), facial edema (RR = 0.20, 95%CI:0.11 to 0.38), low back pain (RR = 0.28, 95%CI:0.16 to 0.49), urinary retention (RR = 0.12, 95%CI:0.05 to 0.30) and haemorrhage (RR = 0.19, 95%CI:0.07 to 0.55). CONCLUSIONS: The results showed that the ERAS protocol is effective and safe in CRS patients who undergo ESS. However, Due to the limited overall methodological quality included studies, caution should be exercised in the interpretation of the results. More high-quality, multiple-centre, and large-sample studies are in demand in the future to further validate its clinical efficacy.