Summary of ERAS elements.

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.

研究目标
加速康复外科（Enhanced Recovery After Surgery, ERAS）目前已得到广泛临床应用，并展现出令人鼓舞的获益。近年来，ERAS在接受鼻内镜鼻窦手术（Endoscopic Sinus Surgery, ESS）的慢性鼻-鼻窦炎（Chronic Rhinosinusitis, CRS）患者中的应用也日益普及。然而，ERAS应用于此类患者的实际疗效尚未完全明确，相关循证证据仍较为薄弱。本系统评价与荟萃分析旨在评估ERAS用于接受ESS的CRS患者围手术期管理的有效性与安全性。

研究方法
我们检索了截至2023年2月的PubMed、Web of Science、EMBASE、Cochrane CENTRAL、Ovid、中国知网（China National Knowledge Infrastructure）、中国生物医学文献数据库、万方数据知识服务平台及维普数据库中的随机对照试验（randomized controlled trial, RCT），以分析ERAS应用于CRS患者ESS围手术期管理的有效性与安全性。采用Cochrane协作网偏倚风险评估工具对纳入的RCT进行方法学质量评价，并采用推荐意见分级、制定与评价（Grading of Recommendations Assessment, Development and Evaluation, GRADE）工具评估证据质量。使用Review Manager 5.3与Stata 12.0软件完成荟萃分析、亚组分析及敏感性分析。此外，通过Begg检验、Egger检验及漏斗图检测潜在的发表偏倚。

研究结果
本研究共纳入28项研究，涉及2636例患者。与标准护理（Standard Care, SC）组相比，加速康复外科组在以下指标中展现出显著优势：住院时长（均差MD=-2.50，95%置信区间CI：-3.04~-1.97）、疼痛评分（MD=-1.07，95%CI：-1.46~-0.67）、焦虑评分（标准化均差SMD=-2.13，95%CI：-2.83~-1.44）、抑郁评分（SMD=-2.42，95%CI：-3.13~-1.71）、住院费用及生活质量。同时，加速康复外科组的不良事件发生率显著低于标准护理组，具体包括总体并发症（相对风险RR=0.28，95%CI：0.20~0.41）、术后恶心呕吐（RR=0.33，95%CI：0.21~0.50）、面部水肿（RR=0.20，95%CI：0.11~0.38）、腰背痛（RR=0.28，95%CI：0.16~0.49）、尿潴留（RR=0.12，95%CI：0.05~0.30）及出血（RR=0.19，95%CI：0.07~0.55）。

研究结论
结果表明，加速康复外科方案应用于接受ESS的CRS患者时，兼具有效性与安全性。但由于纳入研究的整体方法学质量有限，对本研究结果的解读应保持谨慎。未来仍需开展更多高质量、多中心、大样本量的研究，以进一步验证其临床疗效。