
==== Front
Int J Surg
Int J Surg
JS9
International Journal of Surgery (London, England)
1743-9191
1743-9159
Lippincott Williams & Wilkins Hagerstown, MD

38857506
IJS-D-24-02205
10.1097/JS9.0000000000001771
00147
3
Correspondence
Reply to the commentary on ‘Safety and efficacy of enhanced recovery after surgery among patients undergoing percutaneous nephrolithotomy: a systematic review and meta-analysis’
Liu Liang MM ab*mnwkll@163.com

Suo Yong BSM c17713210037@163.com

Xiao Yu MM xiaoy3@outlook.com
de
An Lin MM f173745817@qq.com

Yue Xiao BSM ab54858737@qq.com

Zheng Ji PhD gh*Jizheng@tmmu.edu.cn

Wang Qiang PhD ab*18031296066@163.com

a Department of Urology, Baoding No.1 Central Hospital, Baoding, Hebei, China
b Prostate & Andrology Key Laboratory of Baoding, Baoding, Hebei, China
c Department of Urology, Affiliated Hospital of Hebei University, Baoding, Hebei, China
d Psychosomatic Medical Center, The Fourth People's Hospital of Chengdu, Chengdu, Sichuan, China
e Psychosomatic Medical Center, The Clinical Hospital of Chengdu Brain Science Institute, MOE Key Lab for Neuroinformation, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
f Department of Medical Oncology, Affiliated Hospital of Hebei University, Hebei Key Laboratory of Cancer Radiotherapy and Chemotherapy, Baoding, Hebei, China
g Department of Urology, Urologic Surgery Center, Xinqiao Hospital, Army Medical University, Chongqing, China
h State Key Laboratory of Trauma and Chemical Poisoning, Third Military Medical University (Army Medical University), Chongqing, China
* Corresponding author. Address: Department of Urology, Prostate and Andrology Key Laboratory of Baoding, Baoding No.1 Central Hospital, Changcheng North Street and Number 320, Baoding 071000, People’s Republic of China. Tel.: +312 597 5015. E-mail: mnwkll@163.com (L. Liu), and E-mail: 18031296066@163.com (Q. Wang); Department of Urology, Urologic Surgery Center, Xinqiao Hospital, Army Medical University, Chongqing 400037, People’s Republic of China. Tel.: +86 023 687 658 46. E-mail: jizheng023@aliyun.com (J. Zheng).
9 2024
10 6 2024
110 9 60386042
21 5 2024
27 5 2024
Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0/

OPEN-ACCESSTRUE
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pmc Dear Editor,

We have read the comments comprehensively and carefully to our paper1 (Liu L., Xiao Y., Yue X., et al. Safety and efficacy of enhanced recovery after surgery among patients undergoing percutaneous nephrolithotomy: a systematic review and meta-analysis. International Journal of Surgery. 2024. doi:10.1097/JS9.0000000000001158) by Huang et al.2. We appreciate the authors’ concern for our article. At the same time, as a result of their insightful suggestions, we are grateful to the editors, reviewers, and Huang et al. who contributed to this process. These insightful suggestions will greatly improve the authenticity and credibility of our study, and minimize the bias and limitations of our research. And we know how important it is to clarifying these questions in detail.

Enhanced recovery after surgery program aimed to promote rapid recovery from surgery by using perioperative management to block or reduce the body’s stress response after surgery. An improved enhanced recovery after surgery protocol was introduced in colorectal surgery in the 1990s for the purpose of reducing the perioperative burden and speeding up recovery for patients. Today, enhanced recovery after surgery is being applied to a range of complex laparoscopic surgical procedures and specialties, including liver resections and gynecologic oncology, and the benefits of the procedure have been well established3. In clinical practice, percutaneous nephrolithotomy is the most common treatment for large renal calculi, however, the clinical application of the enhanced recovery after surgery program in this setting has not been effectively evaluated. As a result, we conducted a systematic review and meta-analysis of the efficacy and safety of the enhanced recovery after surgery program in percutaneous nephrolithotomy to provide evidence for clinical practice. Enhanced recovery after surgery ensures the safety and efficiency in percutaneous nephrolithotomy while also promoting postoperative rehabilitation of patients such as postoperative hospital time, postoperative indwelling nephrostomy tube time, and lower complication rate.

First, the present study has some limitations, as do all research studies. As you said ‘the meta-analysis only included studies conducted in China. The specific implementation of the Enhanced Recovery After Surgery (ERAS) protocols can vary due to hospital policies and geographical locations, and different cultural beliefs and social factors in various regions may also affect patients’ compliance with ERAS recommendations’. First, in order to control biases generated by study retrieval and data extraction, we developed extensive search strategies in advance to yield as much information as possible. As well as a search of the English databases, we also searched the Chinese databases for our meta-analysis, including four English databases (Wan Fang database, Chinese Biomedical Literature Service System, Chinese National Knowledge Infrastructure, Chinese Science and Technology Journal Full Text Database) and four Chinese databases (PubMed, Embase, Cochrane Library, and Web of Science). In parallel, we also conducted comprehensive literature searches by hand‐searching of grey literature. As we described in Literature search and inclusion criteria, we searched for relevant literature using subject terms and free words, and manual search in order to gather as much information as possible. The Cochrane Library search strategy is presented in Table 1. Second, to ensure the quality of the included studies and the reliability of the results, we determined and implemented strict inclusion and exclusion criteria. Finally, 25 studies4–28 from China were included in the final analysis after searching for well articles and screenings.

Table 1 Cochrane library search strategy

Search number	Search detail	
#1	enhanced recovery after surgery (ti,ab,kw)	
#2	enhanced postsurgical recovery (ti,ab,kw)	
#3	postsurgical recoveries, enhanced (ti,ab,kw)	
#4	postsurgical recovery, enhanced (ti,ab,kw)	
#5	recovery, enhanced postsurgical (ti,ab,kw)	
#6	ERAS (ti,ab,kw)	
#7	FTS (ti,ab,kw)	
#8	#1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7	
#9	nephrolithotomy, percutaneous (ti,ab,kw)	
#10	nephrolithotomies, percutaneous (ti,ab,kw)	
#11	percutaneous nephrolithotomies (ti,ab,kw)	
#12	percutaneous nephrolithotomy (ti,ab,kw)	
#13	PCNL (ti,ab,kw)	
#14	#9 OR #10 OR #11 OR #12 OR #13	
#15	#8 AND #14	

Secondly, Huang et al.2 indicated that random effects models should be used for analyses when significant heterogeneity was present, which is a robust method. However, there may also be residual confounding from unmeasured or incompletely measured covariates. Across different clinical trials, methodological designs vary, especially in subsequent patient care for our article, which may affect the outcome. To solve this doubt, each study’s management measures of enhanced recovery after surgery in the perioperative period has been documented and evaluated in detail. Sixteen items were included, and if the item was less than 6 and missing either of the preoperative, intraoperative, and postoperative care phases when we performed subgroup analyses based on factors such as sample size and stone location, the study was excluded. Each item of enhanced recovery after surgery in the perioperative period was listed in Tables 2–4. Finally, three studies (Ma, 2014; Lin, 2015; Li, 2017)22,24,25 were excluded. Results showed large heterogeneity between studies about postoperative duration of hospital stay. We still divided the study population into subgroups based on sample size and stone location. Additionally, there were no significant differences between each subgroup’s heterogeneity and that of the entire sample, and the results of each subgroup analysis were also consistent with the overall results (Figs 1,2). Thus, our results are relatively consistent and reliable. Therefore, we assumed that the differences in subsequent patient care might not be responsible for clinical heterogeneity between the included studies.

Table 2 Number of ERAS items adopted in preoperative interventions in the included RCTs.

References	Patient education/counseling	Shortened fasting	Optimized diets	Prophylactic antibiotics	
Zhang et al. 4	√	√			
Yang et al. 5	√	√	√		
Ou et al. 6	√	√	√		
Chen et al. 7	√				
Li et al. 8	√	√	√		
Shen et al. 9	√	√	√	√	
Cai et al. 10	√	√	√		
Li et al. 11	√	√	√	√	
Zhang et al. 12	√	√	√		
Tan13		√	√	√	
Li14	√	√	√		
Luo et al. 15	√	√	√		
Ma et al. 16	√	√	√		
Hou et al. 17	√	√			
Zhuang et al. 18	√	√	√		
Zhou et al. 19	√	√	√		
Wei20	√	√	√		
Mao et al. 21	√	√		√	
Li et al. 22	√				
Yang23	√	√			
Lin et al. 24					
Ma et al. 25	√				
Dong et al. 26	√		√	√	
Chen et al. 27	√	√		√	
Qiao et al. 28	√	√			

Table 3 Number of ERAS items adopted in intraoperative interventions in the included RCTs.

References	Prophylactic antibiotics	Minimally invasive	Epidural anesthesia/nonsteroidal analgesic painkillers	Intravenous fluid restriction	Prevention of hypothermia	Use of drainage tubes	
Zhang et al. 4		√			√	√	
Yang et al. 5		√					
Ou et al. 6		√		√	√	√	
Chen et al. 7	√	√		√	√	√	
Li et al. 8		√		√	√		
Shen et al. 9		√					
Cai et al. 10		√					
Li et al. 11	√	√	√		√	√	
Zhang et al. 12		√	√	√	√	√	
Tan13		√				√	
Li14	√	√					
Luo et al. 15		√			√	√	
Ma et al. 16		√				√	
Hou et al. 17		√		√	√	√	
Zhuang et al. 18	√	√	√	√	√	√	
Zhou et al. 19	√	√	√				
Wei20		√		√	√	√	
Mao et al. 21	√	√	√	√	√	√	
Li et al. 22		√					
Yang23		√		√	√	√	
Lin et al. 24		√				√	
Ma et al. 25		√				√	
Dong et al. 26	√	√	√	√	√	√	
Chen et al. 27	√	√		√		√	
Qiao et al. 28		√			√	√	

Table 4 Number of ERAS items a in postoperative interventions in the included RCTs.

References	Nonsteroidal analgesic painkillers	Intravenous fluid restriction	Early oral feeding	Early ambulation	Prophylactic medication	Early drainage tube removal	Total items	
Zhang et al. 4	√			√		√	8	
Yang et al. 5	√			√	√		7	
Ou et al. 6	√		√	√		√	12	
Chen et al. 7			√	√	√	√	10	
Li et al. 8	√	√	√	√	√		11	
Shen et al. 9	√		√	√			8	
Cai et al. 10	√			√			6	
Li et al. 11	√	√	√	√	√	√	15	
Zhang et al. 12	√	√	√	√		√	13	
Tan13			√	√		√	8	
Li14	√		√	√			9	
Luo et al. 15			√	√		√	9	
Ma et al. 16		√	√	√	√	√	10	
Hou et al. 17	√	√	√	√	√	√	13	
Zhuang et al. 18	√	√	√	√	√	√	15	
Zhou et al. 19	√			√	√		9	
Wei20	√		√	√			10	
Mao et al. 21	√	√	√	√		√	14	
Li et al. 22							2	
Yang23	√		√	√		√	11	
Lin et al. 24	√		√	√	√		6	
Ma et al. 25	√						4	
Dong et al. 26	√						11	
Chen et al. 27	√		√	√			11	
Qiao et al. 28	√						6	

Figure 1 Forest plots showing postoperative hospital stay for subgroup analysis (according to sample size) in the observation and control groups.

Figure 2 Forest plots showing postoperative hospital stay for subgroup analysis (according to stone location) in the observation and control groups.

This study has limitations, as with any research. In view of this, we hope to see more RCTs and more studies with a greater number of subjects to further demonstrate the safety and efficacy of enhanced recovery after surgery in percutaneous nephrolithotomy.

Ethical approval

Ethical approval was not required

Consent

Not applicable.

Source of funding

Not applicable.

Author contribution

L.L., J.Z., and Q.W.: contributed substantially to the conception, design of the protocol, and critically revised the manuscript for intellectual content; L.A. and X.Y.: drafted the manuscript; L.L., Y.S., and Y.X.: drafted the manuscript and critically revised the manuscript for intellectual content.

Conflicts of interest disclosure

The authors declare no conflicts of interest.

Guarantor

Liang Liu.

Data availability statement

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Provenance and peer review

Not commissioned, internally reviewed.

Assistance with the study

Not applicable.

Presentation

Not applicable.

Acknowledgements

Not applicable.

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Published online 10 June 2024
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