Non-drug perioperative interventions to reduce postoperative pulmonary complications after abdominal surgery: systematic review and meta-analysis.

Summary

This PROSPERO-registered systematic review synthesized 255 RCTs (55,260 participants) of 10 classes and 39 subtypes of non-pharmacologic perioperative interventions for abdominal surgery. PPCs occurred in 11.7% across trials, and high-certainty evidence was identified for specific practices (including low FiO2) in preventing PPCs, establishing an evidence hierarchy with trial sequential analyses and GRADE.

Key Findings

• Included 255 randomized trials (n=55,260) covering 10 intervention types and 39 subtypes for PPC prevention in abdominal surgery.
• Across trials, 11.7% of participants developed PPCs, enabling precise pooled estimates.
• High-certainty evidence was identified for specific practices, including low FiO2, and an evidence hierarchy was established using GRADE and trial sequential analysis.

Clinical Implications

Supports incorporating validated non-pharmacologic measures (e.g., appropriately titrated FiO2 and other evidenced practices) into ERAS pathways to reduce PPCs, guide oxygen administration, and standardize respiratory care bundles.

Limitations

• Heterogeneity in intervention types and implementation details may limit direct comparability
• Some PPC subtype definitions and perioperative co-interventions vary across trials

Future Directions

Prospective, standardized multicenter trials comparing prioritized bundles from the evidence hierarchy and evaluating implementation strategies within ERAS pathways.