Contemporary lung-protective ventilation and postoperative pulmonary complications in laparoscopic colorectal and bariatric surgery: A systematic review and meta-analysis

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BACKGROUND Postoperative pulmonary complications (PPCs) remain clinically important after laparoscopic gastrointestinal surgery.Contemporary lung-protective ventilation (LPV) studies evaluate heterogeneous interventions, including multicomponent bundles, individualized positive end-expiratory pressure (PEEP), recruitment maneuvers, and driving-pressure guidance.These strategies and their outcomes are not necessarily interchangeable; therefore, clinically distinct PPCs, atelectasis, hypoxemia, oxygenation, respiratory mechanics, and recovery outcomes require separate evaluation.AIM To systematically evaluate contemporary LPV strategies in laparoscopic colorectal/rectal and bariatric surgery while separating clinically non-equivalent interventions and outcomes. METHODSThe retained review searched PubMed, EMBASE, Web of Science, the Cochrane Library, and ClinicalTrials.govfor controlled clinical studies published from January 2022 to June 3, 2026.The review was registered in PROSPERO, No. CRD420261422048.A revisionstage, from-inception PubMed sensitivity search was run on September 17, 2026 and retrieved 108 records before deduplication or screening; complete reruns of the other databases were not possible from the retained records.The primary outcome was a studydefined composite PPC endpoint.Random-effects pooling was restricted to two colorectal/rectal lung-ultrasound-guided individualized-PEEP trials and was designated post hoc and exploratory. RESULTSThe retained date-restricted dataset comprised 13 studies (eight colorectal/rectal and five bariatric).The from-inception PubMed sensitivity search identified records outside that dataset, including relevant pre-2022 randomized trials; therefore, the retained dataset is not presented as a comprehensive current evidence base.Two lung-ultrasound-guided individualized-PEEP trials were pooled only post hoc and exploratorily.Their composite PPC estimate was imprecise [risk ratio (RR) = 0.42, 95% confidence interval (CI): 0.12-1.52;I 2 = 51%], as was the atelectasis estimate (RR = 0.39, 95%CI: 0.10-1.50;I 2 = 33%).Other strategies and outcomes were synthesized narratively because procedures, comparators, definitions, or assessment times differed. CONCLUSIONWithin the retained 13-study, date-restricted dataset, evidence is heterogeneous and imprecise, and the two-study estimates are hypothesis-generating only.Because the lower date restriction demonstrably omits relevant earlier trials and a complete multidatabase update could not be reconstructed, this review does not establish the overall or current effect of LPV or any component-specific strategy.