CRD summary

This review concluded that enhanced recovery after surgery (ERAS) programmes were safe and effective and increased implementation was justified for perioperative care in colorectal surgery. Methodologically this was a well-conducted review but uncertainty arising from differences between trials and risk of bias in the trials mean that the authors' confident conclusions may be overstated.

Authors' objectives

To assess the safety and efficacy of enhanced recovery after surgery (ERAS) programmes in colorectal surgery compared with traditional care.

Searching

The authors searched PubMed, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) to July 2012. Search terms were reported. No language restrictions were applied. Reference lists of included studies and previous reviews and meta-analyses were screened for additional studies.

Study selection

Randomised controlled trials (RCTs) that compared ERAS with traditional care in adults who underwent elective colorectal surgery (laparotomy or laparoscopy) were eligible for inclusion. Surgery could be for malignant or benign disease. ERAS programmes had to include at least seven out of 20 possible elements. Trials had to report at least one of the review primary outcomes: primary or total postoperative hospital stay; readmission rate within 30 days of surgery; mortality; and total postoperative complications. Secondary outcomes included time to first passage of flatus and stool, and hospital costs.

Included trials were done in various European countries (three in UK) and China and published between 2003 and 2012. Most trials recruited patients who underwent different types of surgery. Mean patient age ranged from 35.1 to 73 years but was mostly over 60. The number of ERAS elements used ranged from eight to 15 (mean 11).

Two reviewers independently selected studies for inclusion; discrepancies were resolved by discussion.

Assessment of study quality

Study quality was assessed with the Cochrane Collaboration risk of bias tool. Quality was assessed by two reviewers independently; discrepancies were resolved by discussion.

Data extraction

Data were extracted to derive relative risks (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, each with associated 95% confidence intervals (CI). Data reported as medians with range or interquartile range were converted to means and standard deviations.

Two reviewers independently extracted data; discrepancies were resolved by discussion.

Methods of synthesis

Pooled effect estimates were derived using random-effects models where there was evidence of heterogeneity and a fixed-effect model where there was no such evidence. Heterogeneity was assessed using the Q test and Ι² statistic. Publication bias was assessed using funnel plots and Egger's test. The quality of evidence for each outcome was rated using the GRADE system.

Results of the review

Thirteen RCTs (1,910 participants) were included. Eight trials reported adequate methods for randomisation. Six trials reported adequate methods for allocation concealment. Only one trial reported blinding of outcome assessors. All trials were at low risk of bias for incomplete outcome data but none were completely free from risk of other sources of bias.

Compared with traditional care, ERAS was associated with shorter primary length of stay (MD 2.44 days, 95% CI 1.83 to 3.06; Ι²=88%; 11 RCTs), total length of stay (MD 2.39 days, 95% CI 1.09 to 3.70; Ι²=85%; seven RCTs) and total complications (RR 0.71, 95% CI 0.58 to 0.86; Ι²=65%; 13 RCTs). Statistical heterogeneity was significant for all these outcomes. There was no significant difference for readmission rates (RR 0.93, 95% CI 0.56 to 1.54; Ι²=0%; 11 RCTs). Times to first flatus and stool were shorter in the ERAS group. Mortality did not differ between groups.

Quality of evidence was rated low for primary hospital stay, total complications and mortality and rated moderate for total hospital stay and readmission rate. Results for other outcomes were reported. Funnel plots were asymmetrical for some outcomes, which indicated possible publication bias.

Cost information

Hospital costs were reported in three trials. Costs were significantly lower in the ERAS group in two trials and there was no significant difference in the third.

Authors' conclusions

ERAS programmes were safe and effective and increased implementation was justified for perioperative care in elective colorectal surgery.

CRD commentary

The review objectives and inclusion criteria were clear. The search covered several relevant databases. There were no language restrictions. There was no attempt to locate unpublished trials and evidence of possible publication bias was found. Measures were taken to minimise errors or bias during the review process. Study quality was assessed using appropriate criteria and the results were used in the synthesis (GRADE profiles).

Trials were pooled by meta-analysis. High levels of statistical heterogeneity were present for some outcomes. As noted by the authors this heterogeneity probably reflected differences between trials in details of the ERAS programme, how programmes were implemented in practice and definitions of discharge criteria and complications. The presence of substantial heterogeneity increased the uncertainty around the results of the meta-analyses and this was not fully reflected in the authors' conclusions. GRADE evidence profiles indicated that further research was likely to change the estimates of effect for some outcomes; this reflected relatively high risk of bias in many of the included trials that was not fully taken into account in the authors' conclusions.

Methodologically this was a well-conducted review. The findings about reduced length of stay and complications with ERAS programmes reflect the evidence presented but uncertainty arising from differences between trials and risk of bias in the trials mean that the authors' confident conclusions may be overstated.

Implications of the review for practice and research

Practice: The authors stated that implementation of ERAS programmes may require collaboration involving various health professionals and patients.

Research: The authors stated a need for RCTs with long-term follow-up to assess effects of ERAS on hospital costs and quality of life. They also recommended trials in elderly patients and patients having other types of gastrointestinal surgery.

Funding

Clinical nutriology of medical supporting discipline of Zhejiang Province, China.

Bibliographic details

Zhuang CL, Ye XZ, Zhang XD, Chen BC, Yu Z. Enhanced recovery after surgery programs versus traditional care for colorectal surgery: a meta-analysis of randomized controlled trials. Diseases of the Colon and Rectum 2013; 56(5): 667-678. [PubMed: 23575408]

Original Paper URL

http://journals.lww.com/dcrjournal/Abstract/2013/05000/Enhanced_Recovery_After_Surgery_Programs_Versus.18.aspx

Indexing Status

Subject indexing assigned by NLM

MeSH

Adolescent; Adult; Aged; Aged, 80 and over; Colonic Diseases /surgery; Female; Humans; Length of Stay /statistics & numerical data; Male; Middle Aged; Outcome Assessment (Health Care); Patient Readmission /statistics & numerical data; Perioperative Care /methods /statistics & numerical data; Postoperative Complications /epidemiology /prevention & control; Randomized Controlled Trials as Topic; Rectal Diseases /surgery; Young Adult

AccessionNumber

12013020420

Database entry date

01/05/2013

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.