CRD summary

This review assessed fast-track recovery programmes compared with standard care in elective colorectal surgery. The authors concluded that fast-track programmes were effective in reducing overall hospital stay without compromising patient safety or increasing morbidity. Overall, this was a well-conducted systematic review and the authors' conclusions are likely to be reliable.

Authors' objectives

To assess fast-track protocols compared with standard care in elective colorectal surgery involving segmental colonic and/or rectal resection.

Searching

MEDLINE, EMBASE and The Cochrane Library were searched from 1995 to July 2008; search terms were reported. The related article function on PubMed was used to identify additional relevant studies. No language restrictions were applied.

Study selection

Studies that compared a perioperative fast-track protocol with standard care in patients who underwent elective segmental colonic, rectal or colorectal resection for benign or malignant disease were eligible for inclusion. Studies had to report on at least one of the following outcomes: short-term morbidity; length of primary postoperative hospital stay; length of total postoperative hospital stay (including possible readmissions); readmission rate; and mortality. Studies had to clearly document the multimodal fast-track programme implemented. Studies were excluded if the outcomes of interest were not reported clearly for the two treatment groups or if it was impossible to extrapolate or calculate the necessary data from the published results.

The included studies had between four and 14 fast-track elements in the fast-track protocol. The most commonly used fast-track elements were preoperative counselling, epidural analgesia, no routine use of nasogastric tubes, enforced postoperative mobilisation and enforced postoperative oral feeding. The average age of patients in the included studies ranged from 39 to 73 years.

The authors did not state how papers were selected for the review.

Assessment of study quality

Case control studies were assessed using the Newcastle-Ottawa scale. Randomised controlled trials (RCTs) were assessed using the Jadad scale. Patient selection, comparability of study groups and assessment of outcome were assessed. Two reviewers assessed the quality of the included studies. Case control studies that scored at least 7 out of a possible 11 points and RCTs that scored at least 3 out of a possible 5 points were considered to be higher quality.

Data extraction

Short-term morbidity, readmission rate and mortality were extracted as percentages. Length of primary postoperative hospital stay and length of total postoperative hospital stay were extracted as days. Relative risks (RRs) with 95% confidence intervals (CIs) were calculated for dichotomous data. Mean differences with 95% CIs were calculated for continuous data.

Two reviewers independently extracted data from the included studies.

Methods of synthesis

Relative risks and weighted mean differences, with 95% CIs, were pooled using both fixed-effect and random-effects models. Heterogeneity was assessed using the X² and I² tests. Subgroup analyses were undertaken to assess the effect of trial design on results (RCT versus case control study). Funnel plots were used to assess for publication bias.

Results of the review

Four RCTs and seven case control studies were included in the review (n=1,021 patients). Sample sizes ranged from 25 to 260 patients. Three RCTs scored 3 out of 5 points for quality; one scored 2 out of 5. One of the RCTs used a random number generator to randomise patients and the others used sealed envelopes. Blinding of participants and medical staff was not possible. Losses to follow-up were not reported. All case control studies scored at least 7 out of 11 points for quality. Duration of follow-up was 30 days for most studies.

Primary postoperative hospital stay was statistically significantly shorter for the fast-track group than for the standard care group (weighted mean difference (WMD) -2.35 days, 95% CI -3.24 to -1.46; nine studies). Subgroup analysis by trial design did not significantly affect the results. There was significant heterogeneity when all studies were pooled and when case control studies only were pooled for this outcome.

Total postoperative hospital stay was statistically significantly shorter for the fast-track group than for the standard care group (WMD -2.46 days, 95% CI -3.43 to -1.48; five studies). Subgroup analysis by trial design did not significantly affect the results.

Morbidity rates were statistically significantly lower in the fast-track group than the standard care group (RR 0.56, 95% CI 0.45 to 0.69; nine studies). Subgroup analysis by trial design did not significantly affect the results.

Readmission rates were not statistically significantly different between the fast-track group and the standard care group when RCTs and case control studies were pooled together. However, in the subgroup analysis of case control studies, readmission rates were statistically significantly higher in the fast-track protocol group (RR 1.51, 95% CI 1.06 to 2.17; six studies).

Mortality rates were not statistically significantly different between the fast-track group and the standard care group.

Further results were reported for other clinical outcomes.

Authors' conclusions

Fast-track recovery programmes were effective in reducing overall hospital stay without compromising patient safety or increasing morbidity.

CRD commentary

The review addressed a clear question and was supported by well-defined inclusion criteria. The search strategy was adequate and had no language restrictions, which reduced potential for language bias. Limited attempts were made to identify unpublished studies. The authors stated that funnel plots were used to assess for publication bias, but the results were not presented. Study quality was assessed using appropriate criteria and results were reported; most studies were considered higher quality. Two reviewers assessed study quality and extracted data, which reduced potential for reviewer bias and error. The authors did not state how studies were selected for the review; therefore, potential for reviewer bias and error in the stage of the review process could not be assessed. Appropriate methods were used to pool results and assess statistical heterogeneity. Overall, this was a well-conducted systematic review and the authors' conclusions are likely to be reliable.

Implications of the review for practice and research

Practice: The authors stated that fast-track recovery programmes should form the mainstay of elective colorectal surgery. However, multidisciplinary teams that comprised surgeons, anaesthetists and nursing staff all required additional training and management in order to undertake respective fast-track roles. A significant emphasis on organisation and structure was needed before such a complex programme could be implemented consistently and low compliance with the protocol must be resolved. The authors also stated that all fast-track protocols must have rigid and strict discharge criteria.

Research: The authors stated that future RCTs should investigate the relative value of each element of fast-track programmes. Studies should also investigate possible causes of low compliance with the fast-track protocol. More evidence was required on selection of patients for fast-track programmes. Future studies should be stratified into upper and lower gastrointestinal surgery as well as anatomically specific planned surgery.

Funding

Not stated.

Bibliographic details

Gouvas N, Tan E, Windsor A, Xynos E, Tekkis PP. Fast-track vs standard care in colorectal surgery: a meta-analysis update. International Journal of Colorectal Disease 2009; 24(10): 1119-1131. [PubMed: 19415308]

Original Paper URL

http://www.springerlink.com/content/y141587wg85315j8/

Indexing Status

Subject indexing assigned by NLM

MeSH

Colorectal Surgery /methods /mortality /statistics & numerical data; Controlled Clinical Trials as Topic; Delivery of Health Care /methods; Fatigue; Humans; Immune System; Intubation, Gastrointestinal; Length of Stay; Morbidity; Pain Measurement; Patient Readmission; Quality of Life; Respiratory Function Tests; Treatment Outcome

AccessionNumber

12010000303

Database entry date

14/07/2010

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.