Enhanced Recovery Protocols for Adults Undergoing Colorectal Surgery: A Systematic Review and Meta-analysis

BACKGROUND: Enhanced surgical recovery protocols are designed to reduce hospital length of stay and health care costs. OBJECTIVE: This study aims to systematically review and summarize evidence from randomized and controlled clinical trials comparing enhanced recovery protocols versus usual care in adults undergoing elective colorectal surgery with emphasis on recent trials, protocol components, and subgroups for surgical approach and colorectal condition. DATA SOURCES: MEDLINE from 2011 to July 2017; reference lists of existing systematic reviews and included studies were reviewed to identify all eligible trials published before 2011. STUDY SELECTION: English language trials comparing a protocol of preadmission, preoperative, intraoperative, and postoperative components with usual care in adults undergoing elective colorectal surgery were selected. INTERVENTION: The enhanced recovery protocol for colorectal surgery was investigated. MAIN OUTCOME MEASURES: Length of stay, perioperative morbidity, mortality, readmission within 30 days, and surgical site infection were the primary outcomes measured. RESULTS: Twenty-five trials of open or laparoscopic surgery for cancer or noncancer conditions were included. Enhanced recovery protocols consisted of 4 to 18 components. Few studies fully described the various components. Length of stay (mean reduction, 2.6 days; 95% CI, –3.2 to –2.0) and risk of overall perioperative morbidity (risk ratio, 0.66; 95% CI, 0.54–0.80) were lower in enhanced recovery protocol groups than in usual care groups (moderate-quality evidence). All-cause mortality (rare), readmissions, and surgical site infection rates were similar between protocol groups (low-quality evidence). In predefined subgroup analyses, findings did not vary by surgical approach (open vs laparoscopic) or colorectal condition. LIMITATIONS: Protocols varied across studies and little information was provided regarding compliance with, or implementation of, specific protocol components. CONCLUSIONS: Enhanced recovery protocols for adults undergoing colorectal surgery improve patient outcomes with no increase in adverse events. Evidence was insufficient regarding which components, or component combinations, are key to improving patient outcomes. PROSPERO registration number: CRD42017067991.

[1]  P. Kipnis,et al.  Enhanced Recovery After Surgery Program Implementation in 2 Surgical Populations in an Integrated Health Care Delivery System , 2017, JAMA surgery.

[2]  Y. Doki,et al.  Safety and efficacy of an “enhanced recovery after surgery” protocol for patients undergoing colon cancer surgery: a multi-institutional controlled study , 2017, Surgery Today.

[3]  H. Körner,et al.  Enhanced Recovery After Colorectal Surgery (ERAS) in Elderly Patients Is Feasible and Achieves Similar Results as in Younger Patients , 2017, Gerontology & geriatric medicine.

[4]  D. Brunelli,et al.  Randomized Trial on Fast Track Care in Colorectal Surgery for Deep Infiltrating Endometriosis. , 2017, Journal of minimally invasive gynecology.

[5]  Christine S. M. Lau,et al.  Enhanced Recovery After Surgery Programs Improve Patient Outcomes and Recovery: A Meta-analysis , 2017, World Journal of Surgery.

[6]  K. Fearon,et al.  Enhanced Recovery After Surgery: A Review , 2017, JAMA surgery.

[7]  R. Thiele,et al.  Reducing Readmissions While Shortening Length of Stay: The Positive Impact of an Enhanced Recovery Protocol in Colorectal Surgery , 2017, Diseases of the colon and rectum.

[8]  K. Slim,et al.  Are enhanced recovery programs in colorectal surgery feasible and useful in the elderly? A systematic review of the literature. , 2017, Journal of visceral surgery.

[9]  M. Rossi,et al.  ERAS Protocol Reduces IL-6 Secretion in Colorectal Laparoscopic Surgery: Results From a Randomized Clinical Trial , 2016, Surgical laparoscopy, endoscopy & percutaneous techniques.

[10]  M. Rossi,et al.  Surgical Stress Reduction in Elderly Patients Undergoing Elective Colorectal Laparoscopic Surgery within an ERAS Protocol. , 2016, Chirurgia.

[11]  F. Ruffolo,et al.  Open sphincter-preserving surgery of extraperitoneal rectal cancer without primary stoma and Fast Track Protocol. , 2016, Il Giornale di chirurgia.

[12]  Xiaodong Wang,et al.  The effects of fast-track surgery on inflammation and immunity in patients undergoing colorectal surgery , 2016, International Journal of Colorectal Disease.

[13]  H. Körner,et al.  Compliance with enhanced recovery after surgery criteria and preoperative and postoperative counselling reduces length of hospital stay in colorectal surgery: results of a randomized controlled trial , 2016, Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland.

[14]  Christopher L. Wu,et al.  Organizational Culture Changes Result in Improvement in Patient-Centered Outcomes: Implementation of an Integrated Recovery Pathway for Surgical Patients. , 2015, Journal of the American College of Surgeons.

[15]  Hao Wang,et al.  Short-term quality of life in patients undergoing colonic surgery using enhanced recovery after surgery program versus conventional perioperative management , 2015, Quality of Life Research.

[16]  A. Darzi,et al.  A systematic review of enhanced recovery care after colorectal surgery in elderly patients , 2014, Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland.

[17]  P. Gao,et al.  Fast-track surgery versus traditional perioperative care in laparoscopic colorectal cancer surgery: a meta-analysis , 2014, BMC Cancer.

[18]  D. Chambers,et al.  Effectiveness and implementation of enhanced recovery after surgery programmes: a rapid evidence synthesis , 2014, BMJ Open.

[19]  O. Ljungqvist.  ERAS--enhanced recovery after surgery: moving evidence-based perioperative care to practice. , 2014, JPEN. Journal of parenteral and enteral nutrition.

[20]  F. Feng,et al.  Fast‐track surgery combined with laparoscopy could improve postoperative recovery of low‐risk rectal cancer patients: A randomized controlled clinical trial , 2014, Journal of digestive diseases.

[21]  M. Braga,et al.  Enhanced Recovery Program in Colorectal Surgery: A Meta-analysis of Randomized Controlled Trials , 2014, World Journal of Surgery.

[22]  W. White,et al.  Reduced Length of Hospital Stay in Colorectal Surgery after Implementation of an Enhanced Recovery Protocol , 2014, Anesthesia and analgesia.

[23]  R. Pugliese,et al.  Fast-Track Versus Standard Care in Laparoscopic High Anterior Resection: A Prospective Randomized-Controlled Trial , 2014, Surgical laparoscopy, endoscopy & percutaneous techniques.

[24]  Aditya J. Nanavati,et al.  A Comparative Study of ‘Fast-Track’ Versus Traditional Peri-Operative Care Protocols in Gastrointestinal Surgeries , 2014, Journal of Gastrointestinal Surgery.

[25]  Dao-rong Wang,et al.  Fast-track rehabilitation vs conventional care in laparoscopic colorectal resection for colorectal malignancy: a meta-analysis. , 2013, World journal of gastroenterology.

[26]  Zhongxin Li,et al.  Fast-track surgery decreases the incidence of postoperative delirium and other complications in elderly patients with colorectal carcinoma , 2013, Langenbeck's Archives of Surgery.

[27]  Cheng-Le Zhuang,et al.  Enhanced Recovery After Surgery Programs Versus Traditional Care for Colorectal Surgery: A Meta-analysis of Randomized Controlled Trials , 2013, Diseases of the colon and rectum.

[28]  K. Fearon,et al.  Guidelines for Perioperative Care in Elective Colonic Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations , 2013, World Journal of Surgery.

[29]  Yong Shao,et al.  The enhanced recovery after surgery (ERAS) pathway for patients undergoing colorectal surgery: an update of meta-analysis of randomized controlled trials , 2012, International Journal of Colorectal Disease.

[30]  C. Dervenis,et al.  Implementation of Fast-Track Protocols in Open and Laparoscopic Sphincter-Preserving Rectal Cancer Surgery: A Multicenter, Comparative, Prospective, Non-Randomized Study , 2012, Digestive Surgery.

[31]  J. Suo,et al.  Effectiveness of fast‐track rehabilitation vs conventional care in laparoscopic colorectal resection for elderly patients: a randomized trial , 2012, Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland.

[32]  R. Sehgal,et al.  Fast-Track for the Modern Colorectal Department , 2012, World Journal of Surgery.

[33]  G. Wang,et al.  Immunologic Response After Laparoscopic Colon Cancer Operation Within an Enhanced Recovery Program , 2012, Journal of Gastrointestinal Surgery.

[34]  Hua-yun Chen,et al.  Fast-Track Surgery Improves Postoperative Clinical Recovery and Immunity After Elective Surgery for Colorectal Carcinoma: Randomized Controlled Clinical Trial , 2012, World Journal of Surgery.

[35]  Hua-feng Pan,et al.  Fast track rehabilitation programme enhances functional recovery after laparoscopic colonic resection. , 2012, Hepato-gastroenterology.

[36]  Li Liang,et al.  Enhanced Recovery After Surgery (ERAS) Program Attenuates Stress and Accelerates Recovery in Patients After Radical Resection for Colorectal Cancer: A Prospective Randomized Controlled Trial , 2012, World Journal of Surgery.

[37]  Jan Wind,et al.  Laparoscopy in Combination with Fast Track Multimodal Management is the Best Perioperative Strategy in Patients Undergoing Colonic Surgery: A Randomized Clinical Trial (LAFA-study) , 2011, Annals of surgery.

[38]  A. Rawlinson,et al.  A systematic review of enhanced recovery protocols in colorectal surgery. , 2011, Annals of the Royal College of Surgeons of England.

[39]  G. Tomlinson,et al.  Enhanced recovery pathways optimize health outcomes and resource utilization: a meta-analysis of randomized controlled trials in colorectal surgery. , 2011, Surgery.

[40]  C. V. van Laarhoven,et al.  Fast track surgery versus conventional recovery strategies for colorectal surgery. , 2011, The Cochrane database of systematic reviews.

[41]  J. Xu,et al.  Fast-track rehabilitation program vs conventional care after colorectal resection: a randomized clinical trial. , 2011, World journal of gastroenterology.

[42]  O. Ryska,et al.  Fast-track in open intestinal surgery: prospective randomized study (Clinical Trials Gov Identifier no. NCT00123456). , 2009, Clinical nutrition.

[43]  T. Mocan,et al.  Implementing Fast-Track Protocol for Colorectal Surgery: A Prospective Randomized Clinical Trial , 2009, World Journal of Surgery.

[44]  N. Demartines,et al.  A fast-track program reduces complications and length of hospital stay after open colonic surgery. , 2009, Gastroenterology.

[45]  C. K. Khoo,et al.  A Prospective Randomized Controlled Trial of Multimodal Perioperative Management Protocol in Patients Undergoing Elective Colorectal Resection for Cancer , 2007, Annals of surgery.

[46]  M. Gatt,et al.  Randomized clinical trial of multimodal optimization of surgical care in patients undergoing major colonic resection , 2005, The British journal of surgery.

[47]  I. Hozo,et al.  Estimating the mean and variance from the median, range, and the size of a sample , 2005, BMC medical research methodology.

[48]  C. Mcnaught,et al.  Randomized clinical trial of multimodal optimization and standard perioperative surgical care , 2003, The British journal of surgery.

[49]  D. Altman,et al.  Measuring inconsistency in meta-analyses , 2003, BMJ : British Medical Journal.

[50]  Christopher L. Wu,et al.  Impact of Enhanced Recovery After Surgery and Fast Track Surgery Pathways on Healthcare-associated Infections: Results From a Systematic Review and Meta-analysis , 2017, Annals of surgery.

[51]  T. Gao,et al.  Fast track programmes vs. traditional care in laparoscopic colorectal surgery: a meta-analysis of randomized controlled trials. , 2014, Hepato-gastroenterology.

[52]  L. Charúa-Guindic.  [A fast track program reduces complications and length of hospital stay after open colonic surgery]. , 2009, Revista de gastroenterologia de Mexico.