[Implementation of a perioperative multimodal rehabilitation protocol in elective colorectal surgery. A prospective randomised controlled study]. Cir Esp. 2011;89:159-166. [PMID: 21345423 DOI: 10.1016/j.ciresp.2010.12.004]

Enhanced Recovery After Surgery (ERAS) Approach: A Medical Complex Experience

BACKGROUND

Enhanced recovery after surgery (ERAS) is a multimodal, multidisciplinary approach aimed at reducing organ failure and mitigating stress reactions in surgery patients. This investigation sought to assess available data concerning the benefits of ERAS protocols in improving patient outcomes for individuals undergoing significant colorectal surgery.

METHODS

The study involved 65 patients who underwent colectomy and lower anterior resection for rectal cancers. Patients were divided into three groups: Group 1 comprised 22 patients enrolled retrospectively who received the traditional protocol; Group 2 consisted of 20 patients enrolled prospectively who received the ERAS protocol; and Group 3 included 23 patients enrolled retrospectively who received the ERAS protocol. Each patient underwent a comprehensive history, physical examination, laboratory testing, computed tomography, MRI, and chest radiography.

RESULTS

Hospital stay durations were significantly shorter in both ERAS groups during the first and second cycles compared to the non-ERAS group (P<0.001, <0.001), with no significant difference between ERAS groups in either cycle. Delayed intestinal motility was significantly more pronounced in the non-ERAS group compared to ERAS groups in both cycles (P=0.005), with only five (22.7%) cases reported in the non-ERAS group.

CONCLUSION

ERAS implementation in the perioperative management of colorectal surgery patients is associated with improved outcomes and shorter recovery times. Implementation of ERAS in hospitals is feasible and beneficial.

Impact of Preoperative Patient Education on Postoperative Recovery in Abdominal Surgery: A Systematic Review

BACKGROUND

Patient education is recommended as an essential component of Enhanced Recovery after Surgery (ERAS) protocols. However, there are many uncertainties regarding content and methodological criteria, which may have a significant impact on the effectiveness of the intervention. The aim of this review is to assess the effect of preoperative patient education on postoperative recovery in abdominal surgery and to examine different patient education strategies for their effectiveness.

METHODS

We performed a systematic review according to the PRISMA guidelines. PubMed, CINAHL, and Cochrane were searched from 2011 to 2022. All studies investigating the effect of preoperative patient education on postoperative recovery in abdominal surgery were included. A critical quality assessment of all included studies was performed.

RESULTS

We identified 826 potentially suitable articles via a database search and included 12 studies in this review. The majority of the included studies reported a reduction in the length of hospital stay (LOS) and even a reduction in postoperative complications and adverse events. Patients with preoperative education seemed to have lower psychological stress and experience less anxiety. However, the contents, delivery, and general conditions were implemented differently, making comparison difficult. Moreover, the majority of the included studies were weak in quality.

CONCLUSION

With this review, we report potential effects, current implementations, and frameworks of patient education. However, the results must be interpreted with caution and are not directly transferable to clinical practice. Further studies in this field are necessary to make concrete recommendations for clinical practice.

Rapid rehabilitation effect on complications, wound infection, anastomotic leak, obstruction, and hospital re-admission for gastrointestinal surgery subjects: A meta-analysis

We performed a meta‐analysis to evaluate the effect of rapid rehabilitation on the curative effect of gastrointestinal surgery subjects. A systematic literature search up to October 2021 was done and 31 studies included 4448 subjects with gastrointestinal surgery at the start of the study: 2242 of them were provided with rapid rehabilitation and 2206 were standard care. They were reporting relationships about the effect of rapid rehabilitation on the curative effect of gastrointestinal surgery subjects. We calculated the odds ratio (OR) with 95% confidence intervals (CIs) to assess the effect of rapid rehabilitation on the curative effect of gastrointestinal surgery subjects using the dichotomous method with a random‐ or fixed‐effect model. Rapid rehabilitation had significantly lower complications (OR, 0.62; 95% CI, 0.54‐0.71, P < .001) and wound infection (OR, 0.73; 95% CI, 0.55‐0.98, P = .03) compared with standard care in subjects with gastrointestinal surgery. However, rapid rehabilitation had no significant effect on the anastomotic leak (OR, 0.90; 95% CI, 0.66‐1.22, P = .49), obstruction (OR, 0.92; 95% CI, −0.64 to 1.31, P = .65), and hospital re‐admission (OR, 0.78; 95% CI, 0.57‐1.08, P = .13) compared with standard care in subjects with gastrointestinal surgery. Rapid rehabilitation had significantly lower complications and wound infection, and had no significant effect on the anastomotic leak, obstruction, and hospital re‐admission compared with standard care in subjects with gastrointestinal surgery. Further studies are required to validate these findings.

The Japan Society for Surgical Infection: guidelines for the prevention, detection, and management of gastroenterological surgical site infection, 2018

Background

The guidelines for the prevention, detection, and management of gastroenterological surgical site infections (SSIs) were published in Japanese by the Japan Society for Surgical Infection in 2018. This is a summary of these guidelines for medical professionals worldwide.

Methods

We conducted a systematic review and comprehensive evaluation of the evidence for diagnosis and treatment of gastroenterological SSIs, based on the concepts of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The strength of recommendations was graded and voted using the Delphi method and the nominal group technique. Modifications were made to the guidelines in response to feedback from the general public and relevant medical societies.

Results

There were 44 questions prepared in seven subject areas, for which 51 recommendations were made. The seven subject areas were: definition and etiology, diagnosis, preoperative management, prophylactic antibiotics, intraoperative management, perioperative management, and wound management. According to the GRADE system, we evaluated the body of evidence for each clinical question. Based on the results of the meta-analysis, recommendations were graded using the Delphi method to generate useful information. The final version of the recommendations was published in 2018, in Japanese.

Conclusions

The Japanese Guidelines for the prevention, detection, and management of gastroenterological SSI were published in 2018 to provide useful information for clinicians and improve the clinical outcome of patients.

Electronic supplementary material

The online version of this article (10.1007/s00595-020-02181-6) contains supplementary material, which is available to authorized users.

Comprehensive literature review of randomized clinical trials examining novel treatment advances in patients with colon cancer

The treatment of colon cancer has had numerous recent advances, in terms of surgical approach, adjuvant therapies, and more. In this review, the authors examine randomized clinical trials comparing open surgery to laparoscopic surgery (including total mesocolic excision), and also examine the role of robotic surgery. Novel surgical techniques including the no-touch technique, side-to-side anastomosis, suture technique, complete mesocolic excision (CME) with central vascular ligation (CVL), and natural orifice transluminal endoscopic surgery (NOTES) are outlined. The role of placing endoscopic self-expandable metal stents (SEMS) for colonic obstruction is compared and contrasted with the surgical approach, and the effect that the anti-VEGF inhibitor bevacizumab may have on this side effect profile is further explored. The role of the resection of the primary tumor in the setting of metastatic disease is examined with respect to survival benefit. Pathways of perioperative care which can accelerate post-surgical recovery, including enhanced recovery after surgery (ERAS) are examined. The role of adjuvant chemotherapy in patients with high-risk stage II and patients with stage III disease is examined, along with the role on circulating tumor DNA (ctDNA) as well as with the biologic targeted agents cetuximab and bevacizumab. Lastly, the authors detail the postoperative surveillance schedules after surgical resection with respect to survival outcomes.

Multicomponent hospital-led interventions to reduce hospital stay for older adults following elective surgery: a systematic review

Background

Elective older adult inpatient admissions are increasingly common. Older adults are at an elevated risk of adverse events in hospital, potentially increasing with lengthier hospital stay. Hospital-led organisational strategies may optimise hospital stay for elective older adult inpatients.

Objectives

To evaluate the effectiveness and cost-effectiveness of hospital-led multicomponent interventions to reduce hospital stay for older adults undergoing elective hospital admissions.

Data sources

Seven bibliographic databases (MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Health Management Information Consortium, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature and Allied and Complementary Medicine Database) were searched from inception to date of search (August 2017), alongside carrying out of web searches, citation searching, inspecting relevant reviews, consulting stakeholders and contacting authors. This search was duplicated, with an additional cost-filter, to identify cost-effectiveness evidence.

Review methods

Comparative studies were sought that evaluated the effectiveness or cost-effectiveness of relevant interventions in elective inpatients with a mean or median age of ≥ 60 years. Study selection, data extraction and quality assessment were completed independently by two reviewers. The main outcome was length of stay, but all outcomes were considered. Studies were sorted by procedure, intervention and outcome categories. Where possible, standardised mean differences or odds ratios were calculated. Meta-analysis was performed when multiple randomised controlled trials had the same intervention, treatment procedure, comparator and outcome. Findings were explored using narrative synthesis.

Findings

A total of 218 articles were included, with 80 articles from 73 effectiveness studies (n = 26,365 patients) prioritised for synthesis, including 34 randomised controlled trials conducted outside the UK and 39 studies from the UK, of which 12 were randomised controlled trials. Fifteen studies included cost-effectiveness data. The evidence was dominated by enhanced recovery protocols and prehabilitation, implemented to improve recovery from either colorectal surgery or lower limb arthroplasty. Six other surgical categories and four other intervention types were identified. Meta-analysis found that enhanced recovery protocols were associated with 1.5 days’ reduction in hospital stay among patients undergoing colorectal surgery (Cohen’sd = –0.51, 95% confidence interval –0.78 to –0.24;p < 0.001) and with 5 days’ reduction among those undergoing upper abdominal surgery (Cohen’sd = –1.04, 95% confidence interval –1.55 to –0.53;p < 0.001). Evidence from the UK was not pooled (owing to mixed study designs), but it echoed findings from the international literature. Length of stay usually was reduced with intervention or was no different. Other clinical outcomes also improved or were no worse with intervention. Patient-reported outcomes were not frequently reported. Cost and cost-effectiveness evidence came from 15 highly heterogeneous studies and was less conclusive.

Limitations

Studies were usually of moderate or weak quality. Some intervention or treatment types were under-reported or absent. The reporting of variance data often precluded secondary analysis.

Conclusions

Enhanced recovery and prehabilitation interventions were associated with reduced hospital stay without detriment to other clinical outcomes, particularly for patients undergoing colorectal surgery, lower limb arthroplasty or upper abdominal surgery. The impacts on patient-reported outcomes, health-care costs or additional service use are not well known.

Future work

Further studies evaluating of the effectiveness of new enhanced recovery pathways are not required in colorectal surgery or lower limb arthroplasty. However, the applicability of these pathways to other procedures is uncertain. Future studies should evaluate the implementation of interventions to reduce service variation, in-hospital patient-reported outcomes, impacts on health and social care service use, and longer-term patient-reported outcomes.

Study registration

This study is registered as PROSPERO CRD42017080637.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Randomized Controlled Trial of Extended Perioperative Counseling in Enhanced Recovery After Colorectal Surgery

BACKGROUND

Enhanced recovery after surgery programs reduce the length of hospital stay in patients who undergo elective colorectal resection, but the reasons for this reduction are not well understood.

OBJECTIVE

The aim of this randomized controlled trial was to assess the impact of extended perioperative counseling in treatment groups that were otherwise the same with respect to enhanced recovery after surgery criteria.

DESIGN

Patients eligible for open or laparoscopic colorectal resection were randomly assigned to extended counseling (repeated information and guidance by a dedicated nurse) or standard counseling.

SETTINGS

This study was conducted at a single institution.

PATIENTS

Patients (n = 164) were randomly assigned to enhanced recovery after surgery plus extended counseling (n = 80) or enhanced recovery after surgery with standard counseling (n = 84).

MAIN OUTCOME MEASURES

The primary end point was the total length of hospital stay. Discharge criteria were defined. Secondary end points were postoperative complications, postoperative length of hospital stay, readmission rate, and mortality.

RESULTS

Total hospital stay was significantly shorter among patients randomly assigned to enhanced recovery after surgery plus extended counseling (median 5 (range 2-29) days vs 7 (range 2-39) days, p < 0.001). The 2 treatment groups differed in adherence to the elements of postoperative enhanced recovery after surgery such as mobilization and total oral intake. The 2 treatment groups did not differ in overall, major, and minor morbidity; reoperation rate; readmission rate; and 30-day mortality.

LIMITATIONS

The main limitation of this study was the absence of blinding.

CONCLUSIONS

Perioperative information and guidance were important factors in enhanced recovery after surgery care and were associated with a significantly shorter length of hospital stay. Our findings suggest that perioperative counseling enables patients to comply with the elements of postoperative enhanced recovery after surgery and thereby reduces the length of hospital stay. This study was registered with ClinicalTrials.gov (NCT01610726). See Video Abstract at http://links.lww.com/DCR/A505.

Nursing role on rapid recovery programmes fast-track

Rapid recovery (RR) or fast-track programmes are aimed at reducing surgical stress, leading to a reduction in nurse workload, costs and hospital stay, greater patient empowerment, early post-surgical recovery and reduced morbidity and mortality. These new protocols require the coordinated participation of a multidisciplinary team. Based on an integrative review of the literature, this paper aims to define the concept of a RR or fast track programme and show the existing evidence on the implementation of these programmes in nursing. The benefits and low incidence of damage of RR programmes in nursing justify their implementation. The programmes require greater support and diffusion in order to develop, as well as more research to increase the evidence on the effectiveness and efficiency of the protocols.

Standardizing the Protocols for Enhanced Recovery From Colorectal Cancer Surgery: Are We a Step Closer to Ideal Recovery?

PURPOSE

Enhanced recovery protocols are being implemented into the standard of care in surgical practice. This study aimed to insert a steadfast set of elements into the perioperative care pathway to establish an improved recovery program for colorectal cancer patients.

METHODS

Seventy patients planned for elective laparoscopic colorectal resection were randomized into 2 groups: conventional recovery group (n = 35) and enhanced recovery group (n = 35). The primary outcome was the length of hospital stay. Secondary outcomes included the times of removal of nasogastric tubes (NGTs), successful enteral feeding, and removal of drains, postoperative complications, intra-hospital mortality, and rate of readmission.

RESULTS

The mean postoperative hospital stay was 4.49 ± 0.85 days vs. 13.31 ± 6.9 days (P < 0.001), the mean time of removal of NGTs was 0.77 ± 1.031 days vs. 3.26 ± 2.737 days (P < 0.001), the mean time of successful enteral feeding was 1.89 ± 1.13 days vs. 5.46 ± 1.67 days (P < 0.001), and the mean time for removal of intra-abdominal drains was 2.94 ± 1.056 days vs. 9.06 ± 3.757 days (P < 0.001) for the enhanced and the conventional groups, respectively. Complications were significantly lower among patients in the enhanced group (25.7% vs. 65.7%) (P = 0.001). The rates of readmission were similar in the 2 groups.

CONCLUSION

Applying definite evidence-based elements to the colorectal rehabilitation program significantly boosts the recovery pathway with favorable outcomes, including faster recovery of gastrointestinal tract functions, lower morbidities, and eventually earlier discharge from the hospital.

Factors predicting outcome from enhanced recovery programmes in laparoscopic colorectal surgery: a systematic review

OBJECTIVE

To perform a systematic review of published literature for the factors reported to predict outcomes of enhanced recovery after surgery (ERAS) programmes following laparoscopic colorectal surgery.

BACKGROUND

ERAS programmes and the use of laparoscopy have been widely adopted in colorectal surgery bringing short-term patient benefit. However, there is a minority of patients that do not benefit from these strategies and their identification is not well characterised. The factors that underpin outcomes from ERAS programmes for laparoscopic patients are not understood.

METHODS

A systematic search of the MEDLINE, Embase and Cochrane databases was conducted to identify suitable articles published between 2000 and 2015. The search strategy captured terms for ERAS, colorectal resection, prediction and outcome measures.

RESULTS

Thirty-four studies containing 10,861 laparoscopic resections were included. Thirty-one (91 %) studies were confined to elective cases. Predictive analysis of outcome was most frequently based on length of stay (LOS), morbidity and readmission which were the main outcome measures of 29 (85 %), 26 (76 %) and 18 (53 %) of the included studies, respectively. Forty-seven percentage of included studies investigated the impact of ERAS programme compliance on these outcomes. Reduced protocol compliance was the most frequently identified modifiable predictive factor for adverse LOS, morbidity and readmission.

CONCLUSION

Protocol compliance is the most frequently reported predictive factor for outcomes of ERAS programmes following laparoscopic colorectal resection. Reduced compliance increases LOS, morbidity and readmission to hospital. The impact of compliance with individual ERAS protocol elements is insufficiently studied, and the lack of a standardised framework for evaluating ERAS programmes makes it difficult to draw definite conclusions about which factors exert the greatest impact on outcome after laparoscopic colorectal resection.

Cost impact analysis of Enhanced Recovery After Surgery program implementation in Alberta colon cancer patients

BACKGROUND

The Enhanced Recovery After Surgery (eras) colorectal guideline has been implemented widely across Alberta. Our study examined the clinical and cost impacts of eras on colon cancer patients across the province.

METHODS

We first used both summary statistics and multivariate regression methods to compare, before and after guideline implementation, clinical outcomes (length of stay, complications, readmissions) in consecutive elective colorectal patients 18 or more years of age and in colon cancer and non-cancer patients treated at the Peter Lougheed Centre and the Grey Nuns Hospital between February 2013 and December 2014. We then used the differences in clinical outcomes for colon cancer patients, together with the average cost per hospital day, to estimate cost impacts.

RESULTS

The analysis considered 790 patients (398 cancer and 392 non-cancer patients). Mean guideline compliance increased to 60% in cancer patients and 57% in non-cancer patients after eras implementation from 37% overall before eras implementation. From pre- to post-eras, mean length of stay declined to 8.4 ± 5 days from 9.5 ± 7 days in cancer patients, and to 6.4 ± 4 days from 8.8 ± 5.5 days in non-cancer patients (p = 0.0012 and p = 0.0041 respectively). Complications declined significantly in the renal, hepatic, pancreatic, and gastrointestinal groups (difference in proportions: 13% in cancer patients; p < 0.05). No significant change in the risk of readmission was observed. The net cost savings attributable to eras implementation ranged from $1,096 to $2,771 per cancer patient and from $3,388 to $7,103 per non-cancer patient.

CONCLUSIONS

Implementation of eras not only resulted in clinical outcome improvements, but also had a significant beneficial impact on scarce health system resources. The effect for cancer patients was different from that for non-cancer patients, representing an opportunity for further refinement and study.

Incomplete reporting of enhanced recovery elements and its impact on achieving quality improvement

BACKGROUND

Enhanced recovery (ER) protocols are used widely in surgical practice. As protocols are multidisciplinary with multiple components, it is difficult to compare and contrast reports. The present study examined compliance and transferability to clinical practice among ER publications related to colorectal surgery.

METHODS

PubMed, Embase and Cochrane Central Register databases were searched for current colorectal ER manuscripts. Each publication was assessed for the number of ER elements, whether the element was explained sufficiently so that it could be transferred to clinical practice, and compliance with the ER element.

RESULTS

Some 50 publications met the reporting criteria for inclusion. A total of 22 ER elements were described. The median number of elements included in each publication was 9, and the median number of included patients was 130. The elements most commonly included in ER pathways were early postoperative diet advancement (49, 98 per cent) and early mobilization (47, 94 per cent). Early diet advancement was sufficiently explained in 43 (86 per cent) of the 50 publications, but only 22 (45 per cent) of 49 listing the variable reported compliance. The explanation for early mobilization was satisfactory in 41 (82 per cent) of the 50 publications, although only 14 (30 per cent) of 47 listing the variable reported compliance. Other ER elements had similar rates of explanation and compliance. The most frequently analysed outcome measures were morbidity (49, 98 per cent), length of stay (47, 94 per cent) and mortality (45, 90 per cent).

CONCLUSION

The current standard of reporting is frequently incomplete. To transfer knowledge and facilitate implementation of pathways that demonstrate improvements in perioperative care and recovery, a consistent structured reporting platform is needed.

Enhancing surgical performance outcomes through process-driven care: a systematic review

BACKGROUND

Recent evidence has demonstrated the variability in quality of postoperative care, as measured by rates of failure to rescue (FTR). The identification of structure- and process-related factors affecting the quality of postoperative care is the first step towards understanding and improving outcomes. The aim of this review is to review current evidence for structure and process factors affecting postoperative care.

METHODS

A systematic review was conducted. Studies were selected that examined structure or process variables affecting FTR rates and postoperative outcomes. Quality analysis with Jadad and Newcastle-Ottawa scales was conducted and poor-quality studies were excluded.

RESULTS

Thirty-seven studies were included in final analysis. Of these, 23 were related to enhanced recovery protocols in seven surgical specialties. Twenty-one of these 23 studies reported decreases in length of stay. Six studies also reported decreases in morbidity. No studies reported increases in stay duration or morbidity. Of the 16 studies that examined other structural and process factors, the strongest evidence was for the association between nursing ratios and FTR rates. The effects of hospital size, resources, and subspecialist care processes were less clear.

CONCLUSION

Process-led care represents a clear, evidence-based approach that can be integrated on a local scale, without necessitating major structural or organisational change, to improve outcomes and may also be cost effective. To foster success, process improvement must be driven on a local level and backed up by appropriate understanding, education, and multidisciplinary involvement.

Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials

BACKGROUND

Meta-analyses in the literature show that enhanced recovery after surgery (ERAS) is associated with lower morbidity rate and shorter hospital stay after elective colorectal surgery. However, a recent Cochrane review did not indicate the ERAS pathway as being the new standard of care due to the limited number of published trials, together with their poor quality. We conducted a meta-analysis of randomized controlled trials (RCTs) to assess the impact of the ERAS pathway on overall morbidity, single postoperative complications, length of hospital stay, and readmission rate following colorectal surgery.

METHODS

We searched BioMedCentral, PubMed, Scopus, and the Cochrane Central Register of Controlled Trials (CENTRAL) for RCTs comparing the ERAS pathway to conventional perioperative care. No language restrictions were considered. A quality score was calculated for each trial included.

RESULTS

A total of 2,376 patients in 16 RCTs were included in the analysis. The ERAS pathway was associated with a reduction of overall morbidity [relative ratio (RR) = 0.60, (95 % CI 0.46-0.76)], particularly with respect to nonsurgical complications [RR = 0.40, (95 % CI 0.27-0.61)]. The reduction of surgical complications was not significant [RR = 0.76, (95 % CI 0.54-1.08)]. The ERAS pathway shortened hospital stay (WMD = -2.28 days [95 % CI -3.09 to -1.47]), without increasing readmission rate.

CONCLUSIONS

The ERAS pathway reduced overall morbidity rates and shortened the length of hospital stay, without increasing readmission rates. A significant reduction in nonsurgical complications was evident, while no significant reduction was found for surgical complications.

Safety of fast-track rehabilitation after gastrointestinal surgery: Systematic review and meta-analysis

AIM: To compare the safety of fast-track rehabilitation protocols (FT) and conventional care strategies (CC), or FT and laparoscopic surgery (LFT) and FT and open surgery (OFT) after gastrointestinal surgery.

METHODS: We searched MEDLINE, WHO International Trial Register, Embase and The Cochrane Central Register of Controlled Trials up to 2014 for randomized controlled trials (RCTs) comparing FT and CC or comparing LFT and OFT, with 10 or more randomized participants and about 30 d follow-up. Two reviewers independently extracted data on complications, anastomotic leak, obstruction, wound infection, re-admission between FT and CC or LFT and OFT after gastrointestinal surgery.

RESULTS: Twenty-four RCTs of FT vs CC or LFT vs OFT were included. Compared with CC, FT reduced overall complications and wound infection. However, anastomotic leak, obstruction and re-admission were not significantly reduced. The pooled risk ratio (RR) of 0.69 (95%CI: 0.60-0.78; P < 0.001), pooled RR of 0.71 (95%CI: 0.57-0.88; P < 0.001), pooled RR of 0.93 (95%CI: 0.68-1.25; P > 0.05), a pooled RR of 0.87 (95%CI: 0.67-1.15; P > 0.05) and pooled RR of 0.94 (95%CI: 0.73-1.22; P > 0.05) respectively. Compared with OFT, LFT reduced complications, with a pooled RR of 0.66 (95%CI: 0.54-0.81; P < 0.001).

CONCLUSION: FTs are safe after gastrointestinal surgery. Additional large, prospective RCTs should be conducted to establish further the safety of this approach.

Effectiveness and implementation of enhanced recovery after surgery programmes: a rapid evidence synthesis

OBJECTIVES

To assess the evidence on the impact of enhanced recovery programmes for patients undergoing elective surgery in acute hospital settings in the UK.

DESIGN

Rapid evidence synthesis. Eight databases were searched from 1990 to March 2013 without language restrictions. Relevant reports and guidelines, websites and reference lists of retrieved articles were scanned to identify additional studies. Systematic reviews, RCTs not included in the systematic reviews, economic evaluations and UK NHS cost analysis, implementation case studies and surveys of patient experience in a UK setting were eligible for inclusion.

PRIMARY AND SECONDARY OUTCOME MEASURES

We assessed the impact of enhanced recovery programmes on health or cost-related outcomes, and assessed implementation case studies and patient experience in UK settings. Studies were quality assessed where appropriate using the Centre for Reviews and Dissemination Database of Abstracts of Reviews of Effects critical appraisal process.

RESULTS

17 systematic reviews and 12 additional RCTs were included. Ten relevant economic evaluations were included. No cost analysis studies were identified. Most of the evidence focused on colorectal surgery. 14 innovation case studies and 15 implementation case studies undertaken in National Health Service settings described factors critical to the success of an enhanced recovery programme. Evidence for colorectal surgery suggests that enhanced recovery programmes may reduce hospital stays by 0.5-3.5 days compared with conventional care. There were no significant differences in reported readmission rates. Other surgical specialties showed greater variation in reductions in length of stay reflecting the limited evidence identified. Findings relating to other outcomes were hampered by a lack of robust evidence and poor reporting.

CONCLUSIONS

There is consistent, albeit limited, evidence that enhanced recovery programmes can reduce length of patient hospital stay without increasing readmission rates. The extent to which managers and clinicians considering implementing enhanced recovery programmes in UK settings can realise savings will depend on length of stay achieved under their existing care pathway.

Initiatives to reduce length of stay in acute hospital settings: a rapid synthesis of evidence relating to enhanced recovery programmes

Background

There has been growing interest in the NHS over recent years in the use of enhanced recovery programmes for elective surgery to deliver productivity gains through reduced length of stay, fewer postoperative complications, reduced readmissions and improved patient outcomes.

Objectives

To evaluate the clinical effectiveness and cost-effectiveness of enhanced recovery programmes for patients undergoing elective surgery in acute hospital settings. To identify and critically describe key factors associated with successful adoption, implementation and sustainability of enhanced recovery programmes in UK settings. To summarise existing knowledge about patient experience of enhanced recovery programmes in UK settings.

Data sources

Eight databases, including Database of Abstracts of Reviews and Effects, International Prospective of Systematic Reviews, NHS Economic Evaluation Database and MEDLINE, were searched from 1990 to March 2013 without language restrictions. Relevant reports and guidelines and reference lists of retrieved articles were scanned to identify additional studies.

Review methods

Systematic reviews, randomised controlled trials (RCTs), economic evaluations, and UK NHS cost analysis studies were included if they evaluated the impact of enhanced recovery programmes on any health- and cost-related outcomes. Eligible studies included patients undergoing elective surgery in an acute hospital setting. Implementation case studies and surveys of patient experience in a UK setting were also eligible for inclusion. Quality assessment of systematic reviews, RCTs and economic evaluations was based on existing Centre for Reviews and Dissemination processes. All stages of the review process were performed by one researcher and checked by a second with discrepancies resolved by consensus. The type and range of evidence precluded meta-analysis and we therefore performed a narrative synthesis, differentiating between clinical effectiveness and cost-effectiveness, implementation case studies and evidence on patient experience.

Results

Seventeen systematic reviews of varying quality were included in this report. Twelve additional RCTs were included; all were considered at high risk of bias. Most of the evidence focused on colorectal surgery. Fourteen innovation case studies and 15 implementation case studies undertaken in NHS settings were identified and provide descriptions of factors critical to the success of an enhanced recovery programme. Ten relevant economic evaluations were identified evaluating costs and outcomes over short time horizons. Despite the plethora of studies, robust evidence was sparse. Evidence for colorectal surgery suggests that enhanced recovery programmes may reduce hospital stays by 0.5–3.5 days compared with conventional care. There were no significant differences in reported readmission rates. Other surgical specialties showed greater variation in reported reductions in length of stay reflecting the limited evidence identified.

Limitations

Findings relating to other clinical outcomes, cost-effectiveness, implementation and patient experience were hampered by a lack of robust evidence and poor reporting.

Conclusions

There is consistent, albeit limited, evidence that enhanced recovery programmes may reduce length of patient hospital stay without increasing readmission rates. The extent to which managers and clinicians considering implementing enhanced recovery programmes can realise reductions and cost savings will depend on length of stays achieved under their existing care pathway. RCTs comparing an enhanced recovery programme with conventional care continue to be conducted and published. Further single-centre RCTs of this kind are not a priority. Rather, what is needed is improved collection and reporting of how enhanced recovery programmes are implemented, resourced and experienced in NHS settings.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

An overview and methodological assessment of systematic reviews and meta-analyses of enhanced recovery programmes in colorectal surgery

OBJECTIVES

To identify and critically assess the extent to which systematic reviews of enhanced recovery programmes for patients undergoing colorectal surgery differ in their methodology and reported estimates of effect.

DESIGN

Review of published systematic reviews. We searched the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA) Database from 1990 to March 2013. Systematic reviews of enhanced recovery programmes for patients undergoing colorectal surgery were eligible for inclusion.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was length of hospital stay. We assessed changes in pooled estimates of treatment effect over time and how these might have been influenced by decisions taken by researchers as well as by the availability of new trials. The quality of systematic reviews was assessed using the Centre for Reviews and Dissemination (CRD) DARE critical appraisal process.

RESULTS

10 systematic reviews were included. Systematic reviews of randomised controlled trials have consistently shown a reduction in length of hospital stay with enhanced recovery compared with traditional care. The estimated effect tended to increase from 2006 to 2010 as more trials were published but has not altered significantly in the most recent review, despite the inclusion of several unique trials. The best estimate appears to be an average reduction of around 2.5 days in primary postoperative length of stay. Differences between reviews reflected differences in interpretation of inclusion criteria, searching and analytical methods or software.

CONCLUSIONS

Systematic reviews of enhanced recovery programmes show a high level of research waste, with multiple reviews covering identical or very similar groups of trials. Where multiple reviews exist on a topic, interpretation may require careful attention to apparently minor differences between reviews. Researchers can help readers by acknowledging existing reviews and through clear reporting of key decisions, especially on inclusion/exclusion and on statistical pooling.

Systematic review and meta-analysis of enhanced recovery programmes in surgical patients

BACKGROUND

Enhanced recovery programmes (ERPs) have been developed over the past 10 years to improve patient outcomes and to accelerate recovery after surgery. The existing literature focuses on specific specialties, mainly colorectal surgery. The aim of this review was to investigate whether the effect of ERPs on patient outcomes varies across surgical specialties or with the design of individual programmes.

METHODS

MEDLINE, Embase, CINAHL and the Cochrane Central Register of Controlled Trials were searched from inception to January 2013 for randomized or quasi-randomized trials comparing ERPs with standard care in adult elective surgical patients.

RESULTS

Thirty-eight trials were included in the review, with a total of 5099 participants. Study design and quality was poor. Meta-analyses showed that ERPs reduced the primary length of stay (standardized mean difference -1·14 (95 per cent confidence interval -1·45 to -0·85)) and reduced the risk of all complications within 30 days (risk ratio (RR) 0·71, 95 per cent c.i. 0·60 to 0·86). There was no evidence of a reduction in mortality (RR 0·69, 95 per cent c.i. 0·34 to 1·39), major complications (RR 0·95, 0·69 to 1·31) or readmission rates (RR 0·96, 0·59 to 1·58). The impact of ERPs was similar across specialties and there was no consistent evidence that elements included within ERPs affected patient outcomes.

CONCLUSION

ERPs are effective in reducing length of hospital stay and overall complication rates across surgical specialties. It was not possible to identify individual components that improved outcome. Qualitative synthesis may be more appropriate to investigate the determinants of success.

Enhanced recovery after surgery programs versus traditional care for colorectal surgery: a meta-analysis of randomized controlled trials

BACKGROUND

Enhanced recovery after surgery programs in colorectal surgery aim to attenuate the surgical stress response, reduce complications and shorten hospital stay.

OBJECTIVE

This study aimed to assess the safety and efficacy of enhanced recovery after surgery programs in colorectal surgery in comparison with traditional care.

DATA SOURCES

PubMed, Embase, and Cochrane databases were electronically searched (date range, January 1966 to July 2012).

STUDY SELECTION

Randomized controlled trials were selected that compared enhanced recovery after surgery programs with traditional care in elective colorectal surgery.

INTERVENTION

Articles were reviewed independently by 2 reviewers, who extracted the data and assessed the quality of the included studies. The outcome measures were analyzed, and the quality of evidence for each outcome was assessed by using the Grading of Recommendations Assessment, Development, and Evaluation system.

MAIN OUTCOME MEASURES

The primary outcome measures were primary and total postoperative hospital stay, readmission rates, total postoperative complications (including general and surgical complications), and mortality.

RESULTS

Thirteen studies (total, 1910 patients) were included in the meta-analysis. In comparison with traditional care, enhanced recovery after surgery programs were associated with significantly decreased primary hospital stay (weighted mean difference, -2.44 days; 95% CI, -3.06 to -1.83 days; p < 0.00001), total hospital stay (weighted mean difference, -2.39 days; 95% CI, -3.70 to -1.09 days; p = 0.0003), total complications (relative risk, 0.71; 95% CI, 0.58-0.86; p = 0.0006), and general complications (relative risk, 0.68; 95% CI, 0.56-0.82; p < 0.0001). No significant differences were found for readmission rates, surgical complications, and mortality.

LIMITATIONS

This study was limited by the risk of bias in most included studies.

CONCLUSIONS

Enhanced recovery after surgery programs are safe and effective, and increased implementation is justified for perioperative care in colorectal surgery. Future studies may examine the benefits of enhanced recovery after surgery programs in elderly patients and in other GI surgery.

Procalcitonin and C-reactive protein as early predictors of anastomotic leak in colorectal surgery: a prospective observational study

BACKGROUND

Although the early diagnosis of anastomotic leak is a key point in reducing its clinical consequences, in daily practice, anastomotic leak diagnosis is often late.

OBJECTIVE

The aim of this study was to determine whether procalcitonin and C-reactive protein are good predictors of anastomotic leak in colorectal surgery.

DESIGN

This is a prospective observational study.

SETTINGS

This study was conducted by a specialized colorectal multidisciplinary team of a tertiary teaching hospital.

PATIENTS

A series of 205 consecutive patients who underwent elective colorectal surgery in a specialized unit was prospectively analyzed. The following data were collected: demographic, surgical, ASA class, POSSUM, and morbidity. During the first 5 postoperative days, procalcitonin, C-reactive protein, leukocytes, platelets, and vital signs were evaluated daily.

INTERVENTIONS

Daily assessment of clinical variable and serological data were conducted in the first 5 postoperative days.

MAIN OUTCOME MEASURES

The primary outcome measure was the area under the curve at receiving operating characteristic curve analysis of the different variables in relation to the anastomotic leak.

RESULTS

Anastomotic leak was detected in 17 (8.3%) patients; 11(5.4%) of the patients had a major anastomotic leak (need for drainage or reoperation). None of the variables evaluated were shown to be reliable in the early detection of anastomotic leak, considering both minor and major (maximum area under the curve <0.80). In contrast, when considering only major anastomotic leaks, procalcitonin and C-reactive protein were reliable predictors on postoperative days 3 to 5 (p < 0.0001, area under the curve >0.80). The best combination was procalcitonin at postoperative day 5 (area under the curve = 0.86), with a cutoff of 0.31 ng/mL, resulting in a 100% sensitivity, 72% specificity, 100% negative predictive value, and 17% positive predictive value.

LIMITATIONS

Only symptomatic patients were investigated to rule out anastomotic leakage.

CONCLUSIONS

Procalcitonin and C-reactive protein are both reliable predictors of major anastomotic leak after colorectal resection, although procalcitonin is more accurate. Raised procalcitonin and C-reactive protein serum concentration on postoperative days 3 to 5 renders necessary a careful evaluation of the patient before discharge.