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Ceresoli M, Pedrazzani C, Pellegrino L, Ficari F, Braga M. Early non compliance to enhanced recovery pathway might be an alert for underlying complications following colon surgery. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:106650. [PMID: 35817632 DOI: 10.1016/j.ejso.2022.06.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 06/26/2022] [Indexed: 11/23/2022]
Abstract
PURPOSE Early non compliance to postoperative ERAS pathway has been reported in 20-30% of patients who underwent elective colon surgery. The aim of the present study is to investigate the possible relationship between early non compliance and postoperative complications. METHODS We reviewed a prospective database including 1391 consecutively collected patients undergoing elective colon surgery in 22 Italian hospitals between January 2017 and June 2020. Early compliance to ERAS protocol was assessed on postoperative day (POD) 2. Failure of oral feeding, urinary catheter removal, intravenous fluids stop, and adequate mobilization were indicators of non compliance. Postoperative follow-up was carried out for 30 days after hospital discharge. The association among early postoperative ERAS compliance and the occurrence of complications was assessed with uni- and multivariate analysis. RESULTS A total of 1089 (78.3%) patients had malignancy and minimally invasive surgery was successfully performed in 1174 (84.3%) patients. Postoperative morbidity occurred in 403 (29.0%) patients. At multivariate analysis, male gender, open surgery, and each of the four non compliance indicators on POD 2 were significantly associated to postoperative complications. Morbidity progressively increased from 16.8% in patients with full compliance to ERAS protocol to 47.2% in patients with two non compliance indicators and 69.2% in patients with all four indicators (p < 0.001). CONCLUSIONS Early non compliance to ERAS protocol was significantly associated with postoperative morbidity.
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Affiliation(s)
- Marco Ceresoli
- General and Emergency Surgery Dept, University of Milano-Bicocca, School of Medicine and Surgery, Monza, Italy
| | | | | | - Ferdinando Ficari
- General Surgery, Careggi Hospital - University of Firenze, Firenze, Italy
| | - Marco Braga
- General and Emergency Surgery Dept, University of Milano-Bicocca, School of Medicine and Surgery, Monza, Italy.
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2
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Bisagni P, D'Abrosca V, Tripodi V, Armao FT, Longhi M, Russo G, Ballabio M. Cost saving in implementing ERAS protocol in emergency abdominal surgery. BMC Surg 2024; 24:70. [PMID: 38389067 PMCID: PMC10885507 DOI: 10.1186/s12893-024-02345-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Accepted: 02/04/2024] [Indexed: 02/24/2024] Open
Abstract
INTRODUCTION ERAS (Enhanced Recovery After Surgery) protocol is now proposed as the standard of care in elective major abdominal surgery. Implementation of the ERAS protocol in emergency setting has been proposed but his economic impact has not been investigated. Aim of this study was to evaluate the cost saving of implementing ERAS in abdominal emergency surgery in a single institution. METHODS A group of 80 consecutive patients treated by ERAS protocol for gastrointestinal emergency surgery in 2021 was compared with an analogue group of 75 consecutive patients treated by the same surgery the year before implementation of ERAS protocol. Adhesion to postoperative items, length of stay, morbidity and mortality were recorded. Cost saving analysis was performed. RESULTS 50% Adhesion to postoperative items was reached on day 2 in the ERAS group in mean. Laparoscopic approach was 40 vs 12% in ERAS and control group respectively (p ,002). Length of stay was shorter in ERAS group by 3 days (9 vs 12 days p ,002). Morbidity and mortality rate were similar in both groups. The ERAS group had a mean cost saving of 1022,78 € per patient. CONCLUSIONS ERAS protocol implementation in the abdominal emergency setting is cost effective resulting in a significant shorter length of stay and cost saving per patient.
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Affiliation(s)
- Pietro Bisagni
- Department of Surgery, Ospedale Maggiore di Lodi, Viale Savoia 1, 26900, Lodi, Italia.
- Università degli Studi Statale di Milano, Milano, Italy.
| | - Vera D'Abrosca
- Department of Surgery, Ospedale Maggiore di Lodi, Viale Savoia 1, 26900, Lodi, Italia
| | - Vincenzo Tripodi
- Department of Surgery, Ospedale Maggiore di Lodi, Viale Savoia 1, 26900, Lodi, Italia
| | - Francesca Teodora Armao
- Department of Surgery, Ospedale Maggiore di Lodi, Viale Savoia 1, 26900, Lodi, Italia
- Università degli Studi Statale di Milano, Milano, Italy
| | - Marco Longhi
- Department of Surgery, Ospedale Maggiore di Lodi, Viale Savoia 1, 26900, Lodi, Italia
| | - Gianluca Russo
- Department of Emergency, Ospedale Maggiore di Lodi, Lodi, Italy
- Università degli Studi Statale di Milano, Milano, Italy
| | - Michele Ballabio
- Department of Surgery, Ospedale Maggiore di Lodi, Viale Savoia 1, 26900, Lodi, Italia
- Università degli Studi Statale di Milano, Milano, Italy
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Roldan HA, Brown AR, Radey J, Hogenbirk JC, Allen LR. Enhanced recovery after surgery reduces length of stay after colorectal surgery in a small rural hospital in Ontario. CANADIAN JOURNAL OF RURAL MEDICINE 2023; 28:179-189. [PMID: 37861602 DOI: 10.4103/cjrm.cjrm_71_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
Introduction Enhanced recovery after surgery (ERAS) programmes include pre-operative, intraoperative and post-operative clinical pathways to improve quality of patient care while reducing length of stay (LOS) and readmission. This study assessed the feasibility and outcomes of an ERAS protocol for colorectal surgery implemented over 2 years in a small, resource-challenged rural hospital. Methods A prospective cohort study used retrospectively matched controls to assess the effect of ERAS on LOS in patients undergoing colorectal surgery in a small rural hospital in northern Ontario, Canada. ERAS patients were matched to two patients in the control group based on diagnosis, age and gender. Patients had open or laparoscopic colorectal surgeries, with those in the intervention group treated per ERAS protocol and given instructions on pre- and post-operative self-care. Results Most of the 47 ERAS patients recruited to the study reported adherence to ERAS protocols before surgery. Adherence to protocol was strongest for chewing gum in the days after surgery. Most patients were sitting in a chair for their afternoon meal by the 1st day and most were walking down the hallway by the 2nd day. The control group had significantly higher (P < 0.001) malignant neoplasm of the colon (C18, 69% vs. 35%) and significantly lower malignant neoplasm of the rectum (C20, 0% vs. 5%). The control group had an average ln-transformed LOS that was significantly longer (exponentiated as 1.7 days) than ERAS patients (t-test, P < 0.001). Conclusion This study found that ERAS could be implemented in a small rural hospital and provided evidence for a reduced LOS of approximately 2 days.
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Affiliation(s)
- Hector A Roldan
- Chief of Surgery, Department of Surgery, Muskoka Algonquin Healthcare, Associate Professor Northern Ontario School of Medicine University, Sudbury, ON, Canada
| | - Andrew Robert Brown
- Chief of Surgery, Department of Surgery, Muskoka Algonquin Healthcare, Associate Professor Northern Ontario School of Medicine University, Sudbury, ON, Canada
| | - Jane Radey
- Chief of Surgery, Muskoka Algonquin Healthcare, Huntsville, ON, Canada
| | - John C Hogenbirk
- Northern Ontario School of Medicine, Centre for Rural and Northern Health Research, Laurentian University, Sudbury, ON, Canada
| | - Lisa Rosalie Allen
- Huntsville Physicians, Parry Sound, South Muskoka Local Education Groups Local Education Group, Huntsville, ON, Canada
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Early Postoperative Low Compliance to Enhanced Recovery Pathway in Rectal Cancer Patients. Cancers (Basel) 2022; 14:cancers14235736. [PMID: 36497217 PMCID: PMC9738259 DOI: 10.3390/cancers14235736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 11/16/2022] [Accepted: 11/21/2022] [Indexed: 11/24/2022] Open
Abstract
Early postoperative low compliance to enhanced recovery protocols has been associated with morbidity following colon surgery. The purpose of this study is to evaluate the possible causes of early postoperative low compliance to the enhanced recovery pathway and its relationship with morbidity following rectal surgery for cancer. A total of 439 consecutive patients who underwent elective surgery for rectal cancer have been included in the study. Compliance to enhanced recovery protocol on postoperative day (POD) 2 was evaluated in all patients. Indicators of compliance were naso-gastric tube and urinary catheter removal, recovery of both oral feeding and mobilization, and the stopping of intravenous fluids. Low compliance on POD 2 was defined as non- adherence to two or more items. One-third of patients had low compliance on POD 2. Removal of urinary catheter, intravenous fluids stop, and mobilization were the items with lowest adherence. Advanced age, duration of surgery, open surgery and diverting stoma were predictive factors of low compliance at multivariate analysis. Overall morbidity and major complications were significantly higher (p < 0.001) in patients with low compliance on POD 2. At multivariate analysis, failure to remove urinary catheter on POD 2 (OR = 1.83) was significantly correlated with postoperative complications. Low compliance to enhanced recovery protocol on POD 2 was significantly associated with morbidity. Failure to remove the urinary catheter was the most predictive indicator. Advanced age, long procedure, open surgery and diverting stoma were independent predictive factors of low compliance.
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Harkouk H, Capmas P, Derridj N, Belbachir A, Nkam L, Aegerter P, Battaglia E, Tharel L, Fletcher D. Limited impact of a top-down approach to improve enhanced recovery programme in French university hospitals: a before-after retrospective survey. Perioper Med (Lond) 2021; 10:29. [PMID: 34482837 PMCID: PMC8419963 DOI: 10.1186/s13741-021-00200-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 06/08/2021] [Indexed: 11/28/2022] Open
Abstract
Background Enhanced recovery programme (ERP) after surgery needs development in Assistance Publique Hôpitaux de Paris (APHP). Methods A retrospective before-and-after study was performed in 2015 and 2017 on three surgical models (total knee arthroplasty (TKA), colectomy and hysterectomy) in 17 hospitals including 29 surgical departments. Data were collected in one control intervention (total hip arthroplasty (THA), gastrectomy and ovariectomy). In 2016, Massive Open Online Course on ERP and a day meeting information were developed by APHP. A national update on ERP was also organized by HAS and a regional professional partnership programme was started. Primary outcomes were length of stay (LOS) and complications after surgery. Data on ERP items were collected in the patients’ chart and in anaesthetist and surgeon interview. Seventy percent application rate reflects application of ERP procedure. Results 1321 patient’s files were analysed (812 in 2015 and 509 in 2017). The LOS (mean (SD)) is reduced by 1.6 day for TKA (2015, 8.7 (6.7) versus 7.1 (3.4) in 2017; p<0.001) but stable for colectomy and hysterectomy. Incidence of severe complications after surgery is unchanged in all types of surgical models. For TKA and hysterectomy respectively applied items of ERP (i.e. >70% application) increased respectively from 5 to 7 out of 17 and 16 in 2015 and 2017. For colectomy, they were stable at 6 out of 21 in 2015 and 2017. The mean application rates of ERP items stayed below 50% in all cases in 2017. The LOS was negatively correlated with ERP items’ application when data collected in 2015 and 2017 were analysed together. Conclusion ERP application did not significantly improved between 2015 and 2017 for three surgical models after an institutional information and diffusion of recommendations in 29 surgical departments of seventeen French University hospitals underlining the limit of a top-down approach.
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Affiliation(s)
- Hakim Harkouk
- Anaesthesia and Intensive Care Department, Ambroise Paré Hospital, APHP, 9 avenue Charles de Gaulle, 92100, Boulogne-Billancourt, France.,Université Paris-Saclay, UVSQ, Inserm, LPPD, 92100, Boulogne, France
| | - Perrine Capmas
- Obstetric Gynecology Department, Bicêtre Hospital, APHP, Le Kremlin-Bicêtre, France
| | - Nawal Derridj
- Clinical Research Unit, Ambroise Paré Hospital, APHP, Boulogne-Billancourt, France
| | - Anissa Belbachir
- Anaesthesia and Intensive Care Department, Cochin Hospital, APHP, Paris, France
| | - Lionelle Nkam
- Clinical Research Unit, Ambroise Paré Hospital, APHP, Boulogne-Billancourt, France
| | - Philippe Aegerter
- GIRCI-IDF, Cellule Méthodologie, Paris, France.,Université Paris-Saclay, UVSQ, Inserm, Équipe d'Épidémiologie respiratoire intégrative, CESP - Centre de recherche en Epidémiologie et Santé des Populations U1018 INSERM UPS UVSQ, 94807, Villejuif, France
| | - Eva Battaglia
- Direction de la Politique et de la Transformation, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Laure Tharel
- Direction de la Politique et de la Transformation, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Dominique Fletcher
- Anaesthesia and Intensive Care Department, Ambroise Paré Hospital, APHP, 9 avenue Charles de Gaulle, 92100, Boulogne-Billancourt, France. .,Université Paris-Saclay, UVSQ, Inserm, LPPD, 92100, Boulogne, France.
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Studying Enhanced Recovery After Surgery (ERAS®) Core Items in Colorectal Surgery: A Causal Model with Latent Variables. World J Surg 2021; 45:928-939. [PMID: 33575826 PMCID: PMC7921056 DOI: 10.1007/s00268-020-05940-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2020] [Indexed: 01/30/2023]
Abstract
Background Previous Enhanced Recovery After Surgery (ERAS®) studies have not always taken into account that ERAS interventions depend on baseline covariates and that several confounding variables affect the composite outcomes. Method A causal latent variable model is proposed to analyze data obtained prospectively concerning 1261 patients undergoing elective colorectal surgery within the ERAS protocol. Primary outcomes (composite of any complication, surgical site infection, medical complications, early ready for discharge (TRD), early actual discharge) and secondary outcomes (composite of late bowel function recovery, IV fluid resumption, nasogastric tube replacement, postoperative nausea and vomiting, re-intervention, re-admission, death) are considered along with their multiple dimensions. Results Concerning the primary outcomes, our results evidence three subpopulations of patients: one with probable good outcome, one with possibly prolonged TRD and discharge without complications, and the other one with probable complications and prolonged TRD and discharge. Epidural anesthesia, waiving surgical drainage, and early ambulation, IV fluid stop and urinary catheter removal act favorably, while preoperative hospital stay and blood transfusion act negatively. Concerning the secondary outcomes our results evidence two subpopulations of patients: one with high probability of good outcome and one with high probability of complications. Epidural anesthesia, waiving surgical drainage, early ambulation and IV fluid stop act favorably, while blood transfusion acts negatively also with respect to these secondary outcomes. Conclusion The multivariate causal latent class two-parameter logistic model, a modern statistical method overcoming drawbacks of traditional models to estimate the average causal effects on the treated, allows us to disentangle subpopulations of patients and to evaluate ERAS interventions.
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Gianotti L, Fumagalli Romario U, De Pascale S, Weindelmayer J, Mengardo V, Sandini M, Cossu A, Parise P, Rosati R, Bencini L, Coratti A, Colombo G, Galli F, Rausei S, Casella F, Sansonetti A, Maggioni D, Costanzi A, Bernasconi DP, De Manzoni G. Association Between Compliance to an Enhanced Recovery Protocol and Outcome After Elective Surgery for Gastric Cancer. Results from a Western Population-Based Prospective Multicenter Study. World J Surg 2019; 43:2490-2498. [PMID: 31240434 DOI: 10.1007/s00268-019-05068-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The association between compliance to an enhanced recovery protocol (ERAS) and outcome after surgery for gastric cancer has been poorly investigated, particularly in Western patients. The aim of the study was to evaluate whether the rate of adherence to the ERAS program was correlated with outcome and time of discharge. METHODS A prospective, observational, multicenter study was designed to be performed at Italian referral centers for gastric surgery. The protocol was discussed and approved by the Italian Research Group on Gastric Cancer. Twenty-three ERAS domains were applied. A multivariate logistic regression was used to assess the association between ERAS compliance and overall and major complication rates. The Poisson regression model (measured as mean ratios) was used to assess the association of ERAS compliance rate and length of stay (LOS). RESULTS Eight centers participated and 290 subjects with a median age of 73 years were enrolled. The overall rates of adherence to pre-, intra-, and postoperative ERAS items were 69.8%, 60.3%, and 82.5%, respectively. At the multivariate model, there was an association between overall rate of morbidity and an overall ERAS compliance rate greater than 70% (OR 0.413; 95% CI 0.235-0.7240; P 0.002). A similar association was found for major complications (OR 0.328; 95% CI 0.151-0.709; P 0.005). The Poisson regression showed that in patients with ERAS compliance rate >70%, LOS was reduced of approximately 20% (mean ratio 0.812; 95% CI 0.694-0.950; P 0.009). CONCLUSIONS These results suggest a moderate compliance to an ERAS program and a significant association between adherence and outcomes.
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Affiliation(s)
- Luca Gianotti
- Department of Surgery, School of Medicine and Surgery, San Gerardo Hospital, Milano - Bicocca University, Monza, Italy
| | | | | | | | - Valentina Mengardo
- General and Esophagogastric Surgery, University of Verona, Verona, Italy
| | - Marta Sandini
- Department of Surgery, School of Medicine and Surgery, San Gerardo Hospital, Milano - Bicocca University, Monza, Italy
| | - Andrea Cossu
- Digestive Surgery, San Raffaele Hospital, San Raffaele Vita e Salute University, Milan, Italy
| | - Paolo Parise
- Digestive Surgery, San Raffaele Hospital, San Raffaele Vita e Salute University, Milan, Italy
| | - Riccardo Rosati
- Digestive Surgery, San Raffaele Hospital, San Raffaele Vita e Salute University, Milan, Italy
| | - Lapo Bencini
- Oncologic and Robotic Surgery, Department of Oncology, Azienda Ospedaliero - Universitaria Careggi, Florence, Italy
| | - Andrea Coratti
- Oncologic and Robotic Surgery, Department of Oncology, Azienda Ospedaliero - Universitaria Careggi, Florence, Italy
| | - Giovanni Colombo
- Department of Surgery, School of Medicine and Surgery, San Gerardo Hospital, Milano - Bicocca University, Monza, Italy
| | | | - Stefano Rausei
- Department of Surgery, ASST Valle Olona, Gallarate, Italy
| | - Francesco Casella
- General Surgery, Vannini-Figlie di San Camillo Hospital, Rome, Italy
| | - Andrea Sansonetti
- General Surgery, Vannini-Figlie di San Camillo Hospital, Rome, Italy
| | - Dario Maggioni
- General Surgery 3, ASST-Monza, Desio Hospital, Desio, Italy
| | | | - Davide P Bernasconi
- Centre of Biostatistics for Clinical Epidemiology, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
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van Dellen J, Carapeti EA, Darakhshan AA, Datta V, George ML, McCorkell S, Williams AB. Intrinsic predictors of prolonged length of stay in a colorectal enhanced recovery pathway: a prospective cohort study and multivariate analysis. Colorectal Dis 2019; 21:1079-1089. [PMID: 31095879 DOI: 10.1111/codi.14704] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 03/16/2019] [Indexed: 12/15/2022]
Abstract
AIM This was a prospective cohort study to determine the intrinsic non-modifiable factors influencing length of stay (LOS) in unselected consecutive patients undergoing elective colorectal surgery within an enhanced recovery pathway. METHODS This study interrogated a prospective database of consecutive elective procedures from October 2006 to April 2011 at a tertiary referral academic hospital in the UK to identify independent predictors of prolonged length of stay (pLOS). pLOS was defined as longer than median length of stay (mLOS). Differences in determinants were identified in three groups of increasing operative complexity. RESULTS In all, 872 procedures were identified and ranged from a simple ileostomy reversal to complex total pelvic exenteration. Preoperative anaemia and American Society of Anesthesiologists (ASA) Grade III+ predicted pLOS in stoma reversal surgery patients (n = 191, mLOS 4 days). In colonic and small bowel surgery (n = 444, mLOS 8 days), an open procedure, new stoma formation, planned critical care admission and ASA III+ predicted pLOS. New stoma formation and planned critical care admission predicted pLOS in patients undergoing pelvic rectal surgery (n = 237, mLOS 11 days). pLOS was associated with significantly higher morbidity across Dindo-Clavien grades and a longer time to postoperative functional recovery and discharge. CONCLUSIONS Operative complexity is associated with longer LOS even with an established enhanced recovery pathway in place. Intrinsic non-modifiable predictors of pLOS differ with operative complexity, and this should be taken into account when planning benchmarking and research across units.
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Affiliation(s)
- J van Dellen
- King's College London, London, UK.,Department of Colorectal Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - E A Carapeti
- Department of Colorectal Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - A A Darakhshan
- Department of Colorectal Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - V Datta
- Department of Colorectal Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - M L George
- Department of Colorectal Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - S McCorkell
- Department of Anaesthetics, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - A B Williams
- Department of Colorectal Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Fagard K, Wolthuis A, D'Hoore A, Verhaegen M, Tournoy J, Flamaing J, Deschodt M. A systematic review of the intervention components, adherence and outcomes of enhanced recovery programmes in older patients undergoing elective colorectal surgery. BMC Geriatr 2019; 19:157. [PMID: 31170933 PMCID: PMC6555702 DOI: 10.1186/s12877-019-1158-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 05/13/2019] [Indexed: 12/20/2022] Open
Abstract
Background Enhanced recovery programmes (ERPs) aim to attenuate the surgical stress response and accelerate recovery after surgery, but are not specifically designed for older patients. The objective of this study was to review the components, adherence and outcomes of ERPs in older patients (≥65 years) undergoing elective colorectal surgery. Methods Pubmed, Embase and Cinahl were searched between 2000 and 2017 for randomised and non-randomised controlled trials, before-after studies, and observational studies. The methodological quality of the studies was evaluated using the MINORS quality assessment. The review was performed and reported according to the PRISMA guidelines. Results Twenty-one studies, including 3495 ERP patients aged ≥65 years, were identified. The ERPs consisted of a median of 13 intervention components. Adherence rates were reported in 9 studies and were the highest (≥80%) for pre-admission counselling, no bowel preparation, limited pre-operative fasting, antithrombotic and antimicrobial prophylaxis, no nasogastric tube, active warming, and limited intra-operative fluids. The median post-operative length of stay was 6 days. The median post-operative morbidity rate (Clavien-Dindo I-IV) was 23.5% in-hospital and 29.8% at 30 days. The in-hospital post-operative mortality rate was 0% in most studies and amounted to a median of 1.4% at 30 days. The median 30-day readmission rate was 4.9% and the median reoperation rate was 5.0%. Conclusions ERPs in older patients were in accordance with the ERP consensus guidelines. Although the number of intervention components applied increased over time, outcomes in earlier and later studies remained comparable. Adherence rates were under-reported. Future studies should explore adherence and age-related factors, such as frailty profile, that could influence adherence. Trial registration PROSPERO 2018 CRD42018084756. Electronic supplementary material The online version of this article (10.1186/s12877-019-1158-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Katleen Fagard
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium.
| | - Albert Wolthuis
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Abdominal Surgical Oncology, KU Leuven, Leuven, Belgium
| | - André D'Hoore
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Abdominal Surgical Oncology, KU Leuven, Leuven, Belgium
| | - Marleen Verhaegen
- Department of Anaesthesia, University Hospitals Leuven, Leuven, Belgium
| | - Jos Tournoy
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), KU Leuven, Leuven, Belgium
| | - Johan Flamaing
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), KU Leuven, Leuven, Belgium
| | - Mieke Deschodt
- Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), KU Leuven, Leuven, Belgium.,Institute of Nursing Science, Department of Public Health, University of Basel, Basel, Switzerland
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Byrnes A, Young A, Mudge A, Banks M, Clark D, Bauer J. Prospective application of an implementation framework to improve postoperative nutrition care processes: Evaluation of a mixed methods implementation study. Nutr Diet 2018; 75:353-362. [DOI: 10.1111/1747-0080.12464] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 07/03/2018] [Accepted: 07/05/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Angela Byrnes
- Centre for Dietetics Research, School of Human Movement and Nutrition Sciences; University of Queensland (UQ); St Lucia Queensland Australia
- Nutrition and Dietetics Department; Royal Brisbane and Women's Hospital (RBWH); Brisbane Queensland Australia
| | - Adrienne Young
- Nutrition and Dietetics Department; Royal Brisbane and Women's Hospital (RBWH); Brisbane Queensland Australia
- School of Exercise and Nutrition Sciences; Brisbane Queensland Australia
| | - Alison Mudge
- Internal Medicine and Aged Care Department; Royal Brisbane and Women's Hospital (RBWH); Brisbane Queensland Australia
- Institute for Health and Biomedical Innovation, Queensland University of Technology (QUT); Brisbane Queensland Australia
- School of Medicine; University of Queensland (UQ); St Lucia Queensland Australia
| | - Merrilyn Banks
- Nutrition and Dietetics Department; Royal Brisbane and Women's Hospital (RBWH); Brisbane Queensland Australia
- School of Exercise and Nutrition Sciences; Brisbane Queensland Australia
| | - David Clark
- School of Medicine; University of Queensland (UQ); St Lucia Queensland Australia
- Surgical and Perioperative Services; Royal Brisbane and Women's Hospital (RBWH); Brisbane Queensland Australia
| | - Judy Bauer
- Centre for Dietetics Research, School of Human Movement and Nutrition Sciences; University of Queensland (UQ); St Lucia Queensland Australia
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EXploring practice gaps to improve PERIoperativE Nutrition CarE (EXPERIENCE Study): a qualitative analysis of barriers to implementation of evidence-based practice guidelines. Eur J Clin Nutr 2018; 73:94-101. [DOI: 10.1038/s41430-018-0276-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 06/22/2018] [Accepted: 07/18/2018] [Indexed: 01/31/2023]
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Hallam S, Rickard F, Reeves N, Messenger D, Shabbir J. Compliance with enhanced recovery protocols in elderly patients undergoing colorectal resection. Ann R Coll Surg Engl 2018; 100:570-579. [PMID: 29909672 DOI: 10.1308/rcsann.2018.0102] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Introduction Enhanced recovery after surgery (ERAS) is associated with reduced length of stay (LOS) and improved outcomes in colorectal surgery. It is unclear whether ERAS can be safely implemented in elderly patients undergoing complex colorectal resections. The aim of this study was to evaluate the feasibility of ERAS in patients of all ages undergoing colorectal surgery. Methods A prospective database of a consecutive series of patients undergoing colorectal resections with ERAS between August 2012 and December 2014 was evaluated. Patients were divided into four age groups. Outcomes studied were compliance with ERAS elements, LOS, morbidity and mortality. Results Of the 294 patients in the study cohort, 79 were <60 years, 81 were 60-69 years, 86 were 70-79 years and 48 were ≥80 years of age. There was no significant difference between age groups in compliance with ERAS elements. Age was not predictive of delayed discharge (LOS >6 days) or morbidity. Factors that were predictive of delayed discharge on multivariate analysis were open surgery (odds ratio [OR]: 2.23, p=0.003), conversion to open surgery (OR: 3.23, p=0.017), stoma formation (OR: 2.10, p=0.019) and chronic obstructive pulmonary disease (OR: 4.12, p=0.038). Factors predictive of morbidity on multivariate analysis comprised conversion to open surgery (OR: 7.72, p=0.004), high creatinine (OR: 1.03 per unit increase in creatinine, p=0.008) and stoma education (OR: 0.31, p=0.030). Conclusions ERAS can be successfully implemented in older patients. There was equal compliance with the ERAS programme across the four age groups and no significant effect of age on LOS or morbidity.
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Affiliation(s)
- S Hallam
- University Hospitals Bristol NHS Foundation Trust , UK
| | - F Rickard
- University Hospitals Bristol NHS Foundation Trust , UK
| | - N Reeves
- University Hospitals Bristol NHS Foundation Trust , UK
| | - D Messenger
- University Hospitals Bristol NHS Foundation Trust , UK
| | - J Shabbir
- University Hospitals Bristol NHS Foundation Trust , UK
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Impact of a colorectal enhanced recovery program implementation on clinical outcomes and institutional costs: A prospective cohort study with retrospective control. Int J Surg 2018; 53:206-213. [DOI: 10.1016/j.ijsu.2018.03.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 03/04/2018] [Accepted: 03/08/2018] [Indexed: 12/20/2022]
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Braga M, Scatizzi M, Borghi F, Missana G, Radrizzani D, Gemma M. Identification of core items in the enhanced recovery pathway. Clin Nutr ESPEN 2018; 25:139-144. [PMID: 29779809 DOI: 10.1016/j.clnesp.2018.03.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 03/13/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS The Enhanced Recovery After Surgery (ERAS) pathway represents an optimal approach in patients undergoing colorectal surgery but complexity in implementing its items could limit its application. The aim of this study is to identify possible core items within an ERAS pathway following elective colorectal resection. METHODS This is a retrospective review of data prospectively collected between January 2014 and September 2015 by 14 Italian Hospitals in an electronic registry dedicated to an ERAS protocol. 722 patients undergoing elective colorectal surgery within an ERAS protocol have been included in the study. Adherence to ERAS items was assessed in all patients. A secondary analysis was restricted to pre- and intraoperative ERAS items. Time to readiness for discharge (TRD) was the primary endpoint of the study. Postoperative overall morbidity was the secondary endpoint. RESULTS Multivariate analyses showed that active intraoperative warming (p = 0.008), early stop of intravenous fluids (p = 0.0001), and early removal of urinary catheter (p = 0.0001) were associated to a shorter TRD, while early stop of intravenous fluids (p < 0.001) also reduced morbidity. When the analysis was restricted to pre- and intraoperative items, removal of NGT at the end of surgery had an independent role to shorten TRD (p < 0.001) and to reduce overall morbidity (p = 0.019), while the absence of oral bowel preparation reduced postoperative overall morbidity (p = 0.021). CONCLUSIONS In implementing an ERAS pathway, hospitals could initially focus on active intraoperative warming, early stop of intravenous fluids, early removal of urinary catheter, removal of NGT at the end of surgery, and absence of oral bowel preparation, keeping on continuous effort to apply the complete ERAS protocol.
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Affiliation(s)
- Marco Braga
- Department of Surgery, Vita-Salute University, San Raffaele Hospital, Milan, Italy.
| | | | | | | | | | - Marco Gemma
- Department of Anesthesiology, Vita-Salute University, San Raffaele Hospital, Milan, Italy
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Currie AC, Malietzis G, Jenkins JT, Yamada T, Ashrafian H, Athanasiou T, Okabayashi K, Kennedy RH. Network meta-analysis of protocol-driven care and laparoscopic surgery for colorectal cancer. Br J Surg 2016; 103:1783-1794. [PMID: 27762436 DOI: 10.1002/bjs.10306] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 06/28/2016] [Accepted: 07/25/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Laparoscopic approaches and standardized recovery protocols have reduced morbidity following colorectal cancer surgery. As the optimal regimen remains inconclusive, a network meta-analysis was undertaken of treatments for the development of postoperative complications and mortality. METHODS MEDLINE, Embase, trial registries and related reviews were searched for randomized trials comparing laparoscopic and open surgery within protocol-driven or conventional perioperative care for colorectal cancer resection, with complications as a defined endpoint. Relative odds ratios (ORs) for postoperative complications and mortality were estimated for aggregated data. RESULTS Forty trials reporting on 11 516 randomized patients were included with the network. Open surgery within conventional perioperative care was the index for comparison. The OR relating to complications was 0·77 (95 per cent c.i. 0·65 to 0·91) for laparoscopic surgery within conventional care, 0·69 (0·48 to 0·99) for open surgery within protocol-driven care, and 0·43 (0·28 to 0·67) for laparoscopic surgery within protocol-driven care. Sensitivity analyses excluding trials of low rectal cancer and those with a high risk of bias did not affect the treatment estimates. Meta-analyses demonstrated that mortality risk was unaffected by perioperative strategy. CONCLUSION Laparoscopic surgery combined with protocol-driven care reduces colorectal cancer surgery complications, but not mortality. The reduction in complications with protocol-driven care is greater for open surgery than for laparoscopic approaches. Registration number: CRD42015017850 (https://www.crd.york.ac.uk/PROSPERO).
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Affiliation(s)
- A C Currie
- Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, UK
| | - G Malietzis
- Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, UK
| | - J T Jenkins
- Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, UK
| | - T Yamada
- Department of Surgery, School of Medicine, Keio University, Shinjuku, Tokyo, Japan
| | - H Ashrafian
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - T Athanasiou
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - K Okabayashi
- Department of Surgery, School of Medicine, Keio University, Shinjuku, Tokyo, Japan
| | - R H Kennedy
- Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, UK
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Pecorelli N, Hershorn O, Baldini G, Fiore JF, Stein BL, Liberman AS, Charlebois P, Carli F, Feldman LS. Impact of adherence to care pathway interventions on recovery following bowel resection within an established enhanced recovery program. Surg Endosc 2016; 31:1760-1771. [PMID: 27538934 DOI: 10.1007/s00464-016-5169-2] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 08/04/2016] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Guidelines recommend incorporation of more than 20 perioperative interventions within an enhanced recovery program (ERP). However, the impact of overall adherence to the pathway and the relative contribution of each intervention are unclear. The aim of this study was to estimate the extent to which adherence to ERP elements is associated with outcomes and identify key ERP elements predicting successful recovery following bowel resection. METHODS Prospectively collected data entered in a registry specifically designed for ERPs were reviewed. Patients undergoing elective bowel resection between 2012 and 2014 were treated within an ERP comprising 23 care elements. Primary outcome was successful recovery defined as the absence of complications, discharge by postoperative day 4 and no readmission. Secondary outcomes were length of hospital stay (LOS), 30-day morbidity, and severity (Comprehensive complication index, CCI, 0-100). Regression analyses were adjusted for potential confounders. RESULTS A total of 347 patients were included in the study. Median primary LOS was 4 days (IQR 3-7). Patients were adherent to median 18 (IQR 16-20) elements. A total of 156 (45 %) patients had successful recovery. Morbidity occurred in 175 (50 %) patients with median CCI 8.6 (IQR 0-22.6). There was a positive association between adherence and successful recovery (OR 1.39 for every additional element, p < 0.001), LOS (11 % reduction for every additional element, p < 0.001), 30-day postoperative morbidity (OR 0.78, p < 0.001), and the CCI (17 % reduction, p < 0.001). Laparoscopy (OR 4.32, p < 0.001), early mobilization out of bed (OR 2.25, p = 0.021), and early termination of IV fluid infusion (OR 2.00, p = 0.013) significantly predicted successful recovery. These factors were also associated with reduced morbidity and complication severity. CONCLUSIONS Increased adherence to ERP interventions was associated with successful early recovery and a reduction in postoperative morbidity and complication severity. In an established ERP where overall adherence was high, laparoscopic approach, perioperative fluid management, and patient mobilization remain key elements associated with improved outcomes.
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Affiliation(s)
- Nicolò Pecorelli
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, 1650 Cedar Ave, L9.309, Montreal, QC, H3G 1A4, Canada
| | - Olivia Hershorn
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, 1650 Cedar Ave, L9.309, Montreal, QC, H3G 1A4, Canada
| | - Gabriele Baldini
- Department of Anesthesia, McGill University Health Centre, Montreal, QC, Canada
| | - Julio F Fiore
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, 1650 Cedar Ave, L9.309, Montreal, QC, H3G 1A4, Canada
| | - Barry L Stein
- Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - A Sender Liberman
- Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Patrick Charlebois
- Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Franco Carli
- Department of Anesthesia, McGill University Health Centre, Montreal, QC, Canada
| | - Liane S Feldman
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, 1650 Cedar Ave, L9.309, Montreal, QC, H3G 1A4, Canada. .,Department of Surgery, McGill University Health Centre, Montreal, QC, Canada.
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Thorn CC, White I, Burch J, Malietzis G, Kennedy R, Jenkins JT. Active and passive compliance in an enhanced recovery programme. Int J Colorectal Dis 2016; 31:1329-39. [PMID: 27112591 DOI: 10.1007/s00384-016-2588-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/08/2016] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Enhanced recovery after surgery (ERAS) is a well-established and accepted practice following colorectal surgery and has been demonstrated to reduce hospital length of stay (LOS) and 30-day morbidity. Despite evidence to support the individual elements on which the programme is based, there remains uncertainty as to how many and which of these are required to realise its benefits. Furthermore, elements of an ERAS programme might either precipitate or reflect recovery, in which case compliance could have a role in the improvement or prediction of outcome. MATERIALS AND METHODS A multidimensional prospective database of 799 consecutive patients undergoing colorectal surgery within an established ERAS programme at a single institution was interrogated. After application of exclusion criteria, 614 patients were studied. The novel concept of 'active compliance' is introduced. An ERAS element is classified as 'active' if the participation of the patient is required to achieve its compliance. This contrasts with 'passive' compliance, where an intervention is delivered to the patient without their direct contribution. The short-term surgical outcomes of this cohort are reported with reference to ERAS protocol compliance. RESULTS Compliance with the passive elements of the programme was higher than with the active elements. Univariate and multivariate analyses demonstrate that poor compliance with active but not passive elements of the programme was significantly associated with major morbidity. Receiver operator characteristic curve analysis demonstrated active compliance to be a stronger predictor of both major morbidity (AUC 0.71 vs. AUC 0.56) and length of stay (AUC 0.83 vs. 0.57) when compared with passive compliance. CONCLUSION The results suggest that poor active compliance may be a surrogate marker of morbidity which can be recognised in the early post-operative period. This implies the potential for timely diagnosis and intervention. This aspect of ERAS compliance is clinically relevant yet has achieved scant attention. Independent validation of our observations is required.
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Affiliation(s)
| | - Ian White
- St. Mark's Hospital, Watford Road, Harrow, London, HA1 3UJ, UK
| | - Jennie Burch
- St. Mark's Hospital, Watford Road, Harrow, London, HA1 3UJ, UK
| | | | - Robin Kennedy
- St. Mark's Hospital, Watford Road, Harrow, London, HA1 3UJ, UK
| | - John T Jenkins
- St. Mark's Hospital, Watford Road, Harrow, London, HA1 3UJ, UK.
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Lee A, Chiu CH, Cho MWA, Gomersall CD, Lee KF, Cheung YS, Lai PBS. Factors associated with failure of enhanced recovery protocol in patients undergoing major hepatobiliary and pancreatic surgery: a retrospective cohort study. BMJ Open 2014; 4:e005330. [PMID: 25011990 PMCID: PMC4120378 DOI: 10.1136/bmjopen-2014-005330] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE This study examined the risk factors associated with failure of enhanced recovery protocol after major hepatobiliary and pancreatic (HBP) surgery. SETTING AND PARTICIPANTS A retrospective cohort of 194 adult patients undergoing major HBP surgery at a university hospital in Hong Kong was followed up for 30 days. The patients were from a larger cohort study of 736 consecutive adults with preoperative urinary cotinine concentration to examine the association between passive smoking and risk of perioperative respiratory complications and postoperative morbidities. OUTCOME MEASURES The primary outcome was failure of enhanced recovery protocol. This was defined as a composite measure of the following events: intensive care unit (ICU) stay more than 24 h after surgery, unplanned admission to ICU within 30 days after surgery, hospital readmission, reoperation and mortality. RESULTS There were 25 failures of enhanced recovery after HBP surgery (12.9%, 95% CI 8.5% to 18.4%). After adjusting for elective ICU admission, smokers (relative risk (RR ) 2.21, 95% CI 1.10 to 4.46), high preoperative alanine transaminase/glutamic-pyruvic transaminase (RR 3.55,95% CI 1.68 to 7.49) and postoperative morbidities (RR 2.69, 95% CI 1.30 to 5.56) were associated with failures of enhanced recovery in the generalised estimating equation risk model. Compared with those managed successfully, failures stayed longer in ICU (median 19 vs 25 h, p<0.001) and in hospital for postoperative care (median 7 vs 13 days, p=0.003). CONCLUSIONS Smokers and patients having high preoperative alanine transaminase/glutamic-pyruvic transaminase concentration or have a high risk of postoperative morbidities are likely to fail enhanced recovery protocol in HBP surgery programmes.
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Affiliation(s)
- Anna Lee
- Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Chun Hung Chiu
- Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Mui Wai Amy Cho
- Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Charles David Gomersall
- Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Kit Fai Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Yue Sun Cheung
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Paul Bo San Lai
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
- Wong Tze Lam – Hing Tak Centre of Surgical Outcome Research, The Chinese University of Hong Kong, Hong Kong
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Chambers D, Paton F, Wilson P, Eastwood A, Craig D, Fox D, Jayne D, McGinnes E. An overview and methodological assessment of systematic reviews and meta-analyses of enhanced recovery programmes in colorectal surgery. BMJ Open 2014; 4:e005014. [PMID: 24879828 PMCID: PMC4039862 DOI: 10.1136/bmjopen-2014-005014] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Duncan Chambers
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Fiona Paton
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Paul Wilson
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Alison Eastwood
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Dawn Craig
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Dave Fox
- Centre for Reviews and Dissemination, University of York, York, UK
| | - David Jayne
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
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