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The enhanced recovery after surgery (ERAS) pathway for patients undergoing colorectal surgery: an update of meta-analysis of randomized controlled trials |
Lv L, Shao YF, Zhou YB |
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CRD summary The authors concluded that an enhanced recovery after surgery programme seemed to reduce the length of hospital stay and complication rates, after major colorectal surgery, without compromising patient safety. There were some inconsistencies in the length of stay in individual trials, and uncertainty in the content of the programmes, which suggest that the authors' conclusions may be overstated. Authors' objectives To assess the safety and efficacy of enhanced recovery programmes for patients undergoing colorectal surgery. Searching MEDLINE, EMBASE, Cochrane Colorectal Cancer Group Trials Register, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for studies from 1966 to April 2012, without language or publication restrictions. Search terms were reported. Reference lists of relevant trials and reviews were handsearched, and authors were contacted for additional data. Study selection Eligible for inclusion were randomised controlled trials (RCTs) of patients undergoing major colorectal surgery (defined in the review). Trials had to compare programmes for enhanced recovery after surgery versus conventional perioperative care, and have a minimum follow-up of 30 days after surgery. The primary outcome of interest was the total primary length of stay (defined in the review). Secondary outcomes were readmission, morbidity (complications), and mortality. The included trials were published between 2003 and 2011. The mean age of patients ranged from 33 to 73 years. The number of elements in the enhanced recovery programme ranged from four to 12. One trial had four arms and was treated as two separate comparisons; laparoscopy plus enhanced recovery versus laparoscopy plus conventional care, and open surgery plus enhanced recovery versus open surgery plus conventional care. Two reviewers independently screened studies for inclusion. Assessment of study quality Two reviewers assessed the quality of the trials for sequence generation, allocation concealment, blinding, incomplete outcome data, selective outcome reporting, and other sources of bias. Discrepancies were resolved through discussion and consensus. Data extraction Two reviewers extracted dichotomous data to calculate risk ratios and 95% confidence intervals. The means and standard deviations were extracted or calculated, for continuous data, to estimate mean differences and 95% confidence intervals. Where means were not available, medians were used. Methods of synthesis A fixed-effect model, or a random-effects model where heterogeneity was evident, was used to combine the risk ratios, mean differences, and their 95% confidence intervals. Statistical heterogeneity was explored using Χ² and Ι². Where possible, analyses were performed on an intention-to-treat basis. Subgroup analysis was performed for major and minor complications. Sensitivity analyses, excluding one trial at a time, were performed to assess the effect of each trial on the overall estimate. Publication bias could not be explored, as there were too few included trials for the funnel plot. Results of the review Seven RCTs (852 patients) were included in the review; one was analysed as two comparisons. Four RCTs were at a high risk of bias, and three (four comparisons) were at a moderate risk of bias. Due to the nature of the procedures, none of the trials were blind. Total length of hospital stay: This was statistically significantly reduced with enhanced recovery (MD -1.88 days, 95% CI -2.91 to -0.86; seven RCTs), but there was evidence of high statistical heterogeneity (Ι²=75%). Sensitivity analysis did not significantly alter the findings. Complications: Enhanced-recovery patients experienced statistically significantly fewer complications than conventional-care patients (RR 0.69, 95% CI 0.51 to 0.93; Ι²=59%; seven RCTs). Separate analyses for major and minor complications indicated no statistically significant differences between treatment groups, and no evidence of statistical heterogeneity. There were no statistically significant differences between treatment groups for readmission rates and mortality, and no evidence of statistical heterogeneity. Authors' conclusions An enhanced recovery after surgery programme seemed to reduce the length of hospital stay and complication rates, after major colorectal surgery, without compromising patient safety. CRD commentary The review question and supporting inclusion criteria were clearly defined. A satisfactory literature search was undertaken with attempts made to reduce the potential for missed data. Each stage of the review process was performed in duplicate, reducing the opportunity for reviewer error and bias. The quality of the trials was assessed, but the care programmes precluded blinding, which left the trials at some risk of bias. Few patient and trial characteristics were reported, and sample sizes were generally small. There was evidence of high statistical heterogeneity for the analyses of length of stay and overall complications, which was not explored in the review. There appears to have been a wide variation in the number of enhanced recovery elements used across trials, and no details were provided on which elements were included. Restricting the review to RCTs was appropriate for the efficacy outcomes, but other study designs might have provided additional evidence for safety. This was a generally well-conducted review, but the conclusions do not fully reflect the limitations of the evidence. There were some inconsistencies in the length of stay in individual trials, and uncertainties for other outcomes, with wide confidence intervals in trials with few patients and events. This and the uncertainty in the content of the enhanced recovery programmes, suggest that the authors' conclusions may be overstated. Implications of the review for practice and research Practice: The authors did not state any implications for practice. Research: The authors stated that future studies should define the active elements of an enhanced recovery programme, to improve future protocols. Bibliographic details Lv L, Shao YF, Zhou YB. The enhanced recovery after surgery (ERAS) pathway for patients undergoing colorectal surgery: an update of meta-analysis of randomized controlled trials. International Journal of Colorectal Disease 2012; 27(12): 1549-1554 Indexing Status Subject indexing assigned by NLM MeSH Adult; Aged; Colorectal Surgery /adverse effects /methods /mortality; Critical Pathways; Humans; Length of Stay; Middle Aged; Patient Readmission; Postoperative Complications /etiology; Publication Bias; Randomized Controlled Trials as Topic; Risk Assessment AccessionNumber 12013016462 Date bibliographic record published 03/04/2013 Date abstract record published 12/04/2013 Record Status This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn. |
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