Original ArticleThe enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: A meta-analysis of randomized controlled trials☆
Introduction
Patients undergoing major open colorectal surgery traditionally undergo prolonged rehabilitation during the postoperative period with profound changes in endocrine, metabolic, neural and pulmonary function. Complication rates of 15–20%,1, 2 and even as high as 45–48%,3, 4 have been reported after major elective open colorectal surgery undertaken in the setting of traditional perioperative care. This may not be surprising since many traditional interventions that have been shown to be outdated, and even harmful, for patients5, 6, 7, 8, 9 are still in use. For patients without complications, a key factor for postoperative recovery is the return of bowel function and this is influenced by several perioperative factors such as preoperative fasting and bowel preparation, analgesic and anesthetic techniques, magnitude and complications of surgery, fluid overload, and also by the patients' co-morbidities.
Enhanced recovery after surgery (ERAS) or ‘fast-track’ surgery pathways have been developed to address these issues and to accelerate recovery by attenuating the stress response so that the length of hospital stay and possibly the incidence of postoperative complications and mortality can be reduced, with the added benefits of reducing healthcare costs.10, 11 The important elements of ERAS and similar fast-track programs in open colorectal surgery included in these studies were factors shown to improve outcomes and many of them also addressed traditional treatments that were proven to be outdated. These measures were then amalgamated into treatment programs that included preoperative counselling, no bowel preparation, no premedication, synbiotics administered before surgery, no preoperative fasting but provision of clear carbohydrate enriched liquids until 2 h before surgery, standard anesthetic techniques, thoracic epidural anesthesia, high inspired oxygen concentrations, avoidance of perioperative fluid overload, maintenance of body temperature, short/transverse incisions, non-opioid analgesia, no routine use of drains and nasogastric decompression tubes, early removal of bladder catheters, standard laxatives and prokinetics, and early postoperative feeding and mobilization.
It has been shown that these ‘multimodal rehabilitation’ or ‘fast-track’ surgery programs improve surgical outcome with decreased hospitalization, increased patient satisfaction and safety after discharge. A systematic review of three randomized controlled trials (RCTs) and three case control trials, showed some benefits of the enhanced recovery pathway in elective open colorectal surgery such as reduction in primary hospital stay and morbidity.12 Three recent meta-analyses also showed a positive influence of implementing the ERAS protocol in this group of patients.13, 14, 15 However, the authors recommended the need for further RCTs as, with a maximum of 198 randomized patients included in the meta-analyses, the data available were too limited to draw firm conclusions. This multimodal approach has been the subject of interest in several other non-randomized, case-controlled and prospective studies including a consensus review of optimal care recommended by the ERAS group in patients undergoing major colorectal surgery.11
The purpose of the present meta-analysis of RCTs was to study the effect of the ERAS pathway in patients undergoing major elective open colorectal surgery in reducing the length of primary hospital stay, and to examine the incidence of postoperative complications, readmission rates and mortality.
Section snippets
Criteria for considering studies for this review
Studies comparing enhanced recovery programs with traditional perioperative care in patients undergoing major elective open colorectal surgery were selected from the initial search. RCTs documenting the individual elements of the ERAS pathway that were implemented, with a minimum of four elements covering the pre-, intra- and postoperative periods of the ERAS pathway, were subsequently included in this meta-analysis.
Non-randomized studies, case-controlled trials, cohorts, retrospective studies
Eligible studies
Six RCTs3, 4, 19, 20, 21, 22 fulfilled the inclusion criteria for the meta-analysis (Fig. 1), leading to a total of 452 patients, 226 in each group, being included (median number of patients in each study 67, range 25–151). All six studies reported appropriate randomization methods (sealed envelope in four studies4, 19, 20, 21; random number generator in two3, 22). None of the RCTs were blinded. Due to the nature of these trials and allocation of patients to treatment groups that become self
Discussion
The results from the present meta-analysis suggest that the implementation of four or more elements of the ERAS pathway leads to a reduction in length of hospital stay by more than 2 days and an almost 50% reduction in complication rates in patients undergoing major open colonic/colorectal surgery. At the same time, no significant difference was noted in readmission rates or mortality between the groups. Although no firm conclusions could be made with regards to the latter two outcome measures,
Conflict of interest
CHCD, KCHF, OL and DNL are members of the Enhanced Recovery After Surgery (ERAS) Group which currently receives an unrestricted grant from Fresenius Kabi, Bad Homburg, Germany.
OL is the owner of a patent for a preoperative carbohydrate drink licensed to a commercially company and available in parts of the world. This drink has been used in some trials studied in this report.
KKV and KRN have no conflicts of interest to declare.
Funding
KKV is a recipient of a Research Fellowship from the Nottingham Digestive Diseases Centre NIHR Biomedical Research Unit, Nottingham.
Acknowledgements
KKV: Study design, literature search, selection of studies, data analysis, data interpretation, writing of the manuscript and final approval.
KRN: Study design, literature search, selection of studies, data analysis, data interpretation, writing of the manuscript and final approval.
CHCD: Study design, data interpretation, critical revision of the manuscript and final approval.
KCHF: Study design, data interpretation, critical revision of the manuscript and final approval.
OL: Study design, data
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This paper was presented to the Annual Conference of the Society for Academic and Research Surgery, London, January 2010 and has been published in abstract form in the British Journal of Surgery.