Effectiveness and safety of the enhanced recovery program in colorectal surgery: overview of systematic reviews
Introduction: Multimodal enhanced recovery programs are a new paradigm in perioperative care.
Objective: To evaluate the certainty of evidence pertaining to the effectiveness and safety of the multimodal perioperative care program in elective colorectal surgery.
Data source: A search was conducted in the Medline, EMBASE, and Cochrane databases, up until February 2020.
Eligibility criteria: Systematic reviews that take into account the perioperative multimodal program in patients with an indication for colorectal surgery were included. The primary outcomes were morbidity and postoperative deaths. The secondary outcome was hospital length of stay.
Study quality and synthesis method: The reviews were evaluated with AMSTAR-2 and the certainty of the evidence with the GRADE methodology. The findings are presented with measures of frequency, risk estimators, or differences.
Results: Six systematic reviews of clinical trials with medium and high quality in AMSTAR-2 were included. Morbidity was reduced between 16 and 48%. Studies are inconclusive regarding postoperative mortality. Hospital length of stay was reduced by an average of 2.5 days (p <0.05). The certainty of the body of evidence is very low.
Limitations: The effect of the program, depending on the combination of elements, is not clear.
Conclusions and implications: Despite the proven evidence that the program is effective in reducing global postoperative morbidity and hospital stay, the body of evidence is of very low quality. Consequently, results may change with new evidence and further research is required.
Weiser TG, Haynes AB, Molina G, Lipsitz SR, Esquivel MM, Uribe-Leitz T, et al. Estimate of the global volume of surgery in 2012: an assessment supporting improved health outcomes. Lancet. 2015;385:S11. doi: http://doi.org/10.1016/S0140-6736(15)60806-6
van der Pas MHGM, Haglind E, Cuesta MA, Fürst A, Lacy AM, Hop WCJ, et al. Laparoscopic versus open surgery for rectal cancer (COLOR II): Short-term outcomes of a randomised, phase 3 trial. Lancet Oncol. 2013;14(3):210-8. doi: http://doi.org/10.1016/S1470-2045(13)70016-0
Vonlanthen R, Slankamenac K, Breitenstein S, Puhan MA, Muller MK, Hahnloser D, et al. The impact of complications on costs of major surgical procedures: A cost analysis of 1200 patients. Ann Surg. 2011;254(6):907-13. doi: http://doi.org/10.1016/S1470-2045(13)70016-0
Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg. 2002;183(6):630-41.
Miller TE, Thacker JK, White WD, Mantyh C, Migaly J, Jin J, et al. Reduced length of hospital stay in colorectal surgery after implementation of an enhanced recovery protocol. Anesth Analg. 2014;118(5):1052-61. doi: http://doi.org/10.1213/ANE.0000000000000206
Pędziwiatr M, Wierdak M, Nowakowski M, Pisarska M, Stanek M, Kisielewski M, et al. Cost minimization analysis of laparoscopic surgery for colorectal cancer within the enhanced recovery after surgery (ERAS) protocol: a single-centre, case-matched study. Videosurgery Other Miniinvasive Tech. 2016;11(1):14. doi: http://doi.org/10.5114/wiitm.2016.58617
Jing X, Zhang B, Xing S, Tian L, Wang X, Zhou M, et al. Cost-benefit analysis of enhanced recovery after hepatectomy in Chinese Han population. Med (United States). 2018;97(34):e11957. doi: http://doi.org/10.1097/MD.0000000000011957
Portinari M, Ascanelli S, Targa S, Dos Santos Valgode EM, Bonvento B, Vagnoni E, et al. 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;53:206-13. doi: http://doi.org/10.1016/j.ijsu.2018.03.005
Shea BJ, Reeves BC, Wells G, Thuku M, Hamel C, Moran J, et al. AMSTAR 2: A critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ. 2017;358:j4008. doi: http://doi.org/10.1136/bmj.j4008
Gaitán H, Rojas M, Alfonso J. Búsqueda, evaluación y síntesis de la evidencia de efectividad y seguridad en evaluaciones de tecnología: Manual metodológico. BID; 2017. http://dx.doi.org/10.18235/0000748
McMaster University. GRADEpro GDT: GRADEpro Guideline Development Tool [Software]. Evidence Prime, Inc. 2015.
Greco M, Capretti G, Beretta L, Gemma M, Pecorelli N, Braga M. Enhanced recovery program in colorectal surgery: A meta-analysis of randomized controlled trials. World J Surg. 2014;38(6):1531-41. doi: http://doi.org/10.1007/s00268-013-2416-8
Greer NL, Gunnar WP, Dahm P, Lee AE, MacDonald R, Shaukat A, et al. Enhanced recovery protocols for adults undergoing colorectal surgery: A Systematic review and meta-analysis. Dis Colon Rectum. 2018;61(9):1108-18. doi: http://doi.org/10.1097/DCR.0000000000001160
Spanjersberg WR, Reurings J, Keus F, van Laarhoven CJ. Fast track surgery versus conventional recovery strategies for colorectal surgery. Cochrane Database Syst Rev. 2011;(2):CD007635. doi: http://doi.org/10.1002/14651858.cd007635.pub2
Zhuang C-L, Ye X-Z, Zhang X-D, Chen B-C, Yu Z. Enhanced recovery after surgery programs versus traditional care for colorectal surgery: a meta-analysis of randomized controlled trials. Dis Colon Rectum. 2013;56(5):667-8. doi: http://doi.org/10.1097/DCR.0b013e3182812842
Bagnall NM, Malietzis G, Kennedy RH, Athanasiou T, Faiz O, Darzi A. A systematic review of enhanced recovery care after colorectal surgery in elderly patients. Colorectal Disease. 2014. p. 947-56. doi: http://doi.org/10.1111/codi.12718
Ni X, Jia D, Chen Y, Wang L, Suo J. Is the Enhanced Recovery After Surgery (ERAS) Program Effective and safe in laparoscopic colorectal cancer surgery? A Meta-analysis of randomized controlled trials. J Gastrointest Surg Off J Soc Surg Aliment Tract. 2019 Jul;23(7):1502-12. doi: http://doi.org/10.1007/s11605-019-04170-8
Chambers D, Paton F, Wilson P, Eastwood A, Craig D, Fox D, et al. An overview and methodological assessment of systematic reviews and meta-analyses of enhanced recovery programmes in colorectal surgery. BMJ Open. 2014;4(5):e005014. doi: http://doi.org/10.1136/bmjopen-2014-005014
Street AD. Dos estudios unicos en los que se destacan los efectos positivos _de los protocolos ERAS (Recuperación rápida después de cirugía) para la atención y la satisfacción de los pacientes. Colombian Journal of Anesthesiology. 2019;47(1):1-4. doi: http://doi.org/10.1097/cj9.0000000000000094
Copyright (c) 2020 Sociedad Colombiana de Anestesiología y Reanimación (S.C.A.R.E.)
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
The Sociedad Colombiana de Anestesiología y Reanimación (S.C.A.R.E.) is the owner of all copyrights to any articles published in the journal. Published manuscripts become the permanent property of S.C.A.R.E. and may not be published elsewhere without written permission. S.C.A.R.E. keeps the right to use these manuscripts in any form, including print, video, audio and digital.
Creative Commons License
Open-access articles can be read, downloaded and shared on a free basis upon publication. The Journal publishes all articles under the CCBY- NC-ND license. Attribution-NonCommercial-NoDerivs: CC BY- NC-ND. Of the six main licenses, this is the most restrictive because it only allows others to download and share articles as long as they give credit to the author, but they cannot in any way change the paper or use it commercially.