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Enhanced recovery program versus conventional care after colorectal surgery in the geriatric population: a systematic review and meta-analysis

  • 2020 SAGES Poster
  • Published:
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Abstract

Introduction

Enhanced recovery after surgery (ERAS) programs for patients undergoing colorectal surgery has yielded promising results. However, there remains controversy regarding the application of ERAS protocols in an elderly population. The aim of this review is to compare the clinical outcomes between ERAS versus conventional peri-operative care (Non-ERAS) for colorectal surgery in patients aged ≥ 65 years old.

Methods

The PRISMA guidelines were adhered to. A comprehensive search was performed using Medline, Embase and the Cochrane Library electronic databases and relevant articles were identified. Indications for the colorectal resections included both benign and malignant diseases, while emergency surgeries were excluded. Primary outcomes include post-operative morbidity, length of stay and re-admission rates. Data analysis was performed using Revman 5.3.

Results

A total of six studies were included, which involved a total of 1174 patients. ERAS was associated with a lower incidence of post-operative morbidity compared to Non-ERAS (OR 0.38, 95% CI 0.25–0.59), p < 0.001). Similarly, ERAS was also associated with a significantly shorter hospital length of stay (MD − 2.49, 95% CI − 4.11 to 0.88, p = 0.002). Return of bowel function as measured by time to flatus was significantly faster in the ERAS group (MD − 20.01 95% CI − 36.23 to 3.79, p = 0.02), but post-operative ileus rates (OR 0.86, 95% CI 0.50–1.47, p = 0.58) were comparable. Re-admission, re-operation and post-operative mortality rates were also similar between both groups.

Conclusion

The application of ERAS protocols in an elderly population provides the advantages of lower post-operative morbidity and shorter hospital length of stay. Future studies should aim to evaluate factors that can improve ERAS compliance rates in this group of patients.

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References

  1. Ljungqvist O, Scott M, Fearon KC (2017) Enhanced recovery after surgery: a review. JAMA Surg 152(3):292–298

    Article  Google Scholar 

  2. Kehlet H, Slim K (2012) The future of fast-track surgery. Br J Surg 99(8):1025–1026

    Article  CAS  Google Scholar 

  3. Wind J, Polle SW, FungKonJin PH, Dejong CH, von Meyenfeldt MF, Ubbink DT, Gouma DJ, Bemelman WA, Laparoscopy and/or Fast Track Multimodal Management Versus Standard Care (LAFA) Study Group; Enhanced Recovery after Surgery (ERAS) Group (2006) Systematic review of enhanced recovery programmes in colonic surgery. Br J Surg 93(7):800–809

    Article  CAS  Google Scholar 

  4. Dhruva Rao PK, Howells S, Haray PN (2015) Does an enhanced recovery programme add value to laparoscopic colorectal resections? Int J Colorectal Dis 30(11):1473–1477

    Article  CAS  Google Scholar 

  5. Meillat H, Brun C, Zemmour C, de Chaisemartin C, Turrini O, Faucher M, Lelong B (2019) Laparoscopy is not enough: full ERAS compliance is the key to improvement of short-term outcomes after colectomy for cancer. Surg Endosc. https://doi.org/10.1007/s00464-019-06987-5

    Article  PubMed  Google Scholar 

  6. Ni X, Jia D, Chen Y, Wang L, Suo J (2019) 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 23(7):1502–1512

    Article  Google Scholar 

  7. Ripollés-Melchor J, Ramírez-Rodríguez JM, Casans-Francés R, Aldecoa C, Abad-Motos A, Logroño-Egea M, García-Erce JA, Camps-Cervantes Á, Ferrando-Ortolá C, Suarez de la Rica A, Cuellar-Martínez A, Marmaña-Mezquita S, Abad-Gurumeta A, Calvo-Vecino JM, POWER Study Investigators Group for the Spanish Perioperative Audit, and Research Network (REDGERM) (2019) Association between use of enhanced recovery after surgery protocol and postoperative complications in colorectal surgery: the postoperative outcomes within enhanced recovery after surgery protocol (POWER) study. JAMA Surg. https://doi.org/10.1001/jamasurg.2019.0995

    Article  PubMed  PubMed Central  Google Scholar 

  8. Ban KA, Berian JR, Ko CY (2019) Does implementation of enhanced recovery after surgery (ERAS) protocols in colorectal surgery improve patient outcomes? Clin Colon Rectal Surg 32(2):109–113

    Article  Google Scholar 

  9. Stone AB, Grant MC, Wu CL, Wick EC (2019) Enhanced recovery after surgery for colorectal surgery: a review of the economic implications. Clin Colon Rectal Surg 32(2):129–133

    Article  Google Scholar 

  10. Bentrem DJ, Cohen ME, Hynes DM, Ko CY, Bilimoria KY (2009) Identification of specific quality improvement opportunities for the elderly undergoing gastrointestinal surgery. Arch Surg 144(11):1013–1020

    Article  Google Scholar 

  11. Finlayson E, Zhao S, Boscardin WJ, Fries BE, Landefeld CS, Dudley RA (2012) Functional status after colon cancer surgery in elderly nursing home residents. J Am Geriatr Soc 60(5):967–973

    Article  Google Scholar 

  12. Lawrence VA, Hazuda HP, Cornell JE, Pederson T, Bradshaw PT, Mulrow CD, Page CP (2004) Functional independence after major abdominal surgery in the elderly. J Am Coll Surg 199(5):762–772

    Article  Google Scholar 

  13. Dworsky JQ, Childers CP, Maggard-Gibbons M, Russell MM (2018) High-risk colorectal surgery: what are the outcomes for geriatric patients? Am Surg 84(10):1650–1654

    Article  Google Scholar 

  14. Gustafsson UO, Scott MJ, Hubner M, Nygren J, Demartines N, Francis N, Rockall TA, Young-Fadok TM, Hill AG, Soop M, de Boer HD (2019) Guidelines for perioperative care in elective colorectal surgery: Enhanced Recovery After Surgery (ERAS®) society recommendations: 2018. World J Surg 43(3):659–695

    Article  CAS  Google Scholar 

  15. Carmichael JC, Keller DS, Baldini G, Bordeianou L, Weiss E, Lee L, Boutros M, McClane J, Feldman LS, Steele SR (2017) Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon Rectum 60(8):761–784

    Article  Google Scholar 

  16. Tan KY, Kawamura YJ, Tokomitsu A, Tang T (2012) Assessment for frailty is useful for predicting morbidity in elderly patients undergoing colorectal cancer resection whose comorbidities are already optimized. Am J Surg 204(2):139–143

    Article  Google Scholar 

  17. Marusch F, Koch A, Schmidt U, Steinert R, Ueberrueck T, Bittner R, Berg E, Engemann R, Gellert K, Arbogast R, Körner T, Köckerling F, Gastinger I, Lippert H, Working Group Colon/Rectum Cancer (2005) The impact of the risk factor "age" on the early postoperative results of surgery for colorectal carcinoma and its significance for perioperative management. World J Surg. 29(8):1013–1021

    Article  Google Scholar 

  18. Messenger DE, Curtis NJ, Jones A, Jones EL, Smart NJ, Francis NK (2017) Factors predicting outcome from enhanced recovery programmes in laparoscopic colorectal surgery: a systematic review. Surg Endosc 31(5):2050–2071

    Article  Google Scholar 

  19. Moher D, Liberati A, Tetzlaff J, Altman DG (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med 151(4):264–269

    Article  Google Scholar 

  20. Higgins JP, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, Savović J, Schulz KF, Weeks L, Sterne JA (2011) The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ 343:d5928

    Article  Google Scholar 

  21. Wells G, Shea B, O'Connell D, Peterson J, Welch V, Losos M, et al (2013) https://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. https://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. Accessed 5 May, 2020

  22. Jia Y, Jin G, Guo S, Gu B, Jin Z, Gao X, Li Z (2014) Fast-track surgery decreases the incidence of postoperative delirium and other complications in elderly patients with colorectal carcinoma. Langenbeck's Arch Surg 399(1):77–84

    Article  Google Scholar 

  23. Ostermann S, Morel P, Chalé JJ, Bucher P, Konrad B, Meier RP, Ris F, Schiffer ER (2019) Randomized controlled trial of enhanced recovery program dedicated to elderly patients after colorectal surgery. Dis Colon Rectum 62(9):1105–1116

    Article  Google Scholar 

  24. Wang Q, Suo J, Jiang J, Wang C, Zhao YQ, Cao X (2012) Effectiveness of fast-track rehabilitation vs conventional care in laparoscopic colorectal resection for elderly patients: a randomized trial. Colorectal Dis 14(8):1009–1013

    Article  CAS  Google Scholar 

  25. Tejedor P, Pastor C, Gonzalez-Ayora S, Ortega-Lopez M, Guadalajara H, Garcia-Olmo D (2018) Short-term outcomes and benefits of ERAS program in elderly patients undergoing colorectal surgery: a case-matched study compared to conventional care. Int J Colorectal Dis 33(9):1251–1258

    Article  Google Scholar 

  26. Zeng WG, Liu MJ, Zhou ZX, Wang ZJ (2018) Enhanced recovery programme following laparoscopic colorectal resection for elderly patients. ANZ J Surg 88(6):582–586

    Article  Google Scholar 

  27. Millan M, Espina-Perez B, Caro-Tarrago A, Jorba-Martin R (2018) ERAS programs in elderly patients: is there a limit? Int J Colorectal Dis 33(9):1313

    Article  Google Scholar 

  28. Bagnall NM, Malietzis G, Kennedy RH, Athanasiou T, Faiz O, Darzi A (2014) A systematic review of enhanced recovery care after colorectal surgery in elderly patients. Colorectal Dis 16(12):947–956

    Article  CAS  Google Scholar 

  29. Fagard K, Wolthuis A, D'Hoore A, Verhaegen M, Tournoy J, Flamaing J, Deschodt M (2019) A systematic review of the intervention components, adherence and outcomes of enhanced recovery programmes in older patients undergoing elective colorectal surgery. BMC Geriatr 19(1):157

    Article  Google Scholar 

  30. Veenhof AA, Vlug MS, van der Pas MH, Sietses C, van der Peet DL, de Lange-de Klerk ES, Bonjer HJ, Bemelman WA, Cuesta MA (2012) Surgical stress response and postoperative immune function after laparoscopy or open surgery with fast track or standard perioperative care: a randomized trial. Ann Surg 255(2):216–221

    Article  CAS  Google Scholar 

  31. Wang G, Jiang Z, Zhao K, Li G, Liu F, Pan H, Li J (2012) Immunologic response after laparoscopic colon cancer operation within an enhanced recovery program. J Gastrointest Surg 16(7):1379–1388

    Article  Google Scholar 

  32. Salo M (1992) Effects of anaesthesia and surgery on the immune response. Acta Anaesthesiol Scand 36(3):201–220

    Article  CAS  Google Scholar 

  33. Shigemitsu Y, Saito T, Kinoshita T, Kobayashi M (1992) Influence of surgical stress on bactericidal activity of neutrophils and complications of infection in patients with esophageal cancer. J Surg Oncol 50(2):90–97

    Article  CAS  Google Scholar 

  34. Nicholson A, Lowe MC, Parker J, Lewis SR, Alderson P, Smith AF (2014) Systematic review and meta-analysis of enhanced recovery programmes in surgical patients. Br J Surg 101(3):172–188

    Article  CAS  Google Scholar 

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Authors and Affiliations

  1. Division of Colorectal Surgery, University Surgical Cluster, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore

    Jarrod Kah Hwee Tan, Jia Jun Ang & Dedrick Kok Hong Chan

  2. Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore

    Dedrick Kok Hong Chan

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  1. Jarrod Kah Hwee Tan
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  2. Jia Jun Ang
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Correspondence to Dedrick Kok Hong Chan.

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Tan, J.K.H., Ang, J.J. & Chan, D.K.H. Enhanced recovery program versus conventional care after colorectal surgery in the geriatric population: a systematic review and meta-analysis. Surg Endosc 35, 3166–3174 (2021). https://doi.org/10.1007/s00464-020-07673-7

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