Advertisement

Surgical Endoscopy

, Volume 29, Issue 8, pp 2091–2100 | Cite as

Laparoscopic versus open colorectal surgery within enhanced recovery after surgery programs: a systematic review and meta-analysis of randomized controlled trials

  • Cheng-Le Zhuang
  • Dong-Dong Huang
  • Fan-Feng Chen
  • Chong-Jun Zhou
  • Bei-Shi Zheng
  • Bi-Cheng Chen
  • Xian ShenEmail author
  • Zhen YuEmail author
Review

Abstract

Background

Laparoscopic surgery and enhanced recovery after surgery (ERAS) programs were two major improvements for the management of colorectal diseases. The purpose of this systemic review was to examine whether laparoscopic colorectal surgery still improved short-term postoperative outcomes in comparison with open surgery when both groups of patients received ERAS programs.

Methods

PubMed, Embase, the Cochrane Central Register of Controlled Trials, and reference lists of the identified studies were searched to identify randomized clinical trials that compared laparoscopic with open surgery in patients undergoing colorectal resection in the context of ERAS programs. The outcome measures were analyzed, and the quality of evidence for each outcome was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.

Results

Five randomized clinical trials encompassing 598 patients were included in the final analysis. Two of them were multicenter trials. The ERAS programs implemented in the five included trials cannot be classified as optimal ERAS programs, but suboptimal ERAS programs. Laparoscopic colorectal surgery significantly reduced total hospital stay (weighted mean difference (WMD) −1.92 days; 95 % confidence interval (CI) −2.61–−1.23 days; P < 0.00001) and number of complications (relative risk (RR) 0.78; 95 % CI 0.66–0.94; P = 0.007) compared with open surgery in the setting of ERAS programs. No significant differences were found between groups for primary hospital stay, number of patients with complications, readmission rates, and mortality. The quality of evidence for all outcomes was low-to-moderate on the GRADE scale, and none had high quality.

Conclusions

Laparoscopic colorectal resection significantly reduced total hospital stay and number of complications when compared with open surgery in the setting of suboptimal ERAS programs, but the benefits of laparoscopic colorectal resection remain to be proved within optimal ERAS programs.

Keywords

Laparoscopic Enhanced recovery after surgery Fast track Colorectal surgery Systematic review Meta-analysis 

Notes

Acknowledgments

This study was supported by the clinical nutriology of medical supporting discipline of Zhejiang Province (No. 11-ZC24).

Disclosures

Drs. Cheng-Le Zhuang, Dong-Dong Huang, Fan-Feng Chen, Chong-Jun Zhou, Bei-Shi Zheng, Bi-Cheng Chen, Xian Shen and Zhen Yu have no conflicts of interest or financial ties to disclose.

References

  1. 1.
    Kehlet H (2008) Fast-track colorectal surgery. Lancet 371:791–793PubMedCrossRefGoogle Scholar
  2. 2.
    Wick EC, Shore AD, Hirose K, Ibrahim AM, Gearhart SL, Efron J, Weiner JP, Makary MA (2011) Readmission rates and cost following colorectal surgery. Dis Colon Rectum 54:1475–1479PubMedCrossRefGoogle Scholar
  3. 3.
    Jacobs M, Verdeja JC, Goldstein HS (1991) Minimally invasive colon resection (laparoscopic colectomy). Surg Laparosc Endosc 1:144–150PubMedGoogle Scholar
  4. 4.
    Wilmore DW, Kehlet H (2001) Management of patients in fast track surgery. BMJ 322:473–476PubMedCentralPubMedCrossRefGoogle Scholar
  5. 5.
    Braga M, Vignali A, Gianotti L, Zuliani W, Radaelli G, Gruarin P, Dellabona P, Di Carlo V (2002) Laparoscopic versus open colorectal surgery: a randomized trial on short-term outcome. Ann Surg 236:759–766 disscussion 767PubMedCentralPubMedCrossRefGoogle Scholar
  6. 6.
    Reza MM, Blasco JA, Andradas E, Cantero R, Mayol J (2006) Systematic review of laparoscopic versus open surgery for colorectal cancer. Br J Surg 93:921–928PubMedCrossRefGoogle Scholar
  7. 7.
    Guillou PJ, Quirke P, Thorpe H, Walker J, Jayne DG, Smith AM, Heath RM, Brown JM (2005) Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet 365:1718–1726PubMedCrossRefGoogle Scholar
  8. 8.
    Clinical Outcomes of Surgical Therapy Study Group (2004) A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med 350:2050–2059CrossRefGoogle Scholar
  9. 9.
    Bardram L, Funch-Jensen P, Jensen P, Crawford ME, Kehlet H (1995) Recovery after laparoscopic colonic surgery with epidural analgesia, and early oral nutrition and mobilisation. Lancet 345:763–764PubMedCrossRefGoogle Scholar
  10. 10.
    Zhuang CL, Ye XZ, Zhang XD, Chen BC, Yu Z (2013) Enhanced recovery after surgery programs versus traditional care for colorectal surgery: a meta-analysis of randomized controlled trials. Dis Colon Rectum 56:667–678PubMedCrossRefGoogle Scholar
  11. 11.
    Kehlet H, Wilmore DW (2008) Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg 248:189–198PubMedCrossRefGoogle Scholar
  12. 12.
    Basse L, Hjort Jakobsen D, Billesbolle P, Werner M, Kehlet H (2000) A clinical pathway to accelerate recovery after colonic resection. Ann Surg 232:51–57PubMedCentralPubMedCrossRefGoogle Scholar
  13. 13.
    Kehlet H, Mogensen T (1999) Hospital stay of 2 days after open sigmoidectomy with a multimodal rehabilitation programme. Br J Surg 86:227–230PubMedCrossRefGoogle Scholar
  14. 14.
    Bardakcioglu O, Khan A, Aldridge C, Chen J (2013) Growth of laparoscopic colectomy in the United States: analysis of regional and socioeconomic factors over time. Ann Surg 258:270–274PubMedCrossRefGoogle Scholar
  15. 15.
    Braga M, Frasson M, Vignali A, Zuliani W, Di Carlo V (2007) Open right colectomy is still effective compared to laparoscopy: results of a randomized trial. Ann Surg 246:1010–1014 discussion 1014–1015PubMedCrossRefGoogle Scholar
  16. 16.
    Tekkis PP, Senagore AJ, Delaney CP, Fazio VW (2005) Evaluation of the learning curve in laparoscopic colorectal surgery: comparison of right-sided and left-sided resections. Ann Surg 242:83–91PubMedCentralPubMedCrossRefGoogle Scholar
  17. 17.
    Bailey MB, Davenport DL, Vargas HD, Evers BM, McKenzie SP (2014) Longer operative time: deterioration of clinical outcomes of laparoscopic colectomy versus open colectomy. Dis Colon Rectum 57:616–622PubMedCrossRefGoogle Scholar
  18. 18.
    Moher D, Liberati A, Tetzlaff J, Altman DG (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 339:b2535PubMedCentralPubMedCrossRefGoogle Scholar
  19. 19.
    Nygren J, Thacker J, Carli F, Fearon KC, Norderval S, Lobo DN, Ljungqvist O, Soop M, Ramirez J (2012) Guidelines for perioperative care in elective rectal/pelvic surgery: enhanced Recovery After Surgery (ERAS(R)) Society recommendations. Clin Nutr 31:801–816PubMedCrossRefGoogle Scholar
  20. 20.
    Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N, McNaught CE, MacFie J, Liberman AS, Soop M, Hill A, Kennedy RH, Lobo DN, Fearon K, Ljungqvist O (2012) Guidelines for perioperative care in elective colonic surgery: enhanced Recovery After Surgery (ERAS(R)) Society recommendations. Clin Nutr 31:783–800PubMedCrossRefGoogle Scholar
  21. 21.
    Higgins JPT, S G (2011) Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane CollaborationGoogle Scholar
  22. 22.
    Huedo-Medina TB, Sanchez-Meca J, Marin-Martinez F, Botella J (2006) Assessing heterogeneity in meta-analysis: Q statistic or I2 index? Psychol Methods 11:193–206PubMedCrossRefGoogle Scholar
  23. 23.
    Higgins JP, Thompson SG (2002) Quantifying heterogeneity in a meta-analysis. Stat Med 21:1539–1558PubMedCrossRefGoogle Scholar
  24. 24.
    Egger M, Davey Smith G, Schneider M, Minder C (1997) Bias in meta-analysis detected by a simple, graphical test. BMJ 315:629–634PubMedCentralPubMedCrossRefGoogle Scholar
  25. 25.
    Atkins D, Best D, Briss PA, Eccles M, Falck-Ytter Y, Flottorp S, Guyatt GH, Harbour RT, Haugh MC, Henry D, Hill S, Jaeschke R, Leng G, Liberati A, Magrini N, Mason J, Middleton P, Mrukowicz J, O’Connell D, Oxman AD, Phillips B, Schunemann HJ, Edejer TT, Varonen H, Vist GE, Williams JW Jr, Zaza S (2004) Grading quality of evidence and strength of recommendations. BMJ 328:1490PubMedCrossRefGoogle Scholar
  26. 26.
    Kennedy RH, Francis EA, Wharton R, Blazeby JM, Quirke P, West NP, Dutton SJ (2014) Multicenter Randomized Controlled Trial of Conventional Versus Laparoscopic Surgery for Colorectal Cancer Within an Enhanced Recovery Programme: EnROL. J Clin Oncol 32(17):1804–1811PubMedCrossRefGoogle Scholar
  27. 27.
    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 16:1379–1388PubMedCrossRefGoogle Scholar
  28. 28.
    Vlug MS, Wind J, Hollmann MW, Ubbink DT, Cense HA, Engel AF, Gerhards MF, van Wagensveld BA, van der Zaag ES, van Geloven AA, Sprangers MA, Cuesta MA, Bemelman WA (2011) Laparoscopy in combination with fast track multimodal management is the best perioperative strategy in patients undergoing colonic surgery: a randomized clinical trial (LAFA-study). Ann Surg 254:868–875PubMedCrossRefGoogle Scholar
  29. 29.
    King PM, Blazeby JM, Ewings P, Franks PJ, Longman RJ, Kendrick AH, Kipling RM, Kennedy RH (2006) Randomized clinical trial comparing laparoscopic and open surgery for colorectal cancer within an enhanced recovery programme. Br J Surg 93:300–308PubMedCrossRefGoogle Scholar
  30. 30.
    Basse L, Jakobsen DH, Bardram L, Billesbolle P, Lund C, Mogensen T, Rosenberg J, Kehlet H (2005) Functional recovery after open versus laparoscopic colonic resection: a randomized, blinded study. Ann Surg 241:416–423PubMedCentralPubMedCrossRefGoogle Scholar
  31. 31.
    Cakir H, van Stijn MF, Lopes Cardozo AM, Langenhorst BL, Schreurs WH, van der Ploeg TJ, Bemelman WA, Houdijk AP (2013) Adherence to enhanced recovery after surgery and length of stay after colonic resection. Colorectal Dis 15:1019–1025PubMedCrossRefGoogle Scholar
  32. 32.
    Gustafsson UO, Hausel J, Thorell A, Ljungqvist O, Soop M, Nygren J (2011) Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Arch Surg 146:571–577PubMedCrossRefGoogle Scholar
  33. 33.
    Zhuang CL, Ye XZ, Zhang CJ, Dong QT, Chen BC, Yu Z (2013) Early versus traditional postoperative oral feeding in patients undergoing elective colorectal surgery: a meta-analysis of randomized clinical trials. Dig Surg 30:225–232PubMedCrossRefGoogle Scholar
  34. 34.
    Smart NJ, White P, Allison AS, Ockrim JB, Kennedy RH, Francis NK (2012) Deviation and failure of enhanced recovery after surgery following laparoscopic colorectal surgery: early prediction model. Colorectal Dis 14:e727–e734PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Cheng-Le Zhuang
    • 1
  • Dong-Dong Huang
    • 1
  • Fan-Feng Chen
    • 1
  • Chong-Jun Zhou
    • 1
  • Bei-Shi Zheng
    • 1
  • Bi-Cheng Chen
    • 2
  • Xian Shen
    • 1
    Email author
  • Zhen Yu
    • 1
    • 3
    Email author
  1. 1.Department of Gastrointestinal SurgeryThe First Affiliated Hospital, Wenzhou Medical UniversityWenzhouChina
  2. 2.Wenzhou Key Laboratory of SurgeryThe First Affiliated Hospital, Wenzhou Medical UniversityWenzhouChina
  3. 3.Department of Gastrointestinal SurgeryShanghai Tenth People’s Hospital Affiliated to Tongji UniversityShanghaiChina

Personalised recommendations