Abstract
Objective
To perform a systematic review of published literature for the factors reported to predict outcomes of enhanced recovery after surgery (ERAS) programmes following laparoscopic colorectal surgery.
Background
ERAS programmes and the use of laparoscopy have been widely adopted in colorectal surgery bringing short-term patient benefit. However, there is a minority of patients that do not benefit from these strategies and their identification is not well characterised. The factors that underpin outcomes from ERAS programmes for laparoscopic patients are not understood.
Methods
A systematic search of the MEDLINE, Embase and Cochrane databases was conducted to identify suitable articles published between 2000 and 2015. The search strategy captured terms for ERAS, colorectal resection, prediction and outcome measures.
Results
Thirty-four studies containing 10,861 laparoscopic resections were included. Thirty-one (91 %) studies were confined to elective cases. Predictive analysis of outcome was most frequently based on length of stay (LOS), morbidity and readmission which were the main outcome measures of 29 (85 %), 26 (76 %) and 18 (53 %) of the included studies, respectively. Forty-seven percentage of included studies investigated the impact of ERAS programme compliance on these outcomes. Reduced protocol compliance was the most frequently identified modifiable predictive factor for adverse LOS, morbidity and readmission.
Conclusion
Protocol compliance is the most frequently reported predictive factor for outcomes of ERAS programmes following laparoscopic colorectal resection. Reduced compliance increases LOS, morbidity and readmission to hospital. The impact of compliance with individual ERAS protocol elements is insufficiently studied, and the lack of a standardised framework for evaluating ERAS programmes makes it difficult to draw definite conclusions about which factors exert the greatest impact on outcome after laparoscopic colorectal resection.
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David E. Messenger, Nathan J. Curtis, Adam Jones, Emma L. Jones, Neil J. Smart and Nader K. Francis have no conflicts of interest or financial ties to disclose.
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David E. Messenger and Nathan J. Curtis have contributed equally to this manuscript and share first authorship.
Appendices
Appendix 1
Search terms used to identify studies for inclusion in the review. Four sets of search criteria were used and were combined using the Boolean operator ‘AND’
Enhanced recovery after surgery |
enhanced recovery.tw. OR eras.tw. OR rapid recovery.tw. OR (fast and track).tw. OR multimodal.tw. OR multi-modal.tw. OR accelerated discharge.tw. OR early discharge.tw. OR early rehabilitation.tw OR clinical pathway.tw. OR accelerated pathway.tw. OR integrated care pathway.tw |
Colorectal resection |
colorectal.tw. OR colo-rectal.tw. OR colo-rectal cancer.tw. OR colorectal cancer.tw. OR CRC.tw. OR bowel.tw. OR bowel resect$.tw. OR bowel surg$.tw. OR colon$.tw. OR rect$.tw. OR proctectomy.tw. OR colectomy.tw. OR segmental colectomy.tw. |
Prediction |
Prognostic.tw. OR prognosis.tw. OR predictive.tw. OR predict$.tw. OR risk.tw. OR risk factor.tw. OR risk factors.tw. OR early detection.tw. OR early warning.tw. OR risk.mp OR predict$.mp. OR impact.tw. |
Outcome measures |
length of stay.tw. OR exp ‘Length of Stay’/OR hospital stay.tw. OR length of hospital stay.tw. OR Patient Discharge.tw. OR patient stay.mp. OR discharge.mp. OR re-admission.tw. OR readmission.tw. OR morbid$.tw OR Postoperative Complications/co, me, mi, mo, ph, pp, su, ur, vi OR (return and to).mp. and theatre.tw. OR complication$.tw. OR mortal$.tw. OR *Neoplasms/OR *Aged/OR *Opportunistic Infections/OR success$.mp. OR failure$.mp. OR Quality of Life.tw. OR qol.tw. OR hrql.tw. OR hrqol.tw. OR patient reported outcome.tw. OR patient-reported outcome.tw. OR patient reported outcome measure.tw. OR patient-reported outcome measure.tw. OR health stat$.tw. OR health stat*.tw. OR PRO.mp. OR PROM.mp. OR pain.mp. OR Pain/cl, co, di, dt, et, hi, im, me, mi, mo, nu, pa, ph, pp, pc, px, rt, st, su OR physical function.tw. OR fatigue.tw. OR well being.tw. OR well-being.tw. OR Euroqol.tw. OR EQ-5D.tw. OR EQ-3D.tw. OR Gastrointestinal quality of life index.tw. OR GIQLI.tw. OR SF-36.tw |
Appendix 2: Data extraction form
Appendix 3
Cochrane Collaboration’s tool for assessing risk of bias in randomised studies 28 included in the review
Author, journal | Selection bias | Performance bias | Detection bias | Attrition bias | Reporting bias | Other bias | |
|---|---|---|---|---|---|---|---|
Random sequence generation | Allocation concealment | ||||||
King et al., Br J Surg [39] (and King et al., Int J Col Dis [40]) | + | ? | − | − | + | + | + |
Levy et al., Br J Surg [41] | + | + | − | − | + | + | + |
Wongyingsinn et al., Reg Anesth Pain Med [42] | + | + | − | + | + | + | + |
Wongyingsinn et al., Br J Anaesth [43] | + | + | − | − | + | + | + |
Zakhaleva et al., Colorectal Dis [44] | + | + | − | − | − | + | − |
Ihedioha et al., Colorectal Dis [45] | + | ? | ? | ? | + | ? | ? |
Kennedy et al., J Clin Onc [46] | + | + | + | ? | + | + | + |
Gillis et al., Anesthesiology [47] | + | + | − | + | + | + | + |
Appendix 4
The MINORS criteria [29] and scores applied to non-randomised studies included in the review
Author, journal | A clearly stated aim | Inclusion of consecutive patients | Prospective collection of data | Endpoints appropriate to the aim of the study | Unbiased assessment of the study endpoint | Follow-up period appropriate to the aim of the study | Loss to follow-up of less than 5 % | Prospective calculation of the study size | Additional criteria for comparative studies | Total | |||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
An adequate control group | Contemporary groups | Baseline equivalence of groups | Adequate statistical analyses | ||||||||||
Loftus, J Healthcare Qual [48] | 2 | 1 | 0 | 2 | 1 | 2 | 2 | 0 | 1 | 0 | 1 | 2 | 14 |
Senagore, Arch Surg [49] | 1 | 2 | 1 | 1 | 0 | 2 | 2 | 0 | 2 | 2 | 0 | 1 | 14 |
Conaghan, Surg Endosc [50] | 1 | 2 | 2 | 0 | 0 | 1 | 2 | 0 | 1 | 2 | 1 | 1 | 13 |
Pawa, World J Surg [51] | 1 | 2 | 1 | 2 | 0 | 2 | 2 | 0 | 1 | 2 | 0 | 1 | 14 |
Gorissen, Br J Surg [52] | 1 | 2 | 0 | 2 | 0 | 1 | 1 | 0 | 1 | 2 | 1 | 2 | 13 |
Zittel, Dis Colon Rectum [53] | 2 | 0 | 1 | 2 | 0 | 1 | 1 | 0 | 1 | 2 | 2 | 2 | 14 |
Lohsiriwat, Tech Coloproctol [54] | 1 | 2 | 2 | 2 | 0 | 2 | 2 | 0 | 2 | 2 | 0 | 1 | 16 |
Martin, Surg Endosc [55] | 2 | 2 | 1 | 2 | 0 | 2 | 2 | 0 | 1 | 0 | 1 | 2 | 15 |
Walter, Surgeon [58] | 2 | 1 | 2 | 2 | 0 | 1 | 1 | 0 | NA | NA | NA | NA | 9 |
Gustafsson et al., Arch Surg [32] | 1 | 2 | 2 | 2 | 1 | 2 | 2 | 0 | NA | NA | NA | NA | 12 |
ERAS Compliance Group, Ann Surg [34] | 2 | 2 | 2 | 2 | 0 | 2 | 2 | 2 | NA | NA | NA | NA | 14 |
Smart et al., Colorectal Dis [57] | 2 | 2 | 0 | 2 | 0 | 2 | 2 | 0 | NA | NA | NA | NA | 10 |
Chand, Int J Surg [56] | 2 | 2 | 2 | 0 | 0 | 2 | 2 | 0 | NA | NA | NA | NA | 10 |
Vlug et al., Colorectal Dis [59] | 2 | 2 | 2 | 2 | 1 | 2 | 2 | 2 | NA | NA | NA | NA | 15 |
Aarts et al., Surg Endosc [60] | 2 | 2 | 2 | 2 | 0 | 2 | 2 | 0 | NA | NA | NA | NA | 12 |
Srinivasa et al., ANZ J Surg [61] | 1 | 2 | 0 | 2 | 0 | 2 | 2 | 0 | NA | NA | NA | NA | 9 |
Lane et al., Colorectal Dis [62] | 1 | 2 | 2 | 2 | 0 | 2 | 2 | 0 | NA | NA | NA | NA | 11 |
Feroci et al., Int J Colorectal Dis [63] | 1 | 2 | 2 | 2 | 0 | 2 | 2 | 0 | NA | NA | NA | NA | 11 |
Cakir et al., Colorectal Dis [64] | 1 | 2 | 0 | 2 | 0 | 2 | 2 | 0 | NA | NA | NA | NA | 9 |
Rossi et al., World J Surg [65] | 2 | 2 | 2 | 2 | 0 | 2 | 2 | 0 | NA | NA | NA | NA | 12 |
Keller et al., Surg Endosc [66] | 1 | 2 | 1 | 2 | 0 | 2 | 2 | 0 | NA | NA | NA | NA | 10 |
Agrafiotis et al., Int J Colorectal Dis [67] | 1 | 2 | 0 | 2 | 0 | 2 | 0 | 0 | NA | NA | NA | NA | 7 |
Larson et al., Br J Surg [68] | 2 | 2 | 1 | 2 | 0 | 1 | 2 | 0 | NA | NA | NA | NA | 10 |
Oh, Surg Endosc [69] | 1 | 2 | 1 | 2 | 0 | 2 | 2 | 0 | NA | NA | NA | NA | 10 |
Bakker, Surgery [70] | 1 | 2 | 2 | 1 | 0 | 2 | 2 | 0 | NA | NA | NA | NA | 10 |
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Messenger, D.E., Curtis, N.J., Jones, A. et al. Factors predicting outcome from enhanced recovery programmes in laparoscopic colorectal surgery: a systematic review. Surg Endosc 31, 2050–2071 (2017). https://doi.org/10.1007/s00464-016-5205-2
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DOI: https://doi.org/10.1007/s00464-016-5205-2