A systematic review of the intervention components, adherence and outcomes of enhanced recovery programmes in older patients undergoing elective colorectal surgery

Abstract

Background Enhanced recovery programmes (ERPs) aim to attenuate the surgical stress response and accelerate recovery after surgery, but are not specifically designed for older patients. The objective of this study was to review the components, adherence and outcomes of ERPs in older patients (≥65 years) undergoing elective colorectal surgery. Methods Pubmed, Embase and Cinahl were searched between 2000 and 2017 for randomised and non-randomised controlled trials, before-after studies, and observational studies. The methodological quality of the studies was evaluated using the MINORS quality assessment. The review was performed and reported according to the PRISMA guidelines. Results Twenty-one studies, including 3495 ERP patients aged ≥65 years, were identified. The ERPs consisted of a median of 13 intervention components. Adherence rates were reported in 9 studies and were the highest (≥80%) for pre-admission counselling, no bowel preparation, limited pre-operative fasting, antithrombotic and antimicrobial prophylaxis, no nasogastric tube, active warming, and limited intra-operative fluids. The median post-operative length of stay was 6 days. The median post-operative morbidity rate (Clavien-Dindo I-IV) was 23.5% in-hospital and 29.8% at 30 days. The in-hospital post-operative mortality rate was 0% in most studies and amounted to a median of 1.4% at 30 days. The median 30-day readmission rate was 4.9% and the median reoperation rate was 5.0%. Conclusions ERPs in older patients were in accordance with the ERP consensus guidelines. Although the number of intervention components applied increased over time, outcomes in earlier and later studies remained comparable. Adherence rates were under-reported. Future studies should explore adherence and age-related factors, such as frailty profile, that could influence adherence. Trial registration PROSPERO 2018 CRD42018084756 . Electronic supplementary material The online version of this article (10.1186/s12877-019-1158-3) contains supplementary material, which is available to authorized users.

A retrospective observational study of enhanced recovery after surgery in older patients undergoing elective colorectal surgery

“…We have not found any study reporting the Comprehensive Complication Index in older patients undergoing elective colorectal surgery to compare our results with. The median postoperative LOS in this study was 1 day longer than the median postoperative LOS in our review [12]. This might be explained by variations in in-and exclusion criteria between our study and some of the studies included in the review, e.g.…”

“…Overall postoperative complication rates and median postoperative LOS were quite high. In a review performed by our team that summarized outcomes of ERPs in older patients (� 65 years) after colorectal surgery, the median overall morbidity was 23.5% and the median postoperative LOS was 6 days [12]. Conducting this review showed that it is challenging to compare postoperative complications among studies, because in-and exclusion criteria differ and because complications are not defined or assessed in a uniform way.…”

“…A recent meta-analysis has demonstrated that ERPs in colorectal surgery are associated with a significant reduction in LOS, postoperative complications, total cost of hospital stay, as well as earlier return of gastro-intestinal function, without increasing 30-day readmission or mortality rates [9]. However, ERPs were not specifically designed for frail older patients and data from these programs in older patients are scarce [10][11][12]. It might be necessary to adapt ERPs for older patients with multi-morbidity, functional, cognitive or psychosocial problems.…”

Multidisciplinary management of elderly patients with rectal cancer: recommendations from the SICG (Italian Society of Geriatric Surgery), SIFIPAC (Italian Society of Surgical Pathophysiology), SICE (Italian Society of Endoscopic Surgery and new technologies), and the WSES (World Society of Emergency Surgery) International Consensus Project

“…This review’s most critical methodological flaw was that only six studies included older patients or subgroups of older patients. Furthermore, the older patients included may be subject to selection bias, as mainly physically and mentally fit patients tend to be recruited in the included studies [ 114 ].…”

Decreasing Readmissions After Ileostomy Creation Through a Perioperative Quality Improvement Program

“…In 2012, the Hospital Readmissions Reduction Program from the Centers for Medicare and Medicaid Services was enacted as part of the Affordable Care Act with the aim of reducing unplanned hospital readmissions and improving the quality of care at discharge. 1 Many health care institutions have developed enhanced recovery after surgery (ERAS) protocols for quality improvement after elective colorectal surgeries, [2][3][4] which have been successful in decreasing postoperative complication rates and shortening the length of stay in the hospital. However, 30-day readmission after ileostomy creation in patients undergoing colorectal surgery remains as high as 43% and has not decreased due to the implementation of ERAS.…”