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Enhanced recovery meta-analysis
Kirsty Cattle
Research Registrar
The paper
Introduction
– Enhanced recovery:
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A combination of interventions aimed at reducing
the operative stress response, resulting in faster
recovery
Therefore often called the “fast-track
programme”
– Aim of study:
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The evidence for enhanced recovery comes
from observational studies and consensus
opinion.
Previous systematic review was felt to be
inadequate
Methods
– Define colorectal enhanced recovery
surgery:
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Enhanced recovery elements:
Methods
– Define colorectal enhanced recovery
surgery:
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Enhanced recovery elements:
Include five elements, at least one from each of
pre-, peri- and post-operative period
“A circumferential segmental excision of any
part, or parts, of the colon and or rectum
involving either a primary anastomosis and or
stoma formation”
– Identify randomised controlled trials and
clinical controlled trials by searching:
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Medline, Embase, Cochrane Colorectal Cancer
Group Database, Cochrane Register of
Controlled Trials (CENTRAL)
1966 to 2006
Review of list of references in relevant articles
– Outcomes:
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Primary: total primary length of stay
Secondary:
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Primary length of stay plus length of any readmissions
Readmissions
Morbidity
Mortality
If necessary, data was obtained by contacting
the authors directly
– Analysis:
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Weighted mean difference for continuous data
Relative risk for categorical data
Heterogeneity examined (I2 test)
Results
– 71 papers assessed, 4 papers included in
meta-analysis
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376 patients, 64 within RCTs
11 deaths
– Bias:
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2 RCTs, both from same centre, inadequacies
with randomization
2 CCTs, comparing different centres or wards
Meta-analysis
– Total primary length of stay:
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Included RCT data only, therefore 64 patients
Homogenous studies
Both primary length of stay and total stay
secondary to readmissions reduced in enhanced
recovery groups:
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Primary LOS reduced by 3.64 (95% CI -4.98 to -2.29)
days
Total 30 day LOS reduced by 3.75 (95% CI -5.11 to 2.40) days
– Morbidity:
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Lower relative risk of 30 day morbidity among
enhanced recovery group:
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RR = 0.44, p < 0.0001, combined RCT and CCT data
No statistically significant difference when RCTs
alone examined
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RR= 0.63, p = 0.06, RCT data only
– Mortality:
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No significant difference in mortality rates
between enhanced recovery and standard care
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RR = 0.92, p = 0.93, RCT data
RR = 2.0, p = 0.32, CCT data
– Readmission rates:
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Equivocal data reported
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Lower readmission rates among enhanced recovery
group reported in one RCT, RR = 0.26, p = 0.21
Lower readmission rates among control group
reported from both CCTs, RR = 1.73, p = 0.05
Pooled data: RR 1.46, p = 0.15
Discussion
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Their conclusions match the conclusions of the
previous meta-analysis and support it by being a
stronger meta-analysis
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Exclusion of non-colorectal papers
Lower heterogeneity
Analysis of total 30-day length of stay
Morbidity and mortality data should be interpreted
with caution due to small numbers
Difficult to determine if enhanced recovery gives
better outcomes due to constituent parts or the
overall package
Critique
– Small numbers, only 4 papers, including
only 2 RCTs, both from same centre, 2 years
apart.
– Primary outcome based on RCTs only
– My conclusions:
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More background reading first