Evidence-based Synthesis Program (ESP) Center, Minneapolis VA Health Care System, Minneapolis, MN
Timothy J. Wilt, MD, MPH, Director
Greer N, Sultan S, Shaukat A, Dahm P, Lee A, MacDonald R, McKenzie L, Ercan-Fang D, Wilt, TJ. Enhanced Recovery After Surgery (ERAS) Programs for Patients Undergoing Colorectal Surgery. VA ESP Project #09-009; 2017.
Enhanced recovery after surgery (ERAS), also referred to as an enhanced recovery program, fast-track rehabilitation, multimodal management, or similar descriptors, is a multidisciplinary approach to perioperative care. A protocol of components related to preadmission, preoperative, intraoperative, and postoperative care is implemented with the goal of improving patient recovery, facilitating earlier discharge from the hospital, and potentially reducing health care costs without increasing complications or hospital readmissions. The protocol components may contribute to minimizing, and/or improving the response to, physiological stress associated with surgery.
Although guidelines for ERAS related to colorectal surgery exist, variation in the number and definition of protocol components contributes to difficulties in determining effectiveness. Little is known about implementation barriers and facilitators as well as components (or combinations of components) key for improved clinical outcomes. In addition, protocol compliance, when reported, may be measured by percentage of elements applied or completed without standardization across elements (timing, regimens, doses, etc).
Preliminary literature searches conducted for topic refinement found several systematic reviews on enhanced recovery for colorectal surgery. However, none reported on subgroups based on surgical approach (open or laparoscopic surgery) or colorectal condition. While several noted the enhanced recovery protocol components from the included studies, the standard care protocols were not documented. None commented on barriers or facilitators to implementation of an enhanced recovery program.
The defining components of an enhanced recovery program for colorectal surgery have been revised over time and new trials have been published since the search dates of the existing reviews. We provide an updated review of randomized controlled trials (RCTs) and controlled clinical trials (CCTs) looking at comparative effectiveness and harms overall and by type of surgery, colorectal condition, and fidelity to an enhanced recovery protocol. We also review barriers and facilitators to implementation and provide a contextual discussion of compliance and outcomes.
KQ1: What is the comparative effectiveness of ERAS versus usual care or a subset of ERAS components for adults undergoing elective colorectal surgery?
KQ2: What are the harms of ERAS versus usual care or a subset of ERAS components for adults undergoing elective colorectal surgery?
KQ3: Do comparative effectiveness and harms vary by fidelity to ERAS components?
KQ4: Do comparative effectiveness and harms vary by type of, and clinical conditions for, colorectal surgery (eg, anatomical site, laparoscopic versus open surgery, reasons for open surgery, etc)?
KQ5: What are the barriers to and facilitators of implementation of ERAS programs?