Abstract
BackgroundEnhanced 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.MethodsPubmed, 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.ResultsTwenty-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%.ConclusionsERPs 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 registrationPROSPERO 2018 CRD42018084756.
Highlights
Enhanced recovery programmes (ERPs) aim to attenuate the surgical stress response and accelerate recovery after surgery, but are not designed for older patients
Studies were excluded if they included patients undergoing emergency surgery, if they referred to general guidelines instead of giving a detailed description of their ERP protocol, if they focused on limited (< 5) intervention components, or if no full text was available
In the 2012 Enhanced recovery after surgery (ERAS)® Society guidelines epidural anaesthesia remains the standard in open surgery, Fig. 1 PRISMA flowchart showing the study selection process
Summary
Enhanced recovery programmes (ERPs) aim to attenuate the surgical stress response and accelerate recovery after surgery, but are not designed for older patients. Fast Track protocols, known as Enhanced Recovery After Surgery (ERAS®), or Enhanced Recovery Programmes (ERPs), have been developed by surgeons and anaesthesiologists to reduce the surgical stress response, accelerate recovery, and improve overall post-operative outcomes [1]. They were initially introduced in the early nineties by Kehlet and colleagues as standard of care for colorectal surgery, and have spread to other surgical specialties [1, 2]. Older patients might benefit more than younger patients, because they are more susceptible to adverse post-operative outcomes and longer hospital stays [9, 10]
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