C. S. Lau1,3, R. S. Chamberlain1,2,3 1Saint Barnabas Medical Center,Surgery,Livingston, NJ, USA 2New Jersey Medical School,Surgery,Newark, NJ, USA 3St. George’s University School Of Medicine,St. George’s, St. George’s, Grenada
Introduction: Enhanced recovery after surgery (ERAS) programs have been developed with the aim to improve patient outcomes and accelerate recovery after surgery. ERAS programs are a multimodal approach, with interventions during all stages of care: preoperative, intraoperative, and postoperative. ERAS programs have been proposed to improve patient outcomes and reduce health care costs. This meta-analysis examines the impact of ERAS programs on patient outcomes and recovery.
Methods: A comprehensive literature search of all published randomized control trials (RCTs) assessing the use of ERAS programs in surgical patients was conducted using PubMed, Cochrane Central Registry of Controlled Trials, and Google Scholar (1966-2015). Keywords searched included ‘enhanced recovery’ and ‘fast track’. Studies using at least 4 components of the ERAS program were included. Primary outcomes analyzed were length of stay (LOS), overall mortality, readmission within 30 days, and total costs. Total complications, time to first flatus, and time to first bowel movement were also analyzed.
Results: 42 RCTs involving 5,241 patients (2,595 receiving ERAS and 2,646 receiving standard of care) were analyzed. ERAS programs significantly reduced LOS by 2.35 days (MD = -2.345; 95%CI, -2.733 to -1.958; p<0.001), total complications by 38.0% (RR=0.620; 95%CI 0.545 – 0.704; p<0.001), and total costs (SMD= -0.789; 95%CI, -1.093 to -0.485; p<0.001). LOS reductions varied by type of surgery, with a 3 day reduction after orthopedic surgery (p=0.017) and no significant reduction after cardiovascular surgery (p=0.073). Return of gastrointestinal (GI) function was also significantly improved, as measured by earlier time to first flatus (SMD= -0.987; 95%CI, -1.389 to -0.585, p<0.001) and time to first bowel movement (SMD= -1.074; 95%CI, -1.396 to -0.752; p<0.001). Overall mortality was reduced by 29.2% (RR=0.708; 95%CI 0.377 – 1.330; p=0.283). Overall, there was no difference in readmission rates within 30 days (RR=1.151; 95%CI 0.822–1.612, p=0.412); however, readmission rates within 30 days after upper GI surgeries nearly doubled with the use of ERAS programs (RR=1.922; 95%CI 1.111 – 3.324; p=0.019).
Conclusion: ERAS programs are associated with a significant reduction in LOS, total complications, total costs, as well as earlier return of GI function. Overall mortality rates remained similar, but readmission rates varied significantly depending on the type of surgery. ERAS programs are effective and a valuable part in improving patient outcomes and accelerating recovery after surgery. Additional studies are required to determine the specific components of the ERAS program that are most beneficial.
