Enhanced recovery meta-analysis

Kirsty Cattle

Research Registrar

The paper

Introduction

– Enhanced recovery:– 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:– 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:– Enhanced recovery elements:

Methods

– Define colorectal enhanced recovery surgery:– 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:– 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:– Primary: total primary length of stay– Secondary:

• Primary length of stay plus length of any readmissions• Readmissions• Morbidity• Mortality

– If necessary, data was obtained by contacting the authors directly

– Analysis:– 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– 376 patients, 64 within RCTs– 11 deaths

– Bias:– 2 RCTs, both from same centre, inadequacies

with randomization– 2 CCTs, comparing different centres or wards

Meta-analysis

– Total primary length of stay:– 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:

• 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:– Lower relative risk of 30 day morbidity among

enhanced recovery group:• RR = 0.44, p < 0.0001, combined RCT and CCT data

– No statistically significant difference when RCTs alone examined

• RR= 0.63, p = 0.06, RCT data only

– Mortality:– No significant difference in mortality rates

between enhanced recovery and standard care• RR = 0.92, p = 0.93, RCT data• RR = 2.0, p = 0.32, CCT data

– Readmission rates:– Equivocal data reported

• 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

– Their conclusions match the conclusions of the previous meta-analysis and support it by being a stronger meta-analysis

– 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:

– More background reading first