Enhanced recovery protocols for major upper gastrointestinal, liver and pancreatic surgery

Giles Bond‐Smith; Ajay P Belgaumkar; Brian R Davidson; Kurinchi Selvan Gurusamy

doi:10.1002/14651858.CD011382.pub2

Scolaris Content Display Scolaris Content Display

Contenido relacionado

Ir a:

Revisiones y protocolos relacionados
Podcasts
Respuestas clínicas Cochrane
Guías
Temas

Revisiones y protocolos relacionados

Respuestas clínicas Cochrane

Topics

Temas

Figure 1

Study flow diagram.

Ir a la figura de la revisiónAbrir en una pestaña nueva

Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Ir a la figura de la revisiónAbrir en una pestaña nueva

Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 1.1

Comparison 1 Enhanced recovery protocol versus standard care, Outcome 1 Short‐term mortality.

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 1.2

Comparison 1 Enhanced recovery protocol versus standard care, Outcome 2 Serious adverse events (proportion).

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 1.3

Comparison 1 Enhanced recovery protocol versus standard care, Outcome 3 Serious adverse events (number).

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 1.4

Comparison 1 Enhanced recovery protocol versus standard care, Outcome 4 Health‐related quality of life.

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 1.5

Comparison 1 Enhanced recovery protocol versus standard care, Outcome 5 Mild adverse events (proportion).

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 1.6

Comparison 1 Enhanced recovery protocol versus standard care, Outcome 6 Mild adverse events (number).

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 1.7

Comparison 1 Enhanced recovery protocol versus standard care, Outcome 7 Length of hospital stay.

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 1.8

Comparison 1 Enhanced recovery protocol versus standard care, Outcome 8 Readmissions.

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 1.9

Comparison 1 Enhanced recovery protocol versus standard care, Outcome 9 Costs.

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 2.1

Comparison 2 Enhanced recovery protocol versus standard care (subgroup analysis), Outcome 1 Short‐term mortality.

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 2.2

Comparison 2 Enhanced recovery protocol versus standard care (subgroup analysis), Outcome 2 Serious adverse events (proportion).

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 2.3

Comparison 2 Enhanced recovery protocol versus standard care (subgroup analysis), Outcome 3 Serious adverse events (number).

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 2.4

Comparison 2 Enhanced recovery protocol versus standard care (subgroup analysis), Outcome 4 Health‐related quality of life.

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 3.1

Comparison 3 Enhanced recovery protocol versus standard care (sensitivity analysis), Outcome 1 Health‐related quality of life.

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 3.2

Comparison 3 Enhanced recovery protocol versus standard care (sensitivity analysis), Outcome 2 Length of hospital stay.

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 3.3

Comparison 3 Enhanced recovery protocol versus standard care (sensitivity analysis), Outcome 3 Costs.

Ir a la figura de la revisiónAbrir en una pestaña nueva

Summary of findings for the main comparison. Enhanced recovery protocol versus standard care for major upper gastrointestinal, liver and pancreatic surgery

Enhanced recovery protocols versus standard care for major upper gastrointestinal, liver and pancreatic surgery
Patient or population: people with major upper gastrointestinal, liver and pancreatic surgery Settings: secondary or tertiary care Intervention: enhanced recovery protocol Control: standard care
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Control	Enhanced recovery protocol versus standard care
None of the trials reported long‐term mortality, medium‐term health‐related quality of life (3 months to 1 year), time to return to normal activity, or time to return to work.
Short‐term mortality	2 per 1000	6 per 1000 (1 to 40)	RR 2.79 (0.44 to 17.73)	868 (7 studies)	⊕⊝⊝⊝ very low^1,2,3
Serious adverse events (proportion)	1 per 1000	6 per 1000 (1 to 46)	RR 5.57 (0.68 to 45.89)	341 (2 studies)	⊕⊝⊝⊝ very low^1,2,3	Since there were no serious adverse events in the control group (in the two trials that reported the proportion of participants with serious adverse events), the control group risk was stated as 0.1% for this outcome alone
Serious adverse events (number)	105 per 1000	76 per 1000 (47 to 119)	Rate ratio 0.72 (0.45 to 1.13)	859 (7 studies)	⊕⊝⊝⊝ very low^1,2,3
Health‐related quality of life (until 3 months)		The mean health‐related quality of life in the intervention groups was 0.29 standard deviations higher (0.04 lower to 0.62 higher)		373 (4 studies)	very low^1,4	SMD 0.29 (‐0.04 to 0.62)
Mild adverse events (proportion)	188 per 1000	109 per 1000 (73 to 160)	RR 0.58 (0.39 to 0.85)	525 (4 studies)	⊕⊕⊝⊝ low¹
Mild adverse events (number)	249 per 1000	129 per 1000 (97 to 174)	Rate ratio 0.52 (0.39 to 0.70)	1014 (9 studies)	⊕⊕⊝⊝ low¹
Length of hospital stay	The mean length of hospital stay in the control groups was 8 days	The mean length of hospital stay in the intervention groups was 2.19 lower (2.53 to 1.85 lower)		1014 (9 studies)	⊕⊕⊝⊝ low¹	The length of hospital stay reported in the trials included only the length of hospital stay during the admission for surgery and does not include the readmissions
Readmissions	24 per 1000	33 per 1000 (16 to 68)	RR 1.4 (0.69 to 2.87)	733 (7 studies)	⊕⊝⊝⊝ very low^1,2,3
Costs	The mean costs in the control groups were USD 7000	The mean costs in the intervention groups were 0.63 lower (0.84 to 0.42 lower)		282 (4 studies)	⊕⊕⊝⊝ low¹
The basis for the assumed risk* is the mean control group risk. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio;
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹ The risk of bias was high in all the trials. ² The confidence intervals were wide (overlaps 0 and 0.75 or 1.25). ³ The total sample size was less than the sample required in a single trial. ⁴ The confidence intervals were wide (overlaps 0 and 0.25 or ‐0.25).

Summary of findings for the main comparison. Enhanced recovery protocol versus standard care for major upper gastrointestinal, liver and pancreatic surgery

Ir a la tabla de la revisión

Table 1. Participants, elements of enhanced recovery protocol and outcomes reported in included trials

Study name	Surgery	Preoperative education	Pain relief protocol	Early mobilisation protocol	Nutritional protocol	Growth factors	Outcomes reported
Barlow 2011	Major upper gastrointestinal surgery (oesophagectomy, gastrectomy and pancreatectomy)	No	No	No	Yes	No	Short‐term mortality Serious adverse events Mild adverse events Length of hospital stay
Jones 2013	Open liver surgery	Yes	No	Yes	Yes	No	Short‐term mortality Serious adverse events Health‐related quality of life Mild adverse events Length of hospital stay Readmissions
Kim 2012	Laparoscopic distal gastrectomy	Yes	Yes	Yes	Yes	No	Short‐term mortality Serious adverse events Health‐related quality of life Mild adverse events Length of hospital stay Readmissions Costs
Lemanu 2013	Laparoscopic sleeve gastrectomy	Yes	Yes	Yes	Yes	No	Serious adverse events Health‐related quality of life Mild adverse events Length of hospital stay Readmissions Costs
Liu 2010	Gastrectomy	Yes	Yes	Yes	Yes	No	Short‐term mortality Serious adverse events Mild adverse events Length of hospital stay Readmissions
Lu 2014	Liver surgery	No	No	Yes	Yes	No	Short‐term mortality Serious adverse events Mild adverse events Length of hospital stay Readmissions
Miyachi 2013	Gastrectomy	No	No	No	No	Yes	None of the outcomes of interest were reported
Ni 2013	Partial liver resection	Yes	Yes	Yes	Yes	No	Short‐term mortality Serious adverse events Health‐related quality of life Mild adverse events Length of hospital stay
Wang 2010	Gastrectomy	Yes	Yes	Ys	Yes	No	Short‐term mortality Mild adverse events Length of hospital stay Readmissions Costs
Zhao 2014	Oesophagectomy	Yes	Yes	N	No	No	Serious adverse events Mild adverse events Length of hospital stay Readmissions Costs
The table shows the surgeries that the participants underwent, the elements of enhanced recovery protocol that were different between the intervention and control, and the outcomes reported in the trials.

Table 1. Participants, elements of enhanced recovery protocol and outcomes reported in included trials

Ir a la tabla de la revisión

Comparison 1. Enhanced recovery protocol versus standard care

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Short‐term mortality Show forest plot	7	868	Risk Ratio (M‐H, Fixed, 95% CI)	2.79 [0.44, 17.73]

2 Serious adverse events (proportion) Show forest plot	2	341	Risk Ratio (M‐H, Fixed, 95% CI)	5.57 [0.68, 45.89]

3 Serious adverse events (number) Show forest plot	7	859	Rate Ratio (Fixed, 95% CI)	0.72 [0.45, 1.13]

4 Health‐related quality of life Show forest plot	4	373	Std. Mean Difference (IV, Random, 95% CI)	0.29 [‐0.04, 0.62]

5 Mild adverse events (proportion) Show forest plot	4	525	Risk Ratio (M‐H, Fixed, 95% CI)	0.58 [0.39, 0.85]

6 Mild adverse events (number) Show forest plot	9	1014	Rate Ratio (Fixed, 95% CI)	0.52 [0.39, 0.70]

7 Length of hospital stay Show forest plot	9	1014	Mean Difference (IV, Fixed, 95% CI)	‐2.19 [‐2.53, ‐1.85]

8 Readmissions Show forest plot	7	733	Risk Ratio (M‐H, Fixed, 95% CI)	1.40 [0.69, 2.87]

9 Costs Show forest plot	4	282	Mean Difference (IV, Fixed, 95% CI)	‐0.63 [‐0.84, ‐0.42]

Comparison 1. Enhanced recovery protocol versus standard care

Ir a la tabla de la revisión

Comparison 2. Enhanced recovery protocol versus standard care (subgroup analysis)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Short‐term mortality Show forest plot	6	747	Risk Ratio (M‐H, Fixed, 95% CI)	0.98 [0.06, 15.17]

1.1 Oesophagectomy	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.2 Gastrectomy	3	548	Risk Ratio (M‐H, Fixed, 95% CI)	0.98 [0.06, 15.17]
1.3 Liver surgery	3	199	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2 Serious adverse events (proportion) Show forest plot	2	341	Risk Ratio (M‐H, Fixed, 95% CI)	5.57 [0.68, 45.89]

2.1 Oesophagectomy	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.2 Gastrectomy	1	44	Risk Ratio (M‐H, Fixed, 95% CI)	3.0 [0.13, 69.87]
2.3 Liver surgery	1	297	Risk Ratio (M‐H, Fixed, 95% CI)	8.39 [0.44, 161.01]
3 Serious adverse events (number) Show forest plot	6		Rate Ratio (Fixed, 95% CI)	0.87 [0.53, 1.43]

3.1 Oesophagectomy	1		Rate Ratio (Fixed, 95% CI)	0.33 [0.01, 8.12]
3.2 Gastrectomy	2		Rate Ratio (Fixed, 95% CI)	1.10 [0.35, 3.49]
3.3 Liver surgery	3		Rate Ratio (Fixed, 95% CI)	0.84 [0.48, 1.48]
4 Health‐related quality of life Show forest plot	4	373	Std. Mean Difference (IV, Random, 95% CI)	0.29 [‐0.04, 0.62]

4.1 Oesophagectomy	0	0	Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
4.2 Gastrectomy	2	122	Std. Mean Difference (IV, Random, 95% CI)	‐0.03 [‐0.39, 0.32]
4.3 Liver surgery	2	251	Std. Mean Difference (IV, Random, 95% CI)	0.52 [0.27, 0.77]

Comparison 2. Enhanced recovery protocol versus standard care (subgroup analysis)

Ir a la tabla de la revisión

Comparison 3. Enhanced recovery protocol versus standard care (sensitivity analysis)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Health‐related quality of life Show forest plot	3	282	Std. Mean Difference (IV, Random, 95% CI)	0.17 [‐0.19, 0.53]

2 Length of hospital stay Show forest plot	3	267	Mean Difference (IV, Fixed, 95% CI)	‐2.31 [‐2.93, ‐1.69]

3 Costs Show forest plot	3	214	Mean Difference (IV, Fixed, 95% CI)	‐0.60 [‐0.81, ‐0.39]

Comparison 3. Enhanced recovery protocol versus standard care (sensitivity analysis)

Ir a la tabla de la revisión

The Cochrane Library

Scolaris Language Selector Scolaris Language Selector

Idioma de la Revisión Cochrane

Idioma de la web

Scolaris Content Language Banner Portlet Scolaris Content Language Banner Portlet