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Meta-Analysis
. 2016 Dec;70(6):995-1003.
doi: 10.1016/j.eururo.2016.05.031. Epub 2016 Jun 11.

Enhanced Recovery Pathways Versus Standard Care After Cystectomy: A Meta-analysis of the Effect on Perioperative Outcomes

Mark D Tyson  1 , Sam S Chang  2
Affiliations
Meta-Analysis

Enhanced Recovery Pathways Versus Standard Care After Cystectomy: A Meta-analysis of the Effect on Perioperative Outcomes

Mark D Tyson et al. Eur Urol. 2016 Dec.

Abstract

Context: Enhanced recovery after surgery (ERAS) protocols aim to improve surgical outcomes by reducing variation in perioperative best practices. However, among published studies, results show a striking variation in the effect of ERAS pathways on perioperative outcomes after cystectomy.

Objective: To perform a systematic review of the literature and a meta-analysis comparing the effectiveness of ERAS versus standard care on perioperative outcomes after cystectomy.

Evidence acquisition: We performed a literature search of PubMed, EMBASE, Web of Science, Google Scholar, the Cochrane Library, and the health-related grey literature in February 2016 according to the Preferred Reporting Items for Systematic Review and Meta-analysis and the Cochrane Handbook. Studies were reviewed according to criteria from the Oxford Centre for Evidence-Based Medicine. Thirteen studies (1493 total patients) met the inclusion criteria (ERAS: 801, standard care: 692). A pooled meta-analysis of all comparative studies was performed using inverse-weighted, fixed-effects models, and random-effects models. Publication bias was graphically assessed using contour-enhanced funnel plots and was formally tested using the Harbord modification of the Egger test.

Evidence synthesis: Pooled data showed a lower overall complication rate (risk ratio [RR]: 0.85, 95% confidence interval [CI]: 0.74-0.97, p = 0.017, I2=35.6%), a shorter length of stay (standardized mean difference:-0.87, 95% CI: -1.31 to -0.42, p=0.001, I2=92.8%), and a faster return of bowel function (standardized mean difference: -1.02, 95% CI: -1.69 to -0.34, p=0.003, I2=92.2%) in the ERAS group. No difference was noted for the overall readmission rates (RR: 0.74, 95% CI: 0.39-1.41, p=0.36, I2=51.4%), although a stratified analysis showed a lower 30-d readmission rate in the ERAS group (RR: 0.39, 95% CI: 0.19-0.83, p=0.015, I2=0%).

Conclusions: ERAS protocols reduce the length of stay, time-to-bowel function, and rate of complications after cystectomy.

Patient summary: Enhanced recovery after surgery pathways for cystectomy reduce complications and the amount of time patients spend in the hospital.

Keywords: Clinical pathways; Collaborative care; Cystectomy; Enhanced recovery; Fast track.

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Conflict of interest statement

Financial disclosures: Mark D. Tyson certifies that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (eg, employment/affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: None.

Figures

Fig. 1
Fig. 1
Forest plot displaying a random-effects meta-analysis of the effect of enhanced recovery after surgery (ERAS) on readmission rates within 30 d and 90 d after cystectomy. Weights are from random-effects analysis. CI = confidence interval; RR = risk ratio; SC = standard care.
Fig. 2
Fig. 2
Forest plot displaying a fixed-effects meta-analysis of the effect of enhanced recovery after surgery (ERAS) on complication rates after cystectomy. CI = confidence interval; RR = risk ratio; SC = standard care.
Fig. 3
Fig. 3
Forest plot displaying a random-effects meta-analysis of the effect of enhanced recovery after surgery (ERAS) on length of stay after cystectomy. Weights are from random-effects analysis. CI = confidence interval; SC = standard care; SMD = standardized mean difference.
Fig. 4
Fig. 4
Forest plot displaying a random-effects meta-analysis of the effect of enhanced recovery after surgery (ERAS) on time to bowel function after cystectomy. Weights are from random-effects analysis. CI = confidence interval; SC, standard care; SMD, standardized mean difference.
Fig. 5
Fig. 5
Contour-enhanced funnel plots for (A) complications, (B) length of stay, (C) readmission, and (D) time-to-bowel movement.
Fig. 5
Fig. 5
Contour-enhanced funnel plots for (A) complications, (B) length of stay, (C) readmission, and (D) time-to-bowel movement.
Fig. 5
Fig. 5
Contour-enhanced funnel plots for (A) complications, (B) length of stay, (C) readmission, and (D) time-to-bowel movement.
Fig. 5
Fig. 5
Contour-enhanced funnel plots for (A) complications, (B) length of stay, (C) readmission, and (D) time-to-bowel movement.
See this image and copyright information in PMC

Comment in

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