Effects of early postoperative mobilization following gastrointestinal surgery: systematic review and meta-analysis

Abstract

Background: Early postoperative mobilization is considered a key element of enhanced recovery after surgery protocols. The aim of this study was to summarize the effect of early postoperative mobilization following gastrointestinal operations on patient recovery, mobility, the morbidity rate and duration of hospital stay.

Methods: A systematic literature search was conducted in December, 2022, using PubMed, Web of Science and the Cochrane Central Register of Controlled Trials. Controlled trials reporting the effects of early postoperative mobilization after gastrointestinal surgery were included. The risk of bias was assessed using a modified Downs and Black tool and the Cochrane Collaboration tool for randomized trials. The outcomes of interest were gastrointestinal recovery (defined passage of first flatus or bowel movements), mobility (step count on postoperative day 3), the morbidity rate and duration of hospital stay.

Results: After elimination of duplicates, 3678 records were identified, and 71 full-text articles were screened. Finally, 15 studies (eight RCTs) reporting on 3538 patients were included. Most trials evaluated early postoperative mobilization after different gastrointestinal operations, including upper gastrointestinal (n = 8 studies), hepatopancreatobiliary (n = 10 studies) and colorectal resections (n = 10 studies). The investigated early postoperative mobilization protocols, operative techniques (minimally invasive or open) and outcome parameters were heterogeneous between the studies. Early postoperative mobilization seemed to significantly accelerate clinical gastrointestinal recovery (mean difference, hours: -11.53 (-22.08, -0.97), P = 0.03). However, early postoperative mobilization did not significantly improve the morbidity rate (risk ratio: 0.93 (0.70, 1.23), P = 0.59), postoperative mobility of patients (step count mean difference: 1009 (-803, 2821), P = 0.28) or shorten the duration of hospital stay (mean difference, days: -0.25 (-0.99,0.43), P = 0.47) in randomized trials.

Conclusion: There is a large heterogeneity among the study cohorts, operations and interventions. The available evidence currently does not support specific early postoperative mobilization protocols as an isolated element to further reduce the morbidity rate and duration of hospital stay. Further well-designed trials are required to identify effective early postoperative mobilization protocols.

Fig. 1

Flow chart for the systematic literature search algorithm (PRISMA 2020 template) *Two articles reported different outcomes of the identical RCT and were not listed separately. ERAS, enhanced recovery after surgery. **No automation tools were used.

Fig. 2

Number of publications per year captured by the MEDLINE search term (PubMed) on early postoperative mobilization after gastrointestinal surgery (total number of retrieved records: 1918) The dashed vertical orange line indicates the year 2015.

Fig. 3

Risk-of-bias assessment of the included RCTs according to the Cochrane Collaboration tool

Fig. 4

Mean step count on postoperative days (POD) 1 (top left), 3 (top right) and 5 (bottom) in the early postoperative mobilization (EPM, intervention) and the control group respectively, reported by RCTs *Step counts on POD 5 were not assessed in this study. EPM, early postoperative mobilization.

Fig. 5

Meta-analysis results (forest plots) of different comparisons in RCTs evaluating early postoperative versus standard mobilization after gastrointestinal surgery a Postoperative 30-day morbidity rate (CDC I–V^,,,, CDC III–V, pneumonia). b Gastrointestinal recovery (time to first flatus or stool in hours). c Length of hospital stay (days). CDC: Clavien-Dindo classification of complications; M-H: Mantel-Haenszel.