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Enhanced recovery meta-analysis

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  1. Enhanced recovery meta-analysis Kirsty Cattle Research Registrar

  2. The paper

  3. 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”

  4. Aim of study: • The evidence for enhanced recovery comes from observational studies and consensus opinion. • Previous systematic review was felt to be inadequate

  5. Methods • Define colorectal enhanced recovery surgery: • Enhanced recovery elements:

  6. 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”

  7. 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

  8. 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

  9. Analysis: • Weighted mean difference for continuous data • Relative risk for categorical data • Heterogeneity examined (I2 test)

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

  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

  16. 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