Impact of enhanced recovery pathways on patient-reported outcomes after abdominal surgery: a systematic review

• Published in: Surgical endoscopy Vol. 37; no. 10; pp. 8043 - 8056
• Main Authors: El-Kefraoui, Charbel, Do, Uyen, Miller, Andrew, Kouyoumdjian, Araz, Cui, David, Khorasani, Elahe, Landry, Tara, Amar-Zifkin, Alexandre, Lee, Lawrence, Feldman, Liane S., Fiore, Julio F.
• Format: Journal Article
• Language: English
• Published: New York Springer US 01-10-2023; Springer Nature B.V
• Subjects: 2023 SAGES Oral; Abdomen; Abdominal Surgery; Clinical outcomes; Gastroenterology; Gynecology; Hepatology; Medicine; Medicine & Public Health; Mental health; Postoperative period; Proctology; Surgery; Systematic review; Perioperative care; Patient-reported outcomes; Surgery; Enhanced recovery
• ISSN: 0930-2794; 1432-2218
• DOI: 10.1007/s00464-023-10289-2

Introduction
Evidence supports that enhanced recovery pathways (ERPs) reduce length of stay and complications; however, these measures may not reflect the perspective of patients who are the main stakeholders in the recovery process. This systematic review aimed to appraise the evidence regarding the impact of ERPs on patient-reported outcomes (PROs) after abdominal surgery.
Methods
Five databases (Medline, Embase, Biosis, Cochrane, and Web of Science) were searched for randomized controlled trials (RCTs) addressing the impact of ERPs on PROs after abdominal surgery. We focused on distinct periods of recovery: early (within 7 days postoperatively) and late (beyond 7 days). Risk of bias was assessed using Cochrane’s RoB 2.0. Results were appraised descriptively as heterogeneity hindered meta-analysis. Certainty of evidence was evaluated using GRADE.
Results
Fifty-six RCTs were identified [colorectal (
n
 = 18), hepatopancreaticobiliary (HPB) (
n
 = 11), upper gastrointestinal (UGI) (
n
 = 10), gynecological (
n
 = 7), urological (
n
 = 7), general surgery (
n
 = 3)]. Most trials had ‘some concerns’ (
n
 = 30) or ‘high’ (
n
 = 25) risk of bias. In the early postoperative period, ERPs improved patient-reported general health (colorectal, HPB, UGI, urological; very low to low certainty), physical health (colorectal, gynecological; very low to low certainty), mental health (colorectal, gynecological; very low certainty), pain (all specialties; very low to moderate certainty), and fatigue (colorectal; low certainty). In the late postoperative period, ERPs improved general health (HPB, UGI, urological; very low certainty), physical health (UGI, gynecological, urological; very low to low certainty), mental health (UGI, gynecological, urological; very low certainty), social health (gynecological; very low certainty), pain (gynecological, urological; very low certainty), and fatigue (gynecological; very low certainty).
Conclusion
This review supports that ERPs may have a positive impact on patient-reported postoperative health status (i.e., general, physical, mental, and social health) and symptom experience (i.e., pain and fatigue) after abdominal surgery; however, data were largely derived from low-quality trials. Although these findings contribute important knowledge to inform evidence-based ERP implementation, there remains a great need to improve PRO assessment in studies focused on postoperative recovery.