Perioperative enhanced recovery programmes for women with gynaecological cancers

Janita Pak Chun Chau, Xu Liu, Suzanne Hoi Shan Lo, Wai Tong Chien, Sze Ki Hui, Kai Chow Choi, Jie Zhao, Janita Pak Chun Chau, Xu Liu, Suzanne Hoi Shan Lo, Wai Tong Chien, Sze Ki Hui, Kai Chow Choi, Jie Zhao

Abstract

Background: Gynaecological cancers account for 15% of newly diagnosed cancer cases in women worldwide. In recent years, increasing evidence demonstrates that traditional approaches in perioperative care practice may be unnecessary or even harmful. The enhanced recovery after surgery (ERAS) programme has therefore been gradually introduced to replace traditional approaches in perioperative care. There is an emerging body of evidence outside of gynaecological cancer which has identified that perioperative ERAS programmes decrease length of postoperative hospital stay and reduce medical expenditure without increasing complication rates, mortality, and readmission rates. However, evidence-based decisions on perioperative care practice for major surgery in gynaecological cancer are limited. This is an updated version of the original Cochrane Review published in Issue 3, 2015.

Objectives: To evaluate the beneficial and harmful effects of perioperative enhanced recovery after surgery (ERAS) programmes in gynaecological cancer care on length of postoperative hospital stay, postoperative complications, mortality, readmission, bowel functions, quality of life, participant satisfaction, and economic outcomes.

Search methods: We searched the following electronic databases for the literature published from inception until October 2020: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PubMed, AMED (Allied and Complementary Medicine), CINAHL (Cumulative Index to Nursing and Allied Health Literature), Scopus, and four Chinese databases including the China Biomedical Literature Database (CBM), WanFang Data, China National Knowledge Infrastructure (CNKI), and Weipu Database. We also searched four trial registration platforms and grey literature databases for ongoing and unpublished trials, and handsearched the reference lists of included trials and accessible reviews for relevant references.

Selection criteria: We included randomised controlled trials (RCTs) that compared ERAS programmes for perioperative care in women with gynaecological cancer to traditional care strategies.

Data collection and analysis: Two review authors independently screened studies for inclusion, extracted the data and assessed methodological quality for each included study using the Cochrane risk of bias tool 2 (RoB 2) for RCTs. Using Review Manager 5.4, we pooled the data and calculated the measures of treatment effect with the mean difference (MD), standardised mean difference (SMD), and risk ratio (RR) with a 95% confidence interval (CI) to reflect the summary estimates and uncertainty.

Main results: We included seven RCTs with 747 participants. All studies compared ERAS programmes with traditional care strategies for women with gynaecological cancer. We had substantial concerns regarding the methodological quality of the included studies since the included RCTs had moderate to high risk of bias in domains including randomisation process, deviations from intended interventions, and measurement of outcomes. ERAS programmes may reduce length of postoperative hospital stay (MD -1.71 days, 95% CI -2.59 to -0.84; I2 = 86%; 6 studies, 638 participants; low-certainty evidence). ERAS programmes may result in no difference in overall complication rates (RR 0.71, 95% CI 0.48 to 1.05; I2 = 42%; 5 studies, 537 participants; low-certainty evidence). The certainty of evidence was very low regarding the effect of ERAS programmes on all-cause mortality within 30 days of discharge (RR 0.98, 95% CI 0.14 to 6.68; 1 study, 99 participants). ERAS programmes may reduce readmission rates within 30 days of operation (RR 0.45, 95% CI 0.22 to 0.90; I2 = 0%; 3 studies, 385 participants; low-certainty evidence). ERAS programmes may reduce the time to first flatus (MD -0.82 days, 95% CI -1.00 to -0.63; I2 = 35%; 4 studies, 432 participants; low-certainty evidence) and the time to first defaecation (MD -0.96 days, 95% CI -1.47 to -0.44; I2 = 0%; 2 studies, 228 participants; low-certainty evidence). The studies did not report the effects of ERAS programmes on quality of life. The evidence on the effects of ERAS programmes on participant satisfaction was very uncertain due to the limited number of studies. The adoption of ERAS strategies may not increase medical expenditure, though the evidence was of very low certainty (SMD -0.22, 95% CI -0.68 to 0.25; I2 = 54%; 2 studies, 167 participants).

Authors' conclusions: Low-certainty evidence suggests that ERAS programmes may shorten length of postoperative hospital stay, reduce readmissions, and facilitate postoperative bowel function recovery without compromising participant safety. Further well-conducted studies are required in order to validate the certainty of these findings.

Trial registration: ClinicalTrials.gov NCT01705288 NCT03347409 NCT03667755 NCT02172638 NCT02687412 NCT02864277 NCT03640299 NCT04063072.

Conflict of interest statement

Janita Pak Chun Chau: none known Xu Liu: none known Suzanne Hoi Shan Lo: none known Wai Tong Chien: none known Sze Ki Hui: none known Kai Chow Choi: none known Jie Zhao: none known