Enhanced recovery after surgery (ERAS) for vascular surgery: an evidence map and scoping review
Systematic Reviews volume 12, Article number: 162 (2023)
Enhanced recovery after surgery (ERAS) interventions aim to improve patient outcomes. Vascular surgery patients have unique requirements and it is unclear which ERAS interventions are supported by an evidence base.
We conducted a scoping review to identify ERAS randomized controlled trials (RCTs) published in the biomedical or nursing literature. We assessed interventions for applicability to vascular surgery and differentiated interventions given at preadmission, preoperative, intraoperative, and postoperative surgery stages. We documented the research in an evidence map.
We identified 76 relevant RCTs. Interventions were mostly administered in preoperative (23 RCTs; 30%) or intraoperative surgery stages (35 RCTs; 46%). The majority of studies reported mortality outcomes (44 RCTs; 58%), but hospital (27 RCTs; 35%) and intensive care unit (9 RCTs; 12%) length of stay outcomes were less consistently described.
The ERAS evidence base is growing but contains gaps. Research on preadmission interventions and more consistent reporting of key outcomes is needed.
Enhanced recovery after surgery (ERAS) consists of interventions designed to support patients recovering from surgery throughout the continuum of care . Improved recovery after surgery benefits patients, practitioners, and healthcare delivery organizations . However, little is known about the applicability ERAS interventions to vascular surgery . Vascular surgery, which includes a wide range of treatments that encompass major open operations and less invasive endovascular procedures, may benefit from ERAS approaches.
To better understand this literature, we conducted a scoping review and created an evidence map of randomized controlled trials (RCTs) for ERAS interventions, mapped by surgical stage, that evaluate key patient-centered outcomes (mortality and length of stay). The evidence map  approach allows readers to view the existing evidence base in one figure and identify key research gaps.
As part of a larger project on ERAS, we searched PubMed and the Cumulative Index to Nursing and Allied Health Literature for published literature, and searched ClinicalTrials.gov for clinical trial records from inception to March 2023 (search strategies shown in Supplementary Material 1). Citations and full text publications were screened by experienced literature reviewers using predetermined eligibility criteria (full criteria shown in Supplementary Material 2). Notably, we restricted to RCTs, a study design that allows strong evidence statements. Abstracted items are also listed in Supplementary Material 2. Results were plotted as an evidence map using data visualization software (R Studio; R Studio Public Benefit Corporation; Boston, MA). All data analyzed in this manuscript is available in Table 1. This study did not involve human subjects and was therefore exempt from RAND Human Subjects Protection Committee review. Our full report on ERAS interventions for vascular surgery, with a search from inception to July 2019, is available on the Patient-Centered Outcomes Research Institute (PCORI) website .
The search identified 4,483 citations, and we included 79 RCTs of ERAS interventions for vascular surgery (evidence table: Table 1) [6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84].
Figure 1 documents the evidence base and distribution of evidence across treatment stages and treatment outcomes. Of the evaluated interventions, 24 (30%) were preoperative, 36 (46%) were intraoperative, 16 (20%) were postoperative, and 3 (4%) were multi-stage. We did not identify any preadmission interventions. Forty-four RCTs (56%) reported mortality outcomes (Fig. 1), and of these interventions, 16 (36%) were preoperative, 20 (45%) were intraoperative, 5 (11%) were postoperative, and 3 (7%) were multi-stage. Length of stay outcomes were reported in 30 RCTs (38%), which evaluated ERAS interventions administered preoperatively (7 RCTs; 23%), intraoperatively (13 RCTS; 43%), postoperatively (8 RCTs; 27%), and across multiple surgical stages (2 RCTs; 7%). Length of stay in intensive care units (ICUs) was measured least frequently, in only 11 RCTs (14%). Of interventions in these studies, 4 (36%) were preoperative, 4 (36%) were intraoperative, 2 (18%) were postoperative, and 1 (9%) was multi-stage.
We identified a substantial body of evidence of ERAS interventions for vascular surgery. Our analysis utilized an evidence map to categorize the available research on RCTs reporting mortality and length of stay outcomes for these interventions by surgical stage, a strategy not previously employed by other reviews. The map shows that existing research has primarily addressed pre- or intraoperative, rather than preadmission, surgical stages. In addition, while more than half of studies reported on mortality, information on hospital or ICU length of stay remains sparse.
A recent review  of 19 RCTs and observational studies of ERAS interventions for vascular surgery found that ERAS interventions reduced length of stay by 3.5 days across five studies. The review did not report pooled effects for mortality outcomes. A comprehensive systematic review and meta-analysis of the effects of ERAS interventions in the extant literature is needed to better estimate treatment effects.
Additional primary research on ERAS interventions is also needed. The existing evidence base lacks studies of preadmission ERAS interventions, and mortality and length of stay outcomes were not consistently reported. Future primary research should aim to study preadmission interventions and consistently measure and report mortality and length of stay outcomes.
ERAS research is rapidly growing and an evidence base for vascular surgery is also emerging. Our evidence map clearly outlines research gaps, including a lack of research on ERAS interventions at all surgery stages and the sparseness of information on key outcomes. ERAS interventions hold promise to improve patient recovery after vascular surgery and further applications should be explored.
Availability of data and materials
All data analyzed in this manuscript is available in Table 1.
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We thank Katharine McGinigle, Thomas Concannon, Paul Koegel, Jeanne Ringel, Rachel Andricosky, Michelle Althuis, and William Lawrence for helpful comments, Sachi Yagyu for conducting literature searches, and Christine Chen for research support.
The manuscript is based on work funded by the Patient-Centered Outcomes Research Institute (contract holder: SH; PCORI [www.pcori.org]; Analytic and Operational Support for the Engagement of the Public and Patients Task Order #18 Topic Briefs on Enhanced Recovery After Surgery and Infantile Epilepsy). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
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Apaydin, E.A., Woo, K., Rollison, J. et al. Enhanced recovery after surgery (ERAS) for vascular surgery: an evidence map and scoping review. Syst Rev 12, 162 (2023). https://doi.org/10.1186/s13643-023-02324-z
- Enhanced recovery
- Evidence map