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Enhanced recovery after surgery (ERAS) for vascular surgery: an evidence map and scoping review

Systematic Reviews volume 12, Article number: 162 (2023) Cite this article

Abstract

Background

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.

Methods

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.

Results

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.

Conclusion

The ERAS evidence base is growing but contains gaps. Research on preadmission interventions and more consistent reporting of key outcomes is needed.

Peer Review reports

Introduction

Enhanced recovery after surgery (ERAS) consists of interventions designed to support patients recovering from surgery throughout the continuum of care [1]. Improved recovery after surgery benefits patients, practitioners, and healthcare delivery organizations [2]. However, little is known about the applicability ERAS interventions to vascular surgery [3]. 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 [4] approach allows readers to view the existing evidence base in one figure and identify key research gaps.

Methods

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 [5].

Results

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].

Table 1 Evidence table
Full size table

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.

Fig. 1
figure 1

Evidence map of reported outcomes in included ERAS studies by surgical stage

Abbreviations: ICU Intensive care unit, LOS Length of stay

Full size image

Discussion

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 [85] 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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Acknowledgements

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.

Funding

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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Authors and Affiliations

  1. Southern California Evidence Review Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA

    Eric A. Apaydin, Aneesa Motala & Susanne Hempel

  2. RAND Health Care, RAND Corporation, Santa Monica, CA, USA

    Eric A. Apaydin, Sangita Baxi, Aneesa Motala & Susanne Hempel

  3. Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA

    Eric A. Apaydin

  4. Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA

    Karen Woo

  5. RAND Health Care, RAND Corporation, Arlington, VA, USA

    Julia Rollison

Authors
  1. Eric A. Apaydin
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  2. Karen Woo
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  3. Julia Rollison
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  4. Sangita Baxi
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  5. Aneesa Motala
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  6. Susanne Hempel
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Contributions

Drs. Eric Apaydin, Karen Woo, Julia Rollison, and Susanne Hempel contributed to the study conception and design. Screening and abstraction were performed by Ms. Sangita Baxi, Dr. Julia Rollison, and Dr. Eric Apaydin. Ms. Sangita Baxi created the evidence maps, and Dr. Eric Apaydin analyzed the data. Ms. Aneesa Motala managed the screening and abstraction databases, and the overall project. The first draft of the manuscript was written by Dr. Eric Apaydin and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Eric A. Apaydin.

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Ethics approval and consent to participate

This study did not involve human subjects and was therefore exempt from RAND Human Subjects Protection Committee review. No human subjects were involved, and thus their consent to participate was not applicable.

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All authors have given consent for publication.

Competing interests

The authors have declared that no competing interests exist.

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Supplementary Information

Additional file 1: Supplementary Material 1.

Search strategies. Supplementary Material 2. Eligibility criteria and data abstraction methods.

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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

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  • DOI: https://doi.org/10.1186/s13643-023-02324-z

Keywords

  • Enhanced recovery
  • Surgery
  • Vascular
  • Evidence map

Systematic Reviews

ISSN: 2046-4053