Background
Methods
Search strategy
Selection of relevant papers
Data extraction and synthesis
Risk of bias (quality) assessment
Data synthesis and analysis
Results
Article selection
Study and patient characteristics
Original study | Country and setting | Study-design | Population | Sample | Age median (range) or mean (±SD), in y | Inclusion criteria (original study) | Exclusion criteria (original study) |
---|---|---|---|---|---|---|---|
Zeng 2017 [16] | China Monocentric, academic | Database analysis | Colorectal Laparoscopic Cancer |
94 ERP ≥ 75y
157 CC ≥75y |
78 (75–88)
78 (75–90) | ≥75y Laparoscopic colorectal surgery Colorectal cancer | Emergency surgery Non-radical resection TNM stage IV Multi-organ resection |
Pirrera 2017 [17] | Italy Monocentric, non-academic | Database analysis | Colorectal Laparoscopic Cancer/Benign |
203 ERP > 75y
175 ERP 66-75y
211 ERP ≤65y |
80 (range NR)
69 (range NR)
56 (range NR) | Colorectal resection Scheduled for laparoscopic approach | Emergency surgery Palliative procedure |
Forsmo 2017 [18] | Norway Monocentric, academic | Secondary analysis of RCT data | Colorectal Open/Lap Cancer/Benign |
19 ERP ≥ 80y
56 ERP 66-79y
79 ERP ≤ 65y |
83 (80–89)
72 (66–78)
58 (23–65) | ≥18y Colorectal surgery With or without stoma Malignant or benign | Multi-organ resection ASA 4 Emergency surgery Impaired mental capacity |
Braga 2017 [19] | Peri-operative Italian Society Registry (11 hospitals) | Database analysis | Colorectal Open/Lap Cancer/Benign |
93 ERP > 80 y
117 ERP 76-80y
105 ERP 71-75y
|
84 (SD ± 3)
77 (SD ± 2)
73 (SD ± 1)
| >70y Elective colorectal surgery | / |
Braga 2016 [20] | Peri-operative Italian Society Registry (11 hospitals) | Database analysis | Colorectal Open/Lap Cancer/Benign |
167 ERP ≥ 70y, ASA 1–2
162 ERP ≥ 70y, ASA 3–4
279 ERP <70y, ASA 1–2 98 ERP <70y, ASA 3–4 |
77 (SD ± 4.6)
78 (SD ± 5.3)
58 (SD ±9) 63 (SD ±5.7) | Elective colorectal surgery | / |
Gonzalez-Ayora 2016 [21] | Spain Multicentric, academic | Database analysis | Colorectal Open/Lap Cancer/Benign |
188 ERP ≥ 70y
|
79 (70–93)
| ≥70y Colorectal surgery | Emergency surgery Palliative procedure |
Pedziwiatr 2015 [22] | Poland Monocentric, academic | Database analysis | Colorectal Laparoscopic Cancer |
34 ERP ≥ 80y
43 ERP ≤55y |
83 (IQR 82–87)
50 (IQR 44–54) | ≥80y or ≤ 55y Laparoscopic colorectal surgery Colorectal adenocarcinoma | Emergency surgery Multi-organ or transanal resection Concomitant IBD ICU stay after surgery |
Kisialeuski 2015 [23] | Poland Monocentric, academic | Prospective observational cohort study | Colorectal Laparoscopic Cancer |
49 ERP > 65y
43 ERP ≤65y |
76.3 (SD NR)
55.8 (SD NR) | Laparoscopic colorectal surgery Colorectal cancer | Emergency surgery Multi-organ resection |
Jia 2014 [24] | China Monocentric, academic | RCT | Colorectal Open Cancer |
117 ERP ≥ 70y
116 CC ≥70y |
75.7 (SD ± 4.2)
74.8 (SD ±4.0) | ≥70y Admitted for open curative resection Colorectal carcinoma | Dementia, Parkinson, alcohol intake ≥250 g/d, long term sleeping pills or anxiolytics, anaesthesia ≤30d Intra-operative blood transfusion or ICU stay after surgery |
Keller 2013 [25] | USA Monocentric, academic | Database analysis | Colonic Laparoscopic Cancer/Benign |
153 ERP ≥ 70y
302 ERP <70y |
77.9 (SD ± 6.1)
52.4 (SD ±13.7) | Elective laparoscopic colon resection (conversions included) | Incomplete medical or financial records |
Feroci 2013 [26] | Italy Monocentric, non-academic | Database analysis | Colorectal Open/Lap Cancer/Benign |
204 ERP ≥ 75y
402 ERP <75y | Overall: 70 (30–94) | Elective colorectal resection (multiple previous laparotomies are included) ASA grades 1 to 4 | Medically unfit for surgery Cancer with distant metastasis <18y or pregnant |
Baek 2013 [27] | Korea Monocentric, academic | Prospective observational cohort study | Colorectal Laparoscopic Cancer |
77 ERP ≥ 70y
226 ERP <70y |
74.8 (SD ± 4.2)
56.7 (SD ±8.9) | Laparoscopic or robotic surgery Colorectal cancer | Emergency surgery ASA 4 ICU stay after surgery Conversion (laparoscopic to open) |
Wang 2012 [28] | China Monocentric, academic | RCT | Colorectal Laparoscopic Cancer |
40 ERP ≥ 65y
38 CC ≥65y |
71 (65–81)
72 (65–82) | ≥ 65y Laparoscopic colorectal resection Colorectal cancer | Distant metastasis (involving pelvic, urethra of iliac vessel invasion) Poor cardiopulmonary function |
Pawa 2012 [29] | UK Monocentric, academic | Database analysis | Colorectal Open/Lap Cancer/Benign |
130 ERP ≥ 80y
558 ERP < 80y |
83 (80–95)
66 (17–79) | Colorectal resection | None |
Walter 2011 [30] | UK Monocentric, non-academic | Database analysis; retrospective control group | Colorectal Open/Lap Cancer/Benign |
68 ERP ≥ 80y
332 ERP < 80y 200 CC | Overall: 67 (IQR 56–77) 69 (IQR 57–78) | Major colorectal resections First 400 consecutive, non-selected, patients managed within an ERP Last 200 patients pre-ERP | Emergency surgery |
Kahokehr 2011 [31] | New Zealand Monocentric, academic | Prospective observational cohort study | Colonic Open/Lap Cancer/Benign |
22 ERP > 75y
78 ERP ≤75y | Overall: 67.5 (IQR 31–92) | Elective colonic surgery within an ERP | Rectal cancer ≤15 cm from the anal verge, patients requiring a stoma or unable to participate (language, cognitive impairment, ASA ≥4) |
Rumstadt 2009 [32] | Germany FTCII programme (24 hospitals) | Database analysis | Colonic Open/Lap Cancer/Benign |
207 ERP ≥ 80y
535 ERP 70-79y
|
74.7 (70–79.9)
83.4 (80–95.7)
| ≥ 70y Elective colonic resection | Emergency surgery Perforation or abscess with septic inflammatory response syndrome |
Hendry 2009 [33] | UK, Norway, Sweden, The Netherlands Multicentric, academic | Database analysis | Colorectal Open Cancer/Benign |
194 ERP ≥ 80y
839 ERP <80 | Overall: 59 (IQR 69–78) | Elective open colorectal surgery with formation of an anastomosis In case of rectal cancer: tumour in the upper 1/3 of the rectum and allows anastomosis in the middle 1/3 ASA grade 1 to 4 | Total mesorectal excision |
Scharfen-berg 2007 [34] | Germany Monocentric, academic | Prospective observational cohort study | Colonic Open/Lap Cancer/Benign |
74 ERP > 70y
|
74 (71–88)
| > 70y Elective colonic resection Benign or malignant disease | Not operated on electively |
Senagore 2003 [35] | USA Monocentric, academic | Retrospective observational cohort study | Colonic Open/Lap Cancer/Benign |
50 ERP ≥ 70y, lap
123 ERP ≥ 70y, open
181 ERP <60y, lap 122 ERP <60y, open |
77.5 (SE ± 4.6)
77.8 (SE ± 5.4)
42.4 (SE ±12.3) 46.7 (SE ±9.8) | 4 age-matched cohorts Elective segmental colectomy Laparoscopic/open when excluded for laparoscopic approach based on standardised criteria | Prior major abdominal surgery Incomplete data |
Bardram 2000 [36] | Denmark Monocentric, academic | Retrospective observational cohort study | Colonic Laparoscopic Cancer/Benign |
39 ERP ≥ 70y, lap
11 ERP ≥70y, converted | Overall: 81 (70–93) | Laparoscopic colonic resection Laparoscopic surgery 70–75y: benign disease or malignant disease with severe cardiopulmonary disease > 75y: malignant disease | Not elective Tumours in the transverse colon or rectum Patients not self-caring and not admitted directly from home |
Risk of bias (quality) assessment
Components of the ERP
Zeng 2017 [16] | Pirrera 2017 [17] | Forsmo 2017 [18] | Braga 2017 [19] | Braga 2016 [20] | Gonzalez-Ayora 2016 [21] | Pedziwiatr 2015 [22] | Kisialeuski 2015 [23] | Jia 2014 [24] | Keller 2013 [25] | Feroci 2013 [26] | Baek 2013 [27] | Wang 2012 [28] | Pawa 2012 [29] | Walter 2011 [30] | Kahokehr 2011 [31] | Rumstadt 2009 [32] | Hendry 2009 [33] | Scharfenberg 2007 [34] | Senagore 2003 [35] | Bardram 2000 [36] |
Total per ERP component (median = 13.5)
| |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
1. Pre-operative counselling | 0 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 |
18
|
2. Pre-operative optimisation | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 1 | 0 | 0 | 1 | 0 | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
4
|
3. Avoidance of bowel preparation in colonic surgery | 1 | 1 | 0 | 1 | 1 | 1 | 1 | 1 | 0 | 0 | 1 | 1 | 0 | 0 | 1 | 1 | 1 | 0 | 0 | 0 | 0 |
12
|
4a. Limited pre-operative fasting time | 1 | 1 | 1 | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 1 | 1 | 0 | 0 | 1 | 1 | 0 | 1 | 0 | 0 | 0 |
16
|
4b. Carbohydrate loading | 0 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 0 | 0 | 0 | 1 | 1 | 1 | 1 | 0 | 1 | 0 | 0 | 0 | |
5. Avoid sedative premedication | 0 | 0 | 1 | 1 | 1 | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | 0 |
5
|
6. Prophylaxis against thromboembolism | 0 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
11
|
7. Antimicrobial prophylaxis | 0 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 0 | 1 | 0 | 0 | 0 | 0 | 1 | 0 | 1 |
13
|
8. Standard anaesthetic protocol1 | 1 | 0 | 1 | 1 | 1 | 0 | 1 | 0 | 1 | 1 | 1 | 0 | 1 | 0 | 1 | 1 | 1 | 1 | 1 | 0 | 1 |
15
|
9. PONV prophylaxis/treatment | 0 | 0 | 0 | 1 | 1 | 0 | 1 | 1 | 0 | 0 | 1 | 0 | 0 | 0 | 0 | 1 | 1 | 1 | 0 | 0 | 0 |
8
|
10. Laparoscopy and modifications of surgical acces2 | 1 | 1 | 1 | 0 | 0 | 0 | 1 | 1 | 0 | 1 | 0 | 1 | 1 | 1 | 1 | 0 | 1 | 1 | 0 | 1 | 1 |
14
|
11. Avoidance of nasogastric tubes | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 |
21
|
12. Prevention intra-operative hypothermia | 0 | 1 | 1 | 1 | 1 | 1 | 0 | 0 | 0 | 0 | 1 | 1 | 0 | 1 | 1 | 1 | 0 | 1 | 0 | 0 | 0 |
11
|
13. Peri-operative fluid management | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 0 | 0 | 0 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 0 | 1 |
17
|
14. Avoid abdominal or pelvic drains | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 0 | 0 | 0 | 0 | 1 | 1 | 1 | 1 | 0 | 0 | 0 | 0 |
13
|
15. Early removal of urinary catheters | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 |
21
|
16. Prevention of post-operative ileus3 | 0 | 1 | 1 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | 0 | 1 | 1 | 1 | 0 | 0 |
7
|
17. Opioid sparing multimodal post-operative analgesia | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 |
21
|
18. Early oral intake | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 |
21
|
19. Peri-operative glycaemic control | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
0
|
20. Early mobilisation | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 |
21
|
Total ERP components per article (median = 13)
|
11
|
15
|
16
|
16
|
16
|
14
|
15
|
16
|
8
|
10
|
15
|
13
|
10
|
14
|
13
|
13
|
13
|
14
|
10
|
7
|
10
|
Adherence to the ERP
Braga 2017 [19] | Braga 2016 [20] | Gonzalez-Ayora 2016 [21] | Pedziwiatr 2015 [22] | Kisialeuski 2015 [23] | Feroci 2013 [26] | Pawa 2012 [29] | Rumstadt 2009 [32] | Scharfen-berg 2007 [34] | range | |||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
71-75y | 76-80y | > 80y | ≥ 70y, ASA 1,2 | ≥ 70y, ASA 3,4 | ≥ 70y | ≥ 80y | > 65y | ≥75y | ≥ 80y | 70-79y | ≥80 y | >70y | ||
n = 105 | n = 117 | n = 93 | n = 167 | n = 162 | n = 188 | n = 34 | n = 49 | n = 204 | n = 130 | n = 535 | n = 207 | n = 74 | ||
1.Pre-admission counselling | 100 | 99 | 97 | 100 | 100 | 100 | 100 | 97–100 | ||||||
3.No bowel preparation | 90 | 86 | 90 | 91 | 85 | 80 | 100 | / | 80 | 83 | / | 80–100 | ||
4a.Limited pre-operative fasting time | / | / | / | / | / | / | / | / | 100 | / | / | / | / | |
4b.Carbohydrate loading | 80 | 81 | 82 | 87 | 73 | 100 | 77 | / | / | / | / | 73–100 | ||
5.No sedative premedication | 40 | 44 | 40 | 40 | 40 | / | / | / | 100 | / | / | / | / | 40–100 |
6.Antithrombotic prophylaxis | 100 | 100 | 100 | 100 | 100 | 100 | 100 | / | / | / | 100 | |||
7.Antimicrobial prophylaxis | 100 | 100 | 100 | 100 | 100 | 100 | 100 | / | / | 100 | ||||
9.PONV prophylaxis | 73 | 66 | 88 | 88 | 61 | / | 60 | / | 93 | 95 | / | 60–95 | ||
10.Minimal invasive surgery | / | / | / | / | / | / | / | / | / | 93 | 39 | 25 | / | 25–93 |
11.No nasogastric tube | 91 | 93 | 90 | 92 | 92 | 100 | 100 | 90–100 | ||||||
12.Active warming | 99 | 97 | 95 | 100 | 100 | / | / | 100 | / | / | / | 95–100 | ||
13.Peri-operative fluid management | 92 | / | ||||||||||||
- Intra-operative fluids (mean ± SD or median and IQR, in ml/kg/h) | 9.7 (±4.1) | 8.5 (±4.0) | 10.3 (±5.9) | 7.2 (4.8–10.1) | 8.9 (6.1–12.6) | 7.2–10.3 | ||||||||
- Infusion < 3000 ml during surgery | 87 | 81 | 81–87 | |||||||||||
- Stop IV fluid POD 1 | 73 | / | 24 | 75 | 62 | 24–75 | ||||||||
- Stop IV fluid POD 2 | 74 | 67 | 60 | 70 | 67 | 60–74 | ||||||||
14.No abdominal drain | 30 | 33 | 44 | 37 | 31 | 43 | 80 | / | / | 30–80 | ||||
15.Early (per protocol) UC removal | 70 | 67 | 69 | 78 | 62 | 65 | 80 | 64 | 56 | 56–80 | ||||
17.Multimodal opioid sparing analgesia | ||||||||||||||
- Non-opioid based analgesia | 74 | 92 | 89 | 74–92 | ||||||||||
- Epidural analgesia | 50 | 51 | 58 | 61 | 43 | 62 | 55 | 86 | 86 | 43–86 | ||||
- Epidural catheter removal ≤ POD 3 | 36 | 38 | 47 | 78 | 75 | 69 | 36–78 | |||||||
18.Early oral intake | ||||||||||||||
- Oral liquids POD 0 | 59 | 59 | 49 | 56 | 57 | 75 | 69 | 84 | 49–84 | |||||
- Oral liquids POD 1 | 90 | 92 | 90 | 87 | 46 | 46–92 | ||||||||
- Oral liquids POD 0–1 | 84 | |||||||||||||
- Solid food POD 1 | 53 | 57 | 52 | 52 | 57 | 82 | 73 | 60 | 51 | 86 | 51–86 | |||
- Solid food POD 2 | 77 | 86 | 82 | 92 | 39 | 39–92 | ||||||||
20.Early mobilisation | ||||||||||||||
- Out of bed POD 0 | 90 | 60 | 71 | 55 | 55–90 | |||||||||
- Out of bed POD 1 | 93 | 91 | 89 | 95 | 86 | 94 | 55 | 20 | 69 | 53 | 20–95 | |||
Global Compliance | 661 | 561 | 562 | 853 | 56–85 |
Outcomes of the ERP
Zeng 2017 [16] | Pirrera 2017 [17] | Forsmo 2017 [18] | Braga 2017 [19] | Braga 2016 [20] | Gonzalez-Ayora 2016 [21] | Pedziwiatr 2015 [22] | Kisialeuski 2015 [23] | Jia 2014 [24] | Keller 2013 [25] | Feroci 2013 [26] | Baek 2013 [27] | Wang 2012 [28] | Pawa 2012 [29] | Walter 2011 [30] | Kahokehr 2011 [31] | Rumstadt 2009 [32] | Hendry 2009 [33] | Scharfenberg 2007 [34] | Senagore 2003 [35] | Bardram 2000 [36] | ||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Age (years) | ≥75 | 66–75 | > 75 | 66–79 | ≥80 | 71–75 | 76–80 | > 80 | ≥70 | ≥70 | ≥80 | > 65 | ≥70 | ≥70 | ≥75 | ≥70 | ≥65 | ≥80 | ≥80 | > 75 | 70–79 | ≥80 | ≥80 | ≥70 | ≥70 | ≥70 |
n of patients | 94 | 175 | 203 | 56 | 19 | 105 | 117 | 93 | 329 | 188 | 34 | 49 | 117 | 153 | 204 | 77 | 40 | 130 | 68 | 22 | 535 | 207 | 194 | 74 | 173 | 39 |
MORBIDITY1 (in %) | ||||||||||||||||||||||||||
- inH | 21.1 | 21.2 | 37.8 | 23.5 | 36.7 | 17.0 | 26.0 | 5.0 | 31.2 | |||||||||||||||||
- 30d | 24.5 | 41.2 | 52.6 | 21.0 | 18.8 | 30.1 | 29.8 | 37.3 | 23.0 | 38.2 | 33.0 | 21.6 | 20.5 | |||||||||||||
MORTALITY (in %) | ||||||||||||||||||||||||||
- inH | 0 | 0 | 0 | 1.6 | 0 | 0 | 0 | 0 | 0 | 1.2 | ||||||||||||||||
- 30d | 2.1 | 3.6 | 5.3 | 0 | 0 | 0 | 0.3 | 0 | 6.4 | 16.2 | 4 | 0 | 1.1 | 1.0 | 3.1 | 1.4 | 5.1 | |||||||||
LOS (in days) | ||||||||||||||||||||||||||
- Post-operative (mean, ±SD) | 4.7 ± 4.5 | 4.7 ±5.1 | 6.2 ± 3.1 | 6.7 ± 3.5 | 7.3 ± 3.6 | 5.4 ±5 | 5.5 ± 4 | |||||||||||||||||||
- Post-operative (median, range) | 6 (4–21) | 5 (2–21) | 6.5 (3–50) | 6 (IQR 5–81 and 4–72) | 5 (IQR 3–7) | 7 (3–43) | 8 (4–27) | 5.5 (IQR 5–6) | 7 (IQR 6–10) | 8 (2–83) | 11 (1–53) | 5 (3–56) | 2.5 (2–90) | |||||||||||||
- total (mean, ±SD) | 9.0 ±1.75 | 5.0 ±4.91 | ||||||||||||||||||||||||
- total (median, range) | 12 (7–31) | 8 (IQR 5–14) | 6 (IQR 3–8) | |||||||||||||||||||||||
READMISSION (in %) - 30d | 4.6 | 4.9 | 25.0 | 21.1 | 5.7 | 1.7 | 1.1 | 2.4 | 6.4 | 2.9 | 6.1 | 4.6 | 1.5 | 11.7 | 6.2 | 4 | 4.7 | 2.4 | 12.2 | 6.4 | 5.1 | |||||
REOPERATION (in %) | 5.3 | 1.2 | 3.4 | 14.3 | 10.5 | 5 | 5 | 4 | 5.2 | 8.5 | 0 | 4.1 | 1.3 | 8.5 | 0.6 | 7.7 |