Rollins, Katie Elisabeth
(2019)
Generating evidence for the perioperative care of patients undergoing elective colorectal surgery.
PhD thesis, University of Nottingham.
Abstract
Background and Aims
The concept of ‘Enhanced Recovery After Surgery’ (ERAS) pathways was introduced almost a quarter of a century ago, consisting of a series of nine interventions. More recent ERAS pathways have included significantly greater numbers of interventions, some of which have been based on variable quality evidence. The aim of this thesis was to identify interventions which are controversial or where new literature may alter their evidence base, then to systematically evaluate this evidence in order to analyse their efficacy as part of a perioperative multimodal intervention.
Methods
The aims of this thesis were investigated by four meta-analyses conducted according to Cochrane Collaboration methodology and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The topics for these meta-analyses were mechanical bowel preparation (MBP), oral antibiotic (OAB) preparation, goal-directed fluid therapy (GDFT) and intravenous lidocaine (IVL) infusion in the perioperative management of patients undergoing elective colorectal surgery.
Results
The role of MBP versus no bowel preparation in elective colorectal surgery was evaluated in a meta-analysis of 36 studies (21,568 patients). In the most comprehensive analysis performed to date, MBP was not associated with a significant difference in any clinical outcome measure examined and as such should not be routinely administered prior to elective colorectal surgery.
A meta-analysis concerning the role of OAB preparation, both with and without MBP, was conducted including 40 studies (74,714 patients). This demonstrated that combined MBP and OAB was associated with a significant reduction in surgical site infection (SSI), anastomotic leak, 30-day mortality, and development of ileus, with no significant difference seen in Clostridium difficile rates versus no preparation. Interestingly, no difference was observed in the incidence of SSI when combined MBP and OAB, and OAB alone were compared.
The role of goal-directed fluid therapy (GDFT) versus conventional fluid management was evaluated in a meta-analysis of 11 RCTs (1113 patients). No benefit was found associated with GDFT in overall morbidity, hospital length of stay (LOS), 30-day mortality, SSI, anastomotic leak, incidence of postoperative ileus, or time to return of gastrointestinal function.
Finally, the administration of perioperative IVL infusion was evaluated in a meta-analysis of 10 RCTs (610 patients). This demonstrated that IVL infusion was associated with a significant reduction in time to defecation, visual analogue scale (VAS) rated pain scores at rest at early time points, VAS score on coughing at 12 hours and hospital LOS. However, no difference was seen in the time to return of flatus, pain at rest at 48 hours, overall morphine consumption, and anastomotic leak or prolonged postoperative ileus rates.
Conclusion
This thesis has provided high-quality evidence on four components which contribute to ERAS pathways in elective colorectal surgery. This thesis has provided evidence suggesting that bowel preparation with either the combination of MBP and OAB, or OAB alone, and perioperative IVL infusion should be considered as a potential standard of care, whereas MBP alone does not have a place due to its potentially deleterious effects and lack of clinical benefit. GDFT does not appear to have a role in low risk patients undergoing elective colorectal surgery, however further evidence is required in high-risk patient groups. This thesis has demonstrated the beneficial effects of evaluation of single components within a multimodal, complex intervention such as ERAS pathways, such that all included interventions do indeed provide ‘aggregation of marginal gains’ which culminate to produce a significant clinical benefit to patients.
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