ERAS In Older Adults Undergoing Major Abdominal Surgery

Key Takeaways

• ERAS was associated with shorter length of stay and fewer total complications than conventional perioperative care.
• Thirty-day readmission was not significantly different, and the mortality estimate favored ERAS but warranted cautious interpretation.
• The evidence base included 15 studies, mostly colorectal surgery, with variable compliance reporting and moderate-to-low certainty across outcomes.

In patients aged 65 years and older undergoing major abdominal surgery, ERAS pathways were associated with a 3.31-day shorter hospital stay than conventional care. A recent systematic review and meta-analysis pooled evidence on older adults treated with ERAS or fast-track surgery. Postoperative complications were also lower with ERAS, while readmission did not differ significantly.

Enhanced recovery after surgery pathways, also described as fast-track surgery, were compared with conventional perioperative care across 15 studies, including 6 randomized trials and 9 prospective cohort studies. The analysis included 2,397 patients, with 1,200 managed in ERAS pathways and 1,197 receiving control care. Most reports involved colorectal procedures, while two studies each evaluated hepatectomy and gastrectomy. Length of hospital stay was the primary outcome, and total complications, 30-day mortality, and 30-day readmission were secondary outcomes.

Hospital stay was shorter with ERAS in the pooled analysis, and subgroup analyses showed a similar direction across randomized and cohort studies. Total complications were lower with ERAS, with a pooled RR of 0.63, 95% CI 0.56 to 0.71, P<0.0001, and I² of 0%. The complication effect was more pronounced in randomized trials than in prospective cohorts, and the subgroup difference reached statistical significance at P=0.038. Heterogeneity was moderate for length of stay at I²=62.2%, but it was absent for complications. Overall, the pooled analysis showed shorter stays and fewer postoperative complications with ERAS.

For 30-day mortality, the pooled RR was 0.53, with a 95% CI of 0.28 to 1.00 and P=0.049, based on 11 versus 24 deaths. Events were few, and the confidence interval reached the null boundary. Thirty-day readmission did not differ significantly, with an RR of 0.78, 95% CI 0.56 to 1.08, P=0.135, and 59 versus 75 events. Common ERAS elements included early feeding, early mobilization, and reduced routine tube use, with several studies also describing counseling, fluid targets, multimodal analgesia, and earlier catheter removal. Overall compliance was reported in 6 of 15 studies and ranged from 42% to 89.6%, limiting assessment of pathway fidelity.

Risk of bias was assessed with Cochrane RoB 2.0 for randomized trials and the Newcastle-Ottawa Scale for cohort studies. GRADE certainty was moderate for length of stay and complications, and low for mortality and readmission. Leave-one-out testing and exclusion of the one non-elderly hepatectomy study produced materially similar results, while possible publication bias for length of stay did not alter trim-and-fill conclusions. Comparability remained limited by mixed study designs, varying age thresholds, procedures, discharge criteria, pathway composition, complication definitions, English-language-only inclusion, and incomplete compliance reporting. The authors concluded that ERAS appeared effective and generally safe in this setting, although implementation variability and lower-certainty secondary outcomes tempered interpretation.