title: An overview and methodological assessment of systematic reviews and meta-analyses of enhanced recovery programmes in colorectal surgery.
abstract: OBJECTIVE
  To identify and critically assess the extent to which systematic reviews of enhanced recovery programmes for patients undergoing colorectal surgery differ in their methodology and reported estimates of effect.
  
  
  METHODS
  Review of published systematic reviews. We searched the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA) Database from 1990 to March 2013. Systematic reviews of enhanced recovery programmes for patients undergoing colorectal surgery were eligible for inclusion.
  
  
  METHODS
  The primary outcome was length of hospital stay. We assessed changes in pooled estimates of treatment effect over time and how these might have been influenced by decisions taken by researchers as well as by the availability of new trials. The quality of systematic reviews was assessed using the Centre for Reviews and Dissemination (CRD) DARE critical appraisal process.
  
  
  RESULTS
  10 systematic reviews were included. Systematic reviews of randomised controlled trials have consistently shown a reduction in length of hospital stay with enhanced recovery compared with traditional care. The estimated effect tended to increase from 2006 to 2010 as more trials were published but has not altered significantly in the most recent review, despite the inclusion of several unique trials. The best estimate appears to be an average reduction of around 2.5 days in primary postoperative length of stay. Differences between reviews reflected differences in interpretation of inclusion criteria, searching and analytical methods or software.
  
  
  CONCLUSIONS
  Systematic reviews of enhanced recovery programmes show a high level of research waste, with multiple reviews covering identical or very similar groups of trials. Where multiple reviews exist on a topic, interpretation may require careful attention to apparently minor differences between reviews. Researchers can help readers by acknowledging existing reviews and through clear reporting of key decisions, especially on inclusion/exclusion and on statistical pooling.
authors.affiliation: Centre for Reviews and Dissemination, University of York, York, UK.
authors.forename: Duncan
authors.initials: D
authors.lastname: Chambers
authors.affiliation: Centre for Reviews and Dissemination, University of York, York, UK.
authors.forename: Fiona
authors.initials: F
authors.lastname: Paton
authors.affiliation: Centre for Reviews and Dissemination, University of York, York, UK.
authors.forename: Paul
authors.initials: P
authors.lastname: Wilson
authors.affiliation: Centre for Reviews and Dissemination, University of York, York, UK.
authors.forename: Alison
authors.initials: A
authors.lastname: Eastwood
authors.affiliation: Centre for Reviews and Dissemination, University of York, York, UK.
authors.forename: Dawn
authors.initials: D
authors.lastname: Craig
authors.affiliation: Centre for Reviews and Dissemination, University of York, York, UK.
authors.forename: Dave
authors.initials: D
authors.lastname: Fox
authors.affiliation: Leeds Teaching Hospitals NHS Trust, Leeds, UK.
authors.forename: David
authors.initials: D
authors.lastname: Jayne
authors.affiliation: Leeds Teaching Hospitals NHS Trust, Leeds, UK.
authors.forename: Erika
authors.initials: E
authors.lastname: McGinnes
mesh_terms: D003106:Colon / Q000601:surgery*; D013505:Digestive System Surgical Procedures / Q000592:standards*; D005069:Evaluation Studies as Topic; D006801:Humans; D015201:Meta-Analysis as Topic; D011300:Preoperative Care / Q000592:standards*; D012007:Rectum / Q000601:surgery*; D012196:Review Literature as Topic
keywords: Enhanced Recovery After Surgery; Fast Track; Surgery