title: Enhanced recovery pathways in abdominal gynecologic surgery: a systematic review and meta-analysis.
abstract: BACKGROUND
  Enhanced recovery pathways have been widely accepted and implemented for different types of surgery. Their overall effect in abdominal gynecologic surgery is still underdetermined. A systematic review and meta-analysis were performed to provide an overview of current evidence and to examine their effect on postoperative outcomes in women undergoing open gynecologic surgery.
  
  
  METHODS
  Searches were conducted using Embase, Medline, CINAHL, and the Cochrane Library up to 27 June 2014. Reference lists were screened to identify additional studies. Studies were included if at least four individual items of an enhanced recovery pathway were described. Outcomes included length of hospital stay, complication rates, readmissions, and mortality. Quantitative analysis was limited to comparative studies. Effect sizes were presented as relative risks or as mean differences (MD) with 95% confidence intervals (CI).
  
  
  RESULTS
  Thirty-one records, involving 16 observational studies, were included. Diversity in reported elements within studies was observed. Preoperative education, early oral intake, and early mobilization were included in all pathways. Five studies, with a high risk of bias, were eligible for quantitative analysis. Enhanced recovery pathways reduced primary (MD -1.57 days, 95% CI CI -2.94 to -0.20) and total (MD -3.05 days, 95% CI -4.87 to -1.23) length of hospital stay compared with traditional perioperative care, without an increase in complications, mortality or readmission rates.
  
  
  CONCLUSIONS
  The available evidence based on a broad range of non-randomized studies at high risk of bias suggests that enhanced recovery pathways may reduce length of postoperative hospital stay in abdominal gynecologic surgery.
authors.affiliation: Department of Family Medicine, CAPHRI, School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands.|Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht, The Netherlands.
authors.forename: Jeanny J A
authors.identifier: http://orcid.org/0000-0002-0000-4752
authors.initials: JJ
authors.lastname: de Groot
authors.affiliation: Department of Family Medicine, CAPHRI, School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands.|Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center, Maastricht, The Netherlands.
authors.forename: Stephanie M C
authors.identifier: http://orcid.org/0000-0002-6460-3287
authors.initials: SM
authors.lastname: Ament
authors.affiliation: Department of Family Medicine, CAPHRI, School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands.|Department of Patient & Integrated Care, Maastricht University Medical Center, Maastricht, The Netherlands.
authors.forename: José M C
authors.identifier: http://orcid.org/0000-0001-9512-488X
authors.initials: JM
authors.lastname: Maessen
authors.affiliation: Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.|NUTRIM, School for Nutrition, Toxicology, and Metabolism, Maastricht University Medical Center, Maastricht, The Netherlands.
authors.forename: Cornelis H C
authors.identifier: http://orcid.org/0000-0003-1824-7303
authors.initials: CH
authors.lastname: Dejong
authors.affiliation: Department of Family Medicine, CAPHRI, School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands.|Kleijnen Systematic Reviews Ltd, York, UK.
authors.forename: Jos M P
authors.identifier: http://orcid.org/0000-0003-2787-7091
authors.initials: JM
authors.lastname: Kleijnen
authors.affiliation: Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht, The Netherlands.|GROW, School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands.
authors.forename: Brigitte F M
authors.identifier: http://orcid.org/0000-0003-2811-3851
authors.initials: BF
authors.lastname: Slangen
mesh_terms: D000005:Abdomen / Q000601:surgery*; D005260:Female; D013509:Gynecologic Surgical Procedures; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay; D010359:Patient Readmission; D019990:Perioperative Care; D011183:Postoperative Complications
keywords: Enhanced recovery; enhanced recovery after surgery; gynecology; perioperative care; surgery