Effect of Enhanced Recovery After Surgery programs on surgical site infection and 30-day readmission in patients undergoing gastro-intestinal procedures: An umbrella review

Abstract

Background: Enhanced Recovery After Surgery programs have been implemented across surgical specialties; however, their effectiveness in reducing surgical site infection and 30-day hospital readmission remains unclear. Objective: To determine the effect of Enhanced Recovery After Surgery programs on the clinical outcomes of surgical site infection and readmission and identify items of and implementation strategies for such programs. Design: An umbrella review of published systematic reviews. Methods: Systematic searches of MEDLINE, Embase, CINAHL, Cochrane Library, and Scopus databases were conducted in January 2025. Systematic reviews of randomised controlled trials and non-randomised studies of interventions comparing Enhanced Recovery After Surgery programs with standard care in adults after major open or laparoscopic gastrointestinal surgery, focusing on surgical site infection and 30-day hospital readmission, were included. Review quality and certainty of evidence were assessed using A MeaSurement Tool to Assess systematic Reviews (AMSTAR 2) and GRADE (Grading of Recommendations Assessment, Development and Evaluation) tools. Results: 49 reviews were included in the analysis. Meta-analysis of 42 unique primary randomised controlled trials with 5112 patients suggests a significant association between Enhanced Recovery After Surgery programs use and surgical site infection reduction (estimated odds ratio 0.70, 95 % confidence interval 0.59-0.82, p < 0.001, I2 = 0 %). Meta-analysis of 53 primary randomised controlled trials with 7360 patients suggests no significant relationship between Enhanced Recovery After Surgery programs and hospital readmission (estimated odds ratio 1.025, 95 % confidence interval 0.85-1.23, p = 0.792, I2 = 0 %). Summary estimates for surgical site infection were similar across non-randomised studies of interventions. GRADE assessments suggest 'very low' certainty across outcomes. Enhanced Recovery After Surgery programs included 5 to 28 components; implementation strategies were not described. Discussion: Results suggest an association between Enhanced Recovery After Surgery programs and reductions in surgical site infection, and no relationship between hospital readmissions. However, the body of evidence is weak and inconclusive. These results also indicate heterogeneity in compliance with Enhanced Recovery After Surgery, reflecting the complexity in standardising this surgical care pathway. Conclusions: Well-controlled primary research is warranted to understand the impact of Enhanced Recovery After Surgery programs. Registration: PROSPERO registration number: CRD42024503357. Social media abstract: Enhanced Recovery After Surgery programs may significantly reduce surgical site infections after GI surgery but there is no clear impact on 30-day readmissions.