Closing the Gap: A Systematic Review and Meta-Analysis of Enhanced Recovery After Surgery Protocols in Primary Cleft Palate Repair

Abstract

Objective Assess the evidence for Enhanced Recovery After Surgery (ERAS) protocols in the cleft palate population. Design A systematic review of MEDLINE, Embase, Cochrane, and CINAHL databases for articles detailing the use of ERAS protocols in patients undergoing primary palatoplasty. Setting New York-Presbyterian Hospital. Patients/Participants Patients with cleft palate undergoing primary palatoplasty. Interventions Meta-analysis of reported patient outcomes in ERAS and control cohorts. Main Outcome Measure(s) Methodological quality of included studies, opioid use, postoperative length of stay (LOS), rate of return to emergency department (ED)/readmission, and postoperative complications. Results Following screening, 6 original articles were included; all were of Modified Downs & Black (MD&B) good or fair quality. A total of 354 and 366 were in ERAS and control cohorts, respectively. Meta-analysis of comparable ERAS studies showed a difference in LOS of 0.78 days for ERAS cohorts when compared to controls ( P < .05). Additionally, ERAS patients utilized significantly less postoperative opioids than control patients ( P < .05). Meta-analysis of the rate of readmission/return to ED shows no difference between ERAS and control groups ( P = .59). However, the lack of standardized reporting across studies limited the power of meta-analyses. Conclusions ERAS protocols for cleft palate repair offer many advantages for patients, including a significant decrease in the LOS and postoperative opioid use without elevating readmission and return to ED rates. However, this analysis was limited by the paucity of literature on the topic. Better standardization of data reporting in ERAS protocols is needed to facilitate pooled meta-analysis to analyze their effectiveness.

Patient Safety and Quality Improvement Initiatives in Cleft Lip and Palate Surgery: A Systematic Review

“…Compared with historical controls, ERAS patients were found to have increased oral intake (22.3 mL/h versus 15.4 mL/h; P < 0.001), less narcotic usage (P < 0.01), and a 36.6% decrease in length of stay (P < 0.0001), without an increase in complications. Similar conclusions were found by Asadourian et al 67 where ERAS cohorts had significantly lower LOS (P < 0.05) and postoperative opioid use (P < 0.05), yet similar rates of readmission or return to the emergency department (P = 0.59).…”

“…Two studies examined the topic of Enhanced Recovery After Surgery (ERAS) in cleft surgery (Supplemental Table 12, Supplemental Digital Content 12, http://links.lww.com/SCS/ E649). 66,67 The ERAS protocol of the study by Hush et al 66 included the use of gabapentinoids, minimal operative narcotic use, and postoperative pain control using non-narcotic first-line agents for cleft palate repair. Compared with historical controls, ERAS patients were found to have increased oral intake (22.3 mL/h versus 15.4 mL/h; P < 0.001), less narcotic usage (P < 0.01), and a 36.6% decrease in length of stay (P < 0.0001), without an increase in complications.…”

Advances in Cleft Lip and Palate Surgery

“…The application of standardized clinical pathways in cleft care has also been shown to decrease length of stay and opioid consumption without concomitant readmissions or return to the emergency department [24]. Multidisciplinary quality improvement studies to decrease opioid use demonstrate the institutional efforts required to reprioritize goals and standardize goal setting between all key stakeholders.…”