Role of regional anesthesia and analgesia in enhanced recovery after colorectal surgery: a systematic review of randomized controlled trials

Background Effective analgesia is an important element of enhanced recovery after surgery (ERAS), but the clinical impact of regional anesthesia and analgesia for colorectal surgery remains unclear. Objective We aimed to determine the impact of regional anesthesia following colorectal surgery in the setting of ERAS. Evidence review We performed a systematic review of nine databases up to June 2020, seeking randomized controlled trials comparing regional anesthesia versus control in an ERAS pathway for colorectal surgery. We analyzed the studies with successful ERAS implementation, defined as ERAS protocols with a hospital length of stay of <= 5 days. Data were qualitatively synthesized. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. Findings Of the 29 studies reporting ERAS pathways, only 13 comprising 1170 patients were included, with modest methodological quality and poor reporting of adherence to ERAS pathways. Epidural analgesia had limited evidence of outcome benefits in open surgery, while spinal analgesia with intrathecal opioids may potentially be associated with improved outcomes with no impact on length of stay in laparoscopic surgery, though dosing must be further investigated. There was limited evidence for fascial plane blocks or other regional anesthetic techniques. Conclusions Although there was variable methodological quality and reporting of ERAS, we found little evidence demonstrating the clinical benefits of regional anesthetic techniques in the setting of successful ERAS implementation, and future studies must report adherence to ERAS in order for their interventions to be generalizable to modern clinical practice. PROSPERO registration number CRD42020161200.