Methodological quality in guidelines for enhanced recovery after surgery was suboptimal

We aimed to appraise the methodological quality of existing guidelines for Enhanced Recovery After Surgery (ERAS) using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument and to identify the concordance of different recommendations. PubMed, Embase, Google Scholar, Web of Science, and clinical practice guideline websites were systematically searched. Four reviewers independently assessed the guidelines using the AGREE II instrument. The mean score of each AGREE II item, number of recommendations, strength of recommendation, and level of evidence were calculated. Agreement among reviewers was assessed using the intraclass correlation coefficient. We identified 23 guidelines from 7,127 records. The overall agreement among reviewers was considered good (intraclass correlation coefficient, 0.92; 95% confidence interval [CI], 0.86–0.96). The mean scores of the six AGREE domains were scope and purpose, 60.1% (95% CI, 55.9–64.1); stakeholder involvement, 40.7% (95% CI, 35.4–46.0); rigor of development, 44.7% (95% CI, 42.2–47.2); clarity and presentation, 69.8% (95% CI, 65.3–74.3); applicability, 37.2% (95% CI, 31.8–42.6); and editorial independence, 47.8% (95% CI, 39.0–56.7). Only 2/23 ERAS guidelines were considered applicable without modifications. The methodological quality of the ERAS management guidelines varied and was generally low. Future guideline development should adhere to the use of the AGREE II instrument and the GRADE system to better guide clinical practice and improve individualized treatment strategies.