Enhanced recovery after surgery protocol allows ambulatory laparoscopic appendectomy in uncomplicated acute appendicitis: a prospective, randomized trial
Previous observational studies have demonstrated the safety of discharging patients after laparoscopic appendectomy within the same day without hospitalization. The application of Enhanced Recovery After Surgery (ERAS) guidelines has resulted in shorter length of stay, fewer complications, and reduction in medical costs. The aim of this study was to investigate if ERAS protocol implementation in patients with acute uncomplicated appendicitis decreases the length of stay enough to allow for ambulatory laparoscopic appendectomy.
In this prospective, randomized controlled clinical trial, 108 patients were randomized into two groups: laparoscopic appendectomy with ERAS (LA-E) or laparoscopic appendectomy with conventional care (LA-C). The primary endpoint was postoperative length of stay. The secondary end points were time to resume diet, postoperative pain, postoperative complications, re-admission rate, and reoperation rate.
From January 2016 through May 2017, 50 patients in the LA-E group and 58 in the LA-C were analyzed. There were no significant differences in preoperative data. Regarding the primary end point of the study, the ERAS protocol significantly reduced the postoperative length of stay with a mean of 9.7 h (SD: 3.1) versus 23.2 h (SD: 6.8) in the conventional group (p < 0.001). The ERAS protocol allowed ambulatory management in 90% of the patients included in this group. There was a significant reduction in time to resume diet (110 vs. 360 min, p < 0.001) and less moderate–severe postoperative pain (28 vs. 62.1%, p < 0.001) in the LA-E versus LA-C group. The rate of complications, readmissions, and reoperations were comparable in both groups (p = 0.772).
ERAS implementation was associated with a significantly shorter length of stay, allowing for the ambulatory management of this group of patients. Ambulatory laparoscopic appendectomy is safe and feasible with similar rates of morbidity and readmissions compared with conventional care.
KeywordsAcute appendicitis Enhanced recovery after surgery Ambulatory surgery Laparoscopic appendectomy
We would like to thank Violeta Díaz-Fermin MD, for helping us in collecting data.
Compliance with Ethical Standards
Mario E. Trejo-Ávila, Sujey Romero-Loera, Eduardo Cárdenas-Lailson, Miguel Blas-Franco, Roberto Delano-Alonso, Carlos Valenzuela-Salazar, and Mucio Moreno-Portillo have no conflicts of interest or financial ties to disclose.
- 1.Gorter RR, Eker HH, Gorter-Stam MA, Abis GS, Acharya A, Ankersmit M, Antoniou SA, Arolfo S, Babic B, Boni L, Bruntink M, van Dam DA, Defoort B, Deijen CL, DeLacy FB, Go PM, Harmsen AM, van den Helder RS, Iordache F, Ket JC, Muysoms FE, Ozmen MM, Papoulas M, Rhodes M, Straatman J, Tenhagen M, Turrado V, Vereczkei A, Vilallonga R, Deelder JD, Bonjer J (2016) Diagnosis and management of acute appendicitis. EAES consensus development conference 2015. Surg Endosc 30(11):4668–4690CrossRefPubMedPubMedCentralGoogle Scholar
- 13.Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N, McNaught CE, MacFie J, Liberman AS, Soop M, Hill A, Kennedy RH, Lobo DN, Fearon K, Ljungqvist O (2013) Guidelines for perioperative care in elective colonic surgery: enhanced recovery after surgery (ERAS) society recommendations. World J Surg 37(2):259–284CrossRefPubMedGoogle Scholar
- 17.Kraft K, Mariette C, Sauvanet A, Balon JM, Douard R, Fabre A, Guidat A, Huten N, Johanet H, Laurent A, Muscari F, Pessaux P, Pierme JP, Piessen G, Raucoules-Aime M, Rault A, Vons C (2011) Indications for ambulatory gastrointestinal and endocrine surgery in adults. J Visc Surg 148(1):69–74CrossRefPubMedGoogle Scholar
- 27.Frazee R, Burlew CC, Regner J, McIntyre R, Peltz E, Cribari C, Dunn J, Butler L, Reckard P, Dissanaike S, Karimi K, Behnfield C, Melo N, Margulies D (2017) Outpatient laparoscopic appendectomy can be successfully performed for uncomplicated appendicitis: a Southwestern Surgical Congress Multicenter Trial. Am J Surg. https://doi.org/10.1016/j.amjsurg.2017.08.029 CrossRefPubMedGoogle Scholar
- 29.Spanjersberg WR, Reurings J, Keus F, van Laarhoven CJ (2011) Fast track surgery versus conventional recovery strategies for colorectal surgery. Cochrane Database Syst Rev 2:CD007635Google Scholar