Skip to main content
SpringerLink
Log in

Adapted ERAS Pathway Versus Standard Care in Patients Undergoing Emergency Small Bowel Surgery: a Randomized Controlled Trial

  • SSAT Plenary Presentation
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Background

Emergency laparotomy for small bowel pathologies comprises a significant number of all emergency surgeries. Application of evidence-based adapted enhanced recovery after surgery (ERAS) protocol can potentially improve the perioperative outcome in these procedures.

Aims

To determine the feasibility, safety, and efficacy of adapted ERAS pathway in emergency small bowel surgery.

Methodology

This was a single-center, prospective, open-labeled, superiority, randomized controlled trial. Patients suspected to have small bowel pathology by the emergency surgical team were randomized preoperatively into standard care and adapted ERAS group. Patients with American Society of Anesthesiologist class ≥ 3, polytrauma patients with associated other intra-abdominal organ injuries, duodenal ulcer perforations, patients presenting with refractory shock, and pregnant patients were excluded. Primary outcome parameter was the length of hospitalization (LOH). Morbidity and other functional recovery parameters were also assessed.

Results

Thirty-five patients were included in the adapted ERAS and standard care group. The laboratory and demographic variables were comparable. Patients in the ERAS group had significantly earlier recovery (days) in terms of first fluid diet (1.48 ± 0.18, p < 0.001), solid diet (2.11 ± 0.17, p < 0.001), time to first flatus (1.25 ± 0.24, p < 0.001), and first stool (1.8 ± 0.27, p < 0.001). Postoperative nausea, vomiting (RR 0.69, p = 0.19), pulmonary complications (RR 0.38, p = 0.16), superficial (RR 0.79, p = 0.33), and deep surgical site infections (RR 0.65, p = 0.39) were similar. Compared with the standard care group, ERAS group had significantly shorter LOH (8 ± 0.38 vs. 10.83 ± 0.42; Mean difference, 2.83 ± 0.56; p < 0.001).

Conclusion

Adapted ERAS pathways are feasible, safe, and significantly reduces the LOH in select patients undergoing emergency small bowel surgery.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg. 2008; 248: 189–98.

    Article  Google Scholar 

  2. Snchez-Jimnez R, Blanco A, Trebol Lpez J, Snchez A, Gutirrez F, Carmona Sez JA. ERAS (Enhanced Recovery after Surgery) in Colorectal Surgery. In: Khan J, editor. Colorectal Cancer - Surgery, Diagnostics and Treatment. First Ed. InTech; 2014; 487-503

  3. Nelson G, Altman AD, Nick A, Meyer LA, Ramirez PT, Achtari C, et al. Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations--Part I. Gynecol Oncol. 2016; 140:313–22.

    Article  CAS  Google Scholar 

  4. White JJE, Houghton-Clemmey R, Marval P. Enhanced recovery after surgery (ERAS): an orthopaedic perspective. J Perioper Pract. 2013;23 :228–32.

    Article  Google Scholar 

  5. Cerantola Y, Valerio M, Persson B, Jichlinski P, Ljungqvist O, Hubner M, et al. Guidelines for perioperative care after radical cystectomy for bladder cancer: Enhanced Recovery After Surgery (ERAS (®)) society recommendations. Clin Nutr Edinb Scotl. 2013; 32:879–87.

    Article  Google Scholar 

  6. Gotlib Conn L, Rotstein OD, Greco E, Tricco AC, Perrier L, Soobiah C, et al. Enhanced recovery after vascular surgery: protocol for a systematic review. Syst Rev. 2012; 1:52.

    Article  Google Scholar 

  7. Padilla Alarcón J, Peñalver Cuesta JC. Experience with lung resection in a fast-track surgery program. Arch Bronconeumol. 2013; 49:89–93.

    Article  Google Scholar 

  8. Batdorf NJ, Lemaine V, Lovely JK, Ballman KV, Goede WJ, Martinez-Jorge J, et al. Enhanced recovery after surgery in microvascular breast reconstruction. J Plast Reconstr Aesthetic Surg. 2015; 68:395–402.

    Article  Google Scholar 

  9. Greco M, Capretti G, Beretta L, Gemma M, Pecorelli N, Braga M. Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials. World J Surg. 2014; 38:1531–41.

    Article  Google Scholar 

  10. Dorcaratto D, Grande L, Pera M. Enhanced recovery in gastrointestinal surgery: upper gastrointestinal surgery. Dig Surg. 2013; 30:70–8.

    Article  Google Scholar 

  11. Varadhan KK, Neal KR, Dejong CHC, Fearon KCH, Ljungqvist O, Lobo DN. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. Clin Nutr Edinb Scotl. 2010; 29:434–40.

    Article  Google Scholar 

  12. Gouvas N, Tan E, Windsor A, Xynos E, Tekkis PP. Fast-track vs standard care in colorectal surgery: a meta-analysis update. Int J Colorectal Dis. 2009; 24:1119–31.

    Article  Google Scholar 

  13. Quiney N, Aggarwal G, Scott M, Dickinson M. Survival After Emergency General Surgery: What can We Learn from Enhanced Recovery Programmes? World J Surg 2016; 40:1283–7.

    Article  CAS  Google Scholar 

  14. Lyon A, Payne CJ, Mackay GJ. Enhanced recovery programme in colorectal surgery: does one size fit all? World J Gastroenterol. 2012 28; 18:5661–3.

  15. Gonenc M, Dural AC, Celik F, Akarsu C, Kocatas A, Kalayci MU, et al. Enhanced postoperative recovery pathways in emergency surgery: a randomised controlled clinical trial. Am J Surg. 2014; 207:807–14.

    Article  Google Scholar 

  16. Mohsina S, Shanmugam D, Sureshkumar S, Kundra P, Mahalakshmy T, Kate V. Adapted ERAS Pathway vs. Standard Care in Patients with Perforated Duodenal Ulcer-a Randomized Controlled Trial. J Gastrointest Surg. 2018; 22:107–16.

    Article  Google Scholar 

  17. Roulin D, Blanc C, Muradbegovic M, Hahnloser D, Demartines N, Hübner M. Enhanced recovery pathway for urgent colectomy. World J Surg. 2014; 38:2153–9.

    Article  Google Scholar 

  18. Lohsiriwat V. Enhanced recovery after surgery vs conventional care in emergency colorectal surgery. World J Gastroenterol. 2014; 20:13950–5.

    Article  Google Scholar 

  19. Low J, Johnson N, Morris C. Epidural analgesia: first do no harm. Anaesthesia.2008;63:1-3.

    Article  CAS  Google Scholar 

  20. Pragatheeswarane M, Muthukumaraswamy R, Kadambari D, Kate V. Early oral feeding vs. traditional feeding in patients undergoing elective open bowel surgery-a randomized controlled trial. J Gastrointest Surg. 2014; 18:1017-23

    Article  CAS  Google Scholar 

  21. Likert R. A technique for the measurement of attitudes. Arch Psychol. 1932; 22:55.

    Google Scholar 

  22. Clavien PA, Barkun J, De Oliveira ML, Vauthey JN, Dindo D, Schulick RD et al. The Clavien-Dindo classification of surgical complications: five-year experience. Am J Surg. 2009; 250:187-9.

    Google Scholar 

  23. Berríos-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR, et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg. 2017 Aug 1;152(8):784–91.

    Article  Google Scholar 

  24. Yamada T, Hayashi T, Cho H, Yoshikawa T, Taniguchi H, Fukushima R, et al. Usefulness of enhanced recovery after surgery protocol as compared with conventional postoperative care in gastric surgery. Gastr Can. 2012; 15:34-41.

    Article  Google Scholar 

  25. Chen Hu J, Xin Jiang L, Cai L, Tao Zheng H, Yuan Hu S, Bing Chen H, et al. Preliminary experience of fast-track surgery combined with laparoscopy-assisted radical distal gastrectomy for gastric cancer. J Gastrointest Surg. 2012; 16:1830-9.

    Article  Google Scholar 

  26. Nelson R, Edwards S, Tse B. Prophylactic nasogastric decompression after abdominal surgery. Cochrane Database Syst Rev. 2007.CD004929.

  27. Spanjersberg WR, Readings J, Keus F, van Laarhoven CJ. Fast track surgery versus conventional recovery strategies for colorectal surgery. Cochrane Database Syst. Rev. 2011; CD007635.

  28. Stoot JH, van Dam RM, Busch OR, van Hillegersberg R, De Boer M, Olde Damink SWM, et al. The effect of a multimodal fast-track programme on outcomes in laparoscopic liver surgery: a multicentre pilot study. HPB. 2009; 11:140–4.

    Article  Google Scholar 

  29. Vather R, Trivedi S, Bissett I. Defining postoperative ileus: results of a systematic review and global survey. J Gastrointest Surg . 2013; 17:962–72.

    Article  Google Scholar 

  30. Nygren J, Thacker J, Carli F, Fearon KCH, Norderval S, Lobo DN, et al. Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clin Nutr Edinb Scotl. 2012; 31:801–16

    Article  CAS  Google Scholar 

  31. Wisely JC, Barclay KL. Effects of an enhanced recovery after surgery programme on emergency surgical patients. ANZ J Surg. 2016. DOI:https://doi.org/10.1111/ans.13465.

  32. Zaouter C, Kaneva P, Carli F. Less urinary tract infection by earlier removal of bladder catheter in surgical patients receiving thoracic epidural analgesia. Reg Anesth Pain Med. 2009; 34:542–8.

    Article  Google Scholar 

  33. Moore FA, Feliciano DV, Andrassy RJ, McArdle AH, Booth FV, Morgenstein-Wagner TB, et al. Early enteral feeding, compared with parenteral, reduces postoperative septic complications. The results of a meta-analysis. Ann Surg. 1992; 216:172–83.

    Article  CAS  Google Scholar 

  34. Egbert LD, Battit GE, Welch CE, Bartlett MK. Reduction of postoperative pain by encouragement and instruction of patients. a study of doctor-patient rapport. N Engl J Med. 1964; 270:825–7.

    Article  CAS  Google Scholar 

  35. Hughes MJ, Ventham NT, McNally S, Harrison E, Wigmore S. Analgesia after open abdominal surgery in the setting of enhanced recovery surgery: a systematic review and meta-analysis. JAMA Surg. 2014; 149:1224–30.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006, India

    Kumar Saurabh, Sathasivam Sureshkumar, Subair Mohsina & Vikram Kate

  2. Department of Preventive Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006, India

    Thulasingam Mahalakshmy

  3. Anesthesia and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006, India

    Pankaj Kundra

Authors
  1. Kumar Saurabh
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sathasivam Sureshkumar
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Subair Mohsina
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Thulasingam Mahalakshmy
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Pankaj Kundra
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Vikram Kate
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Kumar Saurabh: Data collection; Formal analysis; Investigation; Writing-original draft

Sathasivam Sureshkumar: Conceptualization; Supervision; Writing- review and editing

Subair Mohsina: Methodology; Validation; Writing-review and editing

Thulasingam Mahalakshmy: Formal analysis; Supervision; Writing- review and editing

Pankaj Kundra: Formal analysis; Supervision; Writing- review and editing

Vikram Kate: Conceptualization; Formal analysis; Supervision; Validation; Writing- review and editing

Corresponding author

Correspondence to Vikram Kate.

Ethics declarations

Conflict of Interest

The authors declare that they have no conflict of interest.

Financial Disclosure

None to Declare.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Saurabh, K., Sureshkumar, S., Mohsina, S. et al. Adapted ERAS Pathway Versus Standard Care in Patients Undergoing Emergency Small Bowel Surgery: a Randomized Controlled Trial. J Gastrointest Surg 24, 2077–2087 (2020). https://doi.org/10.1007/s11605-020-04684-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11605-020-04684-6

Keywords

Search

Navigation