See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/354608075

Implementation and outcomes of enhanced recovery protocols in pediatric

surgery: a systematic review and meta-analysis

Article  in  Pediatric Surgery International · January 2022

DOI: 10.1007/s00383-021-05008-8

CITATIONS READS

13 147

4 authors:

Arun Kumar Loganathan Anita Joselyn

Christian Medical College Vellore Christian Medical College Vellore
9 PUBLICATIONS   41 CITATIONS    27 PUBLICATIONS   236 CITATIONS   

SEE PROFILE SEE PROFILE

Malavika Babu Susan Jehangir

Cardiff University Christian Medical College Vellore
19 PUBLICATIONS   201 CITATIONS    37 PUBLICATIONS   223 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Rotavirus View project

Pediatric Urology View project

All content following this page was uploaded by Anita Joselyn on 26 October 2022.

The user has requested enhancement of the downloaded file.

Pediatric Surgery International
https://doi.org/10.1007/s00383-021-05008-8

ORIGINAL ARTICLE

Implementation and outcomes of enhanced recovery protocols

in pediatric surgery: a systematic review and meta‑analysis
Arun Kumar Loganathan1 · Anita Shirley Joselyn2 · Malavika Babu3 · Susan Jehangir1 

Accepted: 31 August 2021

© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2021

Abstract
Background  This systematic review examines the feasibility and safety of implementing Enhanced recovery after Surgery
(ERAS) protocols in children.
Study design  A systematic search of Medline, PubMed, and the Cochrane library for papers describing ERAS implementa-
tion in children between January 2000 and January 2021. The systematic review was performed according to the PRISMA
statement. The meta-analysis was done using R Software (Ver 4.0.2). p value of < 0.05 was considered statistically significant.
Results  Sixteen studies, describing a total of 1723 patients, were included in the meta-analysis. An average of 15 (range
11–16) relevant components were implemented with an overall compliance close to 84%. The time to initiate feeds and
reach full enteral nutrition was reduced in ERAS group with mean difference (MD) of − 21.20 h (95% CI − 22.80, − 19.59,
p < 0.01), and − 2.20 days (95% CI − 2.72, − 1.71, p < 0.01), respectively. The use of opioids for postoperative analgesia
was reduced with MD of -0.86 morphine equivalents mg/kg (95% CI − 1.40, − 0.32, p < 0.01). The length of hospital stay
showed a significant reduction with MD of -2.54 days (95% CI − 2.94, − 2.13, p < 0.01). There was no difference in the
complication and readmission rates between the groups.
Conclusion  ERP implementation in pediatric perioperative care is a viable option in a variety of surgical settings. There is
clear evidence of a decrease in hospital stay duration with no increase in complication or readmission rates. The length of
hospital stay reduced in inverse proportion to the number of ERAS elements implemented. Parental satisfaction is increased
by initiating enteral feeding early, minimizing catheter and drain use, and reducing opioid use.

Keywords  ERAS · Enhanced recovery · Paediatric surgery · Children

Introduction techniques where feasible, avoidance or early removal of

The enhanced recovery after surgery (ERAS) pathway is a
multimodal approach that focuses on interventions that aid
in postoperative recovery by preserving preoperative body
composition and organ function [1]. Broadly, it includes pre-
operative counseling and optimization, minimal preoperative
starvation and carbohydrate loading, multimodal analgesia
reducing the use of opiates, minimally invasive surgical
* Susan Jehangir
susanjehangir@cmcvellore.ac.in
1
Department of Pediatric Surgery, Christian Medical College,
Vellore, Tamil Nadu 632002, India
2
Department of Anesthesia, Christian Medical College,
Vellore, Tamil Nadu, India
3
Department of Biostatistics, Christian Medical College,
Vellore, Tamil Nadu, India
drains, tubes, and catheters, early post-operative feeding,
zero fluid balance, and early mobilization. Evidence sug-
gests that ERAS implementation has improved outcomes
and patient satisfaction in a variety of adult specialties by
reducing morbidity and expense [1].
Caring for children undergoing surgery has unique physi-
ologic and psychosocial complexities. Children are more
susceptible to dehydration and hypothermia due to their
larger body surface area and higher surface-to-mass ratio [2].
The smaller blood volume predisposes to reduced tolerance
for intraoperative blood loss and reduced tissue perfusion
[2]. Immature metabolic and immune pathways increase the
risk of anesthesia and medications [3]. Additionally, pre-
operative counseling and education must be age-appropri-
ate and tailored to the family unit necessitating increased
focus and consideration on the part of the counseling team.
Given the inimitable bio-psycho-social factors in children,

13
Vol.:(0123456789)

individual ERAS principles need to be vetted before applica-
tion in children.
In 2016, Shinnick et al. [4] and Pearson et al. [5] per-
formed a systematic review, including five studies and a
scoping review including nine studies, respectively, of exist-
ing evidence regarding the efficacy of enhanced recovery
protocols (ERPs) in children. Interventional features iden-
tified were early post- operative feeding and mobilization,
morphine-sparing analgesia, reduced use of nasogastric
tubes and urinary catheters. Despite the limited scope and
evidence base that informed these studies, they reported
reduced time to oral feeding and stooling and consequently
reduced length of stay (LOS). Paediatric surgeons evaluated
the ERAS society guidelines at an American Academy of
Pediatrics symposium in 2017, and 19 of the 21 elements
were deemed appropriate for children [6]. A surge of interest
in enhanced recovery protocols (ERPs) ensued, evidenced
by several prospective studies with broader scope that fol-
lowed. With the recent publication of additional comparative
studies, we aimed to collate and analyze published literature
examining (1) the scope of application, (2) effectiveness of
ERPs on reducing time to first and full enteral feeds, and
practices related to regional analgesia, use of opioids, drains
and catheters and (3) the impact of ERPs on operating time,
length of hospitalization, readmission rates, reoperation
rates, complications, and cost.
Materials and methods
Search strategy
On January 26th, 2021, an electronic search of the PubMed/
MEDLINE and The Cochrane Central Register of Controlled
Trials databases was conducted. The following Medical Sub-
ject Headings (MeSH) terms were used in the search: pedi-
atric, pediatric, infants, child, children, adolescent, ERAS,
enhanced recovery, and fast track. The study was carried out
in accordance with the Preferred Reporting Items for Sys-
tematic Reviews and Meta-Analyses Protocols (PRISMA-P)
Statement.
Study selection
Studies were eligible for inclusion if they were comparative
studies in children with a well-defined ERP that assessed
multiple outcome variables. Excluded were studies with
select fast track elements or multimodal analgesia focusing
on condition-led discharge, as well as studies involving adult
patients. Cardiovascular, neurosurgery, and orthopedic pro-
cedures were also excluded. Case studies, letters, comments,
review articles containing no original data, and editorial-
style articles were not considered. Two reviewers (AK/SJ)
13
Pediatric Surgery International
independently reviewed the study titles and abstracts, and
potentially eligible studies were identified. Three reviewers
(AK/SJ/AS) completed full-text reviews.
Data extraction
A predesigned data collection sheet was used. One reviewer
(AK) extracted data from eligible studies, which were then
confirmed by the other two reviewers (SJ/AS), who checked
for accuracy. Consensus was used to resolve all disagree-
ments. The elements of ERAS implemented were check
against the Reporting on ERAS Compliance, Outcomes,
and Elements Research (RECOvER) Checklist as a mini-
mum requirement [7]. Additional elements applied were also
noted. The outcomes assessed were ERP implementation,
length of hospital stay, readmission, and complication rates.
Quality assessment
Two reviewers (AK/SJ) examined the definition of the study
population as well as the stipulation of the prognostic factor
and outcome(s) of interest in each study to determine the
clarity of the research question. Quality in Prognostic Stud-
ies (QUIPS), an adopted version of Hayden's quality criteria
scoring list, was used to assess the risk of bias and quality of
the studies reviewed [8].
Statistical methods
Meta-Analysis and Empirical Bayes Meta-Analysis were
used to find the pooled estimates for the binary (complica-
tion and readmission rates) and the continuous (LOS, time
to first orals, time to full feeds and post-operative analgesia)
outcomes. The I2 statistic was used to assess the heteroge-
neity across studies. The random-effect model was fit, and
estimates were presented with 95% confidence interval.
Data were analyzed using R Software (Ver 4.0.2). p value of
< 0.05 was considered statistically significant in all analyses.
Results
Literature search
The literature search yielded a total of 2429 studies. Sixty-
one papers were chosen for full-text review; 16 met the
inclusion criteria (Fig. 1). The same cohort of patients was
reported in two studies (Han et al. [9] and Rove et al. [10]),
but the outcomes examined were different. The relevant find-
ings from both studies were pooled and analyzed.
Pediatric Surgery International
Fig. 1  The PRISMA flow
diagram. Adopted from: Moher
et al. Journal of Clinical Epi-
demiology, 2009
Study designs and characteristics
Table  1 summarizes the characteristics of the studies
included in the systematic review. Two studies were ran-
domized, and one was a prospective nonrandomized con-
trolled trial [11–13]. Three studies used a time-series design
with a retrospective non-protocol control group and a pro-
spective protocol study group [9, 10, 14]. Ten were retro-
spective cohort studies [15–24]. The number of patients
in the studies varied from 30 to 332 patients. Collectively
there were 795 patients in the control group and 928 patients
in the study group. There was a wide range of age (from
neonates to adolescents) and surgical procedure performed
across the studies. Five studies pertained to colorectal sur-
gery [11, 16–19], three hepato-biliary surgery [12, 20, 21],
three urology [9, 10, 24], two upper gastrointestinal surgery
[13, 15], and one each plastic surgery [14] and chest wall
reconstruction [22]. One study included multiple operative
groups [23].
Quality assessment
The quality assessment using the QUIPS scoring list
revealed that the studies reviewed had a low to moderate
13
 Pediatric Surgery International

Table 1  Baseline characteristics of the studies included in the meta-analysis

Author Year Journal Study type Region Number of patients Operative groups
Study Control

Purcell 2021 JPS Retrospective USA 98 41 Colorectal surgery

Yalcin 2020 Surgery for Obesity Retrospective USA 61 51 Laparoscopic Sleeve Gastrectomy
Xu 2020 JPS Prospective China 23 26 Congenital Duodenal Obstruction
Han 2020 PSI Prospective USA 13 26 Reconstructive Urology
Rove 2018 JPU
Tan Yunpu 2020 PSI Retrospective China 15 18 Choledochal cyst
Zhao 2020 JZU Prospective China 65 65 Choledochal cyst
Philips 2019 JPS Retrospective USA 28 23 Irritable Bowel Disease
Yeh 2019 JPS Retrospective USA 145 105 Cholelithiasis
Tang 2019 JPS Prospective China 75 73 Hirschsprung disease in infants
Gao 2019 JIMR Retrospective China 68 57 Appendicitis, Meckel Diveriticulum,
Pyloric Stenosis, Hirshcsprung disease
Hush 2019 Craniofacial surgery Prospective USA 50 50 Primary palatoplasty
Holmes 2019 JPS Retrospective USA 186 146 Minimally invasive pectus excavatum repair
Edney 2018 ASRA Retrospective USA 50 56 Colorectal surgery
Haid 2018 Urology Retrospective Germany 15 15 Bladder Augments
Short 2017 JPS Retrospective USA 36 43 Colorectal surgery

risk of bias (Table 2). The main sources of bias were con-
founding factors and the study group participants' selec-
tion. Across all studies, attrition rates were low, with no
discernible bias in ERP implementation or primary out-
come measurement.
Protocol implementation
Table 3 enlists all ERP components that have been used in
various studies. Seventeen basic components derived from
the RECOvER checklist were analyzed [7]. An average of

Table 2  QUIPS assessment of bias

Author Year Study Participation Study Attrition Prognostic Fac- Outcome Study confoundi-ng Statistical Analy- Overall
tor Measure- Measure- sis and Reporting
ment ment

Purcell 2021 Low Low Low Low Low Low Low

Yalcin 2020 Low Low Low Low Low Low Low
Xu 2020 Low Low Low Low Low Low Low
Han 2020 Moderate Low Low Low Low Low Low
Rove 2018 Moderate Low Low Low Low Low Low
Tan Yunpu 2020 Moderate Low Low Low Low Low Low
Zhao 2020 Moderate Low Low Low Low Low Low
Philips 2019 Low Low Low Low Low Low Low
Yeh 2019 Moderate Low Low Low Moderate Moderate Moderate
Tang 2019 Low Low Low Low Low Low Low
Gao 2019 Low Low Low Low Low Low Low
Hush 2019 Moderate Low Low Low Low Low Low
Holmes 2019 Low Low Low Low Low Low Low
Edney 2018 Low Low Low Low Low Low Low
Haid 2018 Low Low Low Low Moderate Low Low
Short 2017 Low Low Low Low Low Low Low

13
 Table 3  Components of ERAS protocol implemented in individual studies
Components Purcell Yalcin Xu Han/Rove Tan Yunpu Zhao Philips Yeh Tang Gao Hush Holmes Edney Haid Short
Pediatric Surgery International

Basic components
 Preoperative education and counselling + + + + + + + + + + + + + + +
 Optimization of co-morbidities + − + + − − + + + − − + + − +
 Peri-operative nutritional screen + + NA − − + - - + − − + + − −
 Avoid prolonged fasting + + NA + + + + + + + + + + + +
 Preoperative carbohydrate loading + − NA + − − − − + + + − + + +
 Pre-emptive analgesia + + NA − − − + + − − + − + − +
 PONV prophylaxis + + NA + − + + + − − + + + + +
 Regional anaesthesia + + + + − − + + + + + + + + +
 Minimizing opioid usage + + + + − − + + + − + + + + +
 Maintenance of near zero fluid balance + + + + + − + + + + + + + + +
 Maintain normothermia + + + + + − + + + + + + + + +
 Avoid placement or early removal of Nasogastric tube + + + + + + − + + + + + + + +
 Avoid placement or early removal of peri-anastomotic drain − + − + + − − + + + NA + + + +
 Avoid placement or early removal of urinary catheter + + − NA − + + + + + + + + NA +
 Early enteral nutrition + + + + + + + + + + + + + + +
 Maintenance of near zero fluid balance + + + + + − + + + + + + + + +
 Early ambulation + + NA + + + + + + + + + + + +
 Opioid-sparing pain regimen + + + + + − + + − + + + + + +
Additional components
 Avoid or selective bowel prep + + NA + − − + NA − + + NA + + +
 Placement of sequential compression devices (age > 12)/ _ + NA - NA NA − − − − NA − + + +
DVT prophylaxis
 Antibiotic prophylaxis, given < 1 h prior to incision + + + + + − + + + − + − + + +
 Minimal invasive techniques + + + + + − + + + + NA + + NA +
 Aggressive pulmonary toilet − − NA − − − − − − − − + + − +

NA Not Applicable

13

15 of 17 components (ranging from 10 to 17) were imple-
mented in 14 studies. Xu et al. applied eight elements of
ERAS to neonatal duodenal obstruction [13]. Six studies [9,
10, 14, 18, 24] reported protocol compliance for various ele-
ments (Supplementary Table 1). The compliance for various
elements varied from 64% for use of thromboprophylaxis to
100% for selective bowel preparation. The overall compli-
ance varied from 80 to 94 % among the studies. Overall
cumulative compliance to protocol was 84%.
Preoperative elements
Preoperative counseling was available to all patients. Co-
morbidity assessment was mentioned in 9 of the 15 stud-
ies, and nutritional screening was mentioned in 6 of the
15 studies. Where applicable, minimum fasting guidelines
were followed in all studies; however, carbohydrate loading
was followed in only 8 of 14 studies. Preemptive analgesia
with acetaminophen or gabapentin was given in 7 of the 14
studies.
Intraoperative elements
Regional analgesia was used in 13 of the 15 studies, and
measures to reduce opioid use were implemented in 12 of
the 15 studies. Across studies, there was a lack of consist-
ency in reporting the amount of opioids used and assessing
analgesic efficacy. Six studies [11–13, 20, 23, 24] did not go
into detail about post-operative analgesia or the use of opi-
oids. Two studies [17, 22] reported that non- opioid medi-
cations provided adequate pain relief in the study group.
Nine studies mentioned the quantity of opioids used post-
operatively. All ERAS participants reported a statistically
significant decrease in opioid use in these studies. A pooled
analysis was performed on 8 studies (1096 patients) with
comparable reporting of opioid usage (Morphine Equiva-
lents (ME) mg/kg). The ERAS group required less opioid,
with an MD of -0.86 ME mg/kg (95% CI − 1.40, − 0.32,
p < 0.01) (Fig. 2a). Yalcin et al. reported the total volume of
post-operative opioids used, which was statistically signifi-
cantly lower in the ERAS group (10.0ME/mg vs 21.5ME/
mg, p < 0.0001) [14].
Goal-directed fluid therapy with near-zero fluid balance
was used intra and post-operatively in 14 of the 15 studies.
In four of the five studies that reported data, there was a sta-
tistically significant reduction in the amount of intravenous
fluids administered in the ERAS group [10, 11, 15, 17, 18]
(Supplementary Table 2). Measures to maintain normother-
mia were used in all but one study.
Fourteen of 15 studies avoided placement of peri-anas-
tomotic drains. Zhao et al. [12] and Gao et al. [23] demon-
strated a statistically significant reduction in drain removal
13
Pediatric Surgery International
time [4.2 days vs 6.7 days and 1.5 days vs 2.4 days, respec-
tively]. Nasogastric tubes were avoided or removed early in
10 of 14 studies and similarly urinary catheters in 11 of 13
studies. Data from Gao et al. [23], Holmes et al. [22], and
Purcell et al. [16] show that urethral catheters were removed
earlier in the ERAS group (Supplementary Table 3).
Post‑operative elements
All ERAS patients were ambulated early. Enteral feeding
was defined in various ways in the studies. Time to begin
enteral feeds and time to full feeds were the two most
described parameters. Other parameters used to assess bowel
function recovery included time to defecation and duration
of intravenous fluid use. Except in two studies [21, 24],
where enteral feeds were started immediately after surgery
for all patients, there was a statistically significant reduction
in time taken to establish enteral feeds in the ERAS group.
Meta-analysis of pooled data (6 studies comprising 554
patients) showed a significantly shorter duration to initiation
of enteral feeds amongst the protocol group, with a mean
difference (MD) of − 21.20 h (95% CI − 22.80, − 19.59,
p < 0.01) (Fig. 2b). Six studies described time to reach
full enteral nutrition, with pooled data (761 patients) again
showing significant reduction in the ERAS group with a MD
of − 2.20 days (95% CI − 2.72, − 1.71, p < 0.01) (Fig. 2c).
There was significant heterogeneity in both the analysis
(I2~100%), which can be attributed to the variation in surgi-
cal procedures performed across the individual studies.
Outcome assessment
Operating time
Operative time was lower in the ERAS group however sta-
tistical significance was reported only by Yalcin et al. [15]
and Purcell et al. [16] (Supplementary Table 4).
Length of hospital stay
In all studies, the ERAS group had a lower LOS. All patients
were discharged on the day of surgery or the next day in
studies by Yeh et al. and Hush et al. [14, 21]. A meta-anal-
ysis of the remaining studies' pooled data (1373 patients)
revealed a statistically significant reduction in length of stay
with MD of − 2.54 days (95% CI − 2.94, − 2.13, p < 0.01)
(Fig. 3a). The significant heterogeneity (I2 = 97%) can be
explained by differences in the operations performed.
When assessed within groups performing similar
operations, the number of elements of ERAS applied was
inversely proportional to the LOS (Fig. 4).
Pediatric Surgery International

Fig. 2  Meta-analysis of components of ERAS protocol: a amount of post-operative opioids used in morphine equivalents mg/kg; b time to first
enteral Nutrition expressed in hours; c duration to full enteral feeding expressed in days

Readmission rates patients revealed no significant difference in readmission

rates between the protocol and control groups, with an OR
In seven studies [11–13, 20, 21, 23, 24], there were no of 0.59 (95% CI 0.42, 0.82, p = 0.49) and no significant
readmissions within the first 30 days after surgery. A meta- heterogeneity (Fig. 3b). In these studies, surgical causes
analysis of pooled data from other 8 studies involving 1108 were the most common reason for readmission.

13
 Pediatric Surgery International

Fig. 3  Meta-analysis of outcomes of implementation of ERAS protocol. a Length of hospital stay expressed in days. b Complication rates. c
Readmission rates

13
Pediatric Surgery International
Fig. 4  Correlation of number
of elements of ERAS applied to
length of hospital stay in days
Complication rates
In all individual studies, the incidence of complications was
comparable between the study and control groups. A meta-
analysis of pooled results from 15 studies involving 1723
patients revealed a statistically insignificant reduction in the
rate of complications among protocol cohorts compared to
non-protocol cohorts, with an OR of 0.74 (95% CI 0.60,
0.92, p = 0.88) and no significant heterogeneity (Fig. 3c).
Cost and parental satisfaction
Tang et al. and Gao et al. compared the overall cost of hos-
pitalization and identified that the ERAS group had a lower
cost [11, 23]. Tang et al. found that the ERAS group had
higher parental satisfaction than the study group (96% vs
89%) [11].
Discussion
The purpose of this research was to assess the scope, feasi-
bility, effectiveness, and safety of application ERPs in chil-
dren. ERPs were successfully used in 16 eligible studies
involving 928 patients of varying ages and with a hetero-
geneous mix of patient diagnoses and surgical procedures.
Most applied protocols included all 16 basic ERAS com-
ponents. Attrition rates were low in all studies and overall
compliance to protocol was 84% testifying to the feasibility
of ERP application. Because pediatric ERAS is still in its
infancy, a pooled data analysis was justified. Patients in the
ERAS group were fed earlier, used fewer opiates, and were
discharged sooner with comparable complications. These
findings support the safety and efficacy of ERAS across ages
and surgical cohorts.
Summary of components
ERPs are intended to optimize a patient for surgery and
decrease peri-operative stress and fluid shifts. Pre-operative
counseling by a trained team making patients and families
aware of what to expect and answering any queries marks
the beginning of this journey which all included studies per-
formed. The other key elements are nutrition and optimiza-
tion of comorbidities which were mentioned in fewer stud-
ies. Clear fluids and water are thought to leave the stomach
within 60 min [2]. Carbohydrate preloading 2–3 h before
surgery has been shown to reduce insulin resistance, main-
tain glycogen reserves, reduce protein breakdown, improve
muscle strength, and possibly contribute to earlier bowel
function return and decreased LOS in adults [2]. All studies
had a liberalized fasting policy. Carbohydrate loading, on
the other hand, was not universally practiced.
The use of multimodal analgesia perioperatively reduced
stress response to surgery, facilitates early mobilization,
nutrition, and discharge [27, 28]. As evidenced by several
studies in this analysis, regional anesthesia combined with
non-opioid medications resulted in a significant reduction in
post- operative pain scores and opioid requirements. In all
13

eight studies that provided data, the total opioid dosage was
also significantly lower.
Post-operative ileus is attributed to intestinal stretch due
to bowel edema caused by fluid overload during elective
surgery [25]. Dehydration, on the other hand, can lead to
reduced perfusion and organ dysfunction [26]. Careful
attention to maintaining euvolemia by the prudent use of
intraoperative fluids to optimize cardiac output and deliv-
ery of essential nutrients and oxygen to tissues is critical to
preserving cellular function, especially when there is tis-
sue injury and repair required [25]. The combined effect of
minimizing opioid analgesia and optimizing peri-operative
fluids most likely influenced the success of early enteral feed
initiation. In all studies that provided data, the ERAS group
reached full enteral feeds at least 48 h earlier than the con-
ventional group. There was no evidence of emesis or early
feed intolerance.
Urinary tract infections caused by catheters are com-
mon and significantly increase hospitalization costs [29].
They are also caused by pathogens found in hospitals that
are prone to antimicrobial resistance [29]. The duration of
catheterization has been linked to an increased risk of infec-
tion [30]. As evidenced by the findings of Gao, Holmes, Pur-
cell and colleagues, the implementation of ERAS reduced
and frequency and duration of urinary catheterization in the
study group [16, 22, 23]. Zhao et al. and Gao et al. demon-
strated the same diligence in drain removal, reporting earlier
drain removal in the study group with no negative conse-
quences [11, 23].
Summary of outcomes
The increased use of minimal access techniques had no
effect on operating time. The data does not include the time
required for anesthesia, which is affected using regional
anesthesia. Faster anesthesia recovery due to less intra-
operative opioid use, on the other hand, would be expected
to balance the total time in theatre.
The ERAS group had a significantly shorter length of stay
(LOS). Patients undergoing gastrointestinal and reconstruc-
tive urological procedures benefited the most. Most studies
showed a 2-day reduction in LOS, with some studies show-
ing a reduction of up to 5 days [20, 24]. This finding is espe-
cially significant because hospital stay length is regarded as
a major driver of resource utilization and cost. As evidenced
by complications and readmission rates, this reduction in
LOS did not come at the expense of safety. Both groups had
a similar total number of readmissions and complications.
Further, the more recent randomized trials reported greater
parent satisfaction in the ERAS group.
Dagorno et al. recently assessed the current evidence on
ERAS after MIS in children until 2019 which corroborates
our findings [31]. They included 9 studies (1 randomised
13
Pediatric Surgery International
controlled trial, 3 prospective studies, and 5 retrospective
studies) with a total of 531 patients. ERAS has been used in
laparoscopy for digestive (n = 7 studies), urologic (n = 1),
and thoracoscopy (n = 1). The mean LOS in ERAS children
was shorter than in controls (six studies, 1.12 days, 95% CI
1.5–0.82, p = 0.00001). Complication rates did not differ
between ERAS and control children (five studies, 13% vs
14%, OR = 0.84, 95% CI 0.49–1.44, p = 0.52). The 30-day
readmission rate in ERAS children was lower than in con-
trols (six studies, 4% vs 10%, OR = 0.34, 95% CI 0.18–0.66,
p = 0.001). They concluded that, while evidence for ERAS
in MIS is limited, these protocols appear safe and effective
in terms of decreasing LOS and 30-day readmission rates
while not increasing post-operative complication rates [31].
Limitations
Ten of the 16 studies included in this review were retro-
spective, with three including a retrospective control group
and potentially varying degrees of bias inherent in these
designs. Elements like preoperative carbohydrate loading,
time to first postoperative mobilization, time to return of
bowel function, and post-operative nausea and emesis were
not consistently recorded and identified on chart review and
therefore not included in the protocol. The quality of the
studies was however good, and the risk of bias was low to
moderate.
Geographically, the studies were primarily clustered
in some regions of developed countries. (Supplementary
Figure 1). As a result, the impact of differences in clini-
cal setting and available facilities is unknown. The study
populations were diverse, and the protocols used in each
study differed technically. As a result, the random-effects
model was employed for the meta-analysis. Complications
were not defined consistently across studies. Furthermore,
the readmission or re-intervention thresholds may differ
between centers and practices and were not clearly defined
in the studies. Another issue with these studies was the lack
of validated outcome measures for comparing patient satis-
faction across intervention groups.
Although several studies in this analysis included pain
assessments as an objective outcome, we were unable to
perform a formalized analysis as an exploratory outcome
due to the lack of a uniform pain scale.
Conclusions
ERP implementation in pediatric perioperative care is a via-
ble option in a variety of surgical settings. There is clear evi-
dence of a decrease in hospital stay duration with no increase
Pediatric Surgery International
in complication or readmission rates. The length of hospital
stay reduced in inverse proportion to the number of ERAS
elements implemented. Parental satisfaction is increased
by initiating enteral feeding early, minimizing catheter and
drain use, and reducing opioid use.
Supplementary Information  The online version contains supplemen-
tary material available at https://d​ oi.o​ rg/1​ 0.1​ 007/s​ 00383-0​ 21-0​ 5008-8.
Author contributions  AKL: study search, study selection, data extrac-
tion, data synthesis, data interpretation, manuscript writing and editing.
ASJ: study selection, data interpretation, manuscript writing. MB: data
interpretation and statistics. SJ: conceptualization, study search, study
selection, data synthesis, data interpretation, manuscript writing and
editing.
Funding  This research received no specific grant from any funding
agency in the public, commercial or not-for-profit sectors.
Declarations  tion of enhanced recovery after surgery in the treatment of chil-
Conflict of interest  All the authors have no competing interests to dis-
close.
References
1. Brindle ME, Heiss K, Scott MJ, Herndon CA, Ljungqvist O,
Koyle MA, on behalf PediatricERAS (Enhanced Recovery After
Surgery) Society (2019) Embracing change: the era for pediat-
ric ERAS is here. Pediatr Surg Int 35(6):631–634. https://​doi.​
org/​10.​1007/​s00383-​019-​04476-3 (Epub 2019 Apr 25. PMID:
31025092)
2. Imura K, Okada A (2000) Perioperative nutrition and metabolism
in pediatric patients. World J Surg 24(12):1498–1502. https://​doi.​
org/​10.​1007/​s0026​80010​268 (PMID: 11193714)
3. Lee JH, Zhang J, Wei L, Yu SP (2015) Neurodevelopmental impli-
cations of the general anesthesia in neonate and infants. Exp Neu-
rol 272:50–60. https://​doi.​org/​10.​1016/j.​expne​urol.​2015.​03.​028
(PMID: 25862287)
4. Shinnick JK, Short HL, Heiss KF, Santore MT, Blakely ML, Raval
MV (2016) Enhancing recovery in pediatric surgery: a review
of the literature. J Surg Res 202(1):165–176. https://​doi.​org/​10.​
1016/j.​jss.​2015.​12.​051 (Epub 2016 Jan 12 PMID: 27083963)
5. Pearson KL, Hall NJ (2017) What is the role of enhanced recov-
ery after surgery in children? A scoping review. Pediatr Surg Int
33(1):43–51. https://​doi.​org/​10.​1007/​s00383-​016-​3986-y (Epub
2016 Sep 27 PMID: 27679510)
6. Elias KM, Stone AB, McGinigle K, Tankou JI, Scott MJ, Faw-
cett WJ, Demartines N, Lobo DN, Ljungqvist O, Urman RD,
ERAS®SocietyandERAS®USA (2019) The reporting on ERAS
compliance, outcomes, and elements research (RECOvER) check-
list: a joint statement by the ­ERAS® and ­ERAS® USA societies.
World J Surg 43(1):1–8. https://​doi.​org/​10.​1007/​s00268-​018-​
4753-0 (PMID: 30116862; PMCID: PMC6313353)
7. Roberts K, Brindle M, McLuckie D (2020) Enhanced recovery
after surgery in paediatrics: a review of the literature. BJA Educ
20(7):235–241. https://d​ oi.o​ rg/1​ 0.1​ 016/j.b​ jae.2​ 020.0​ 3.0​ 04 (Epub
2020 May 6. PMID: 33456956; PMCID: PMC7807916)
8. Hayden JA, van der Windt DA, Cartwright JL, Côté P, Bombardier
C (2013) Assessing bias in studies of prognostic factors. Ann
Intern Med 158(4):280–286. https://​doi.​org/​10.​7326/​0003-​4819-​
158-4-​20130​2190-​00009 (PMID: 23420236)
9. Han DS, Brockel MA, Boxley PJ, Dönmez Mİ, Saltzman AF,
Wilcox DT, Rove KO (2021) Enhanced recovery after surgery and
anesthetic outcomes in pediatric reconstructive urologic surgery.
Pediatr Surg Int 37(1):151–159. https://​doi.​org/​10.​1007/​s00383-​
020-​04775-0 (Epub 2020 Nov 7 PMID: 33161476)
10. Rove KO, Brockel MA, Saltzman AF, Dönmez MI, Brodie KE,
Chalmers DJ, Caldwell BT, Vemulakonda VM, Wilcox DT (2018)
Prospective study of enhanced recovery after surgery protocol
in children undergoing reconstructive operations. J Pediatr Urol
14(3):252.e1-252.e9. https://d​ oi.o​ rg/1​ 0.1​ 016/j.j​ purol.2​ 018.0​ 1.0​ 01
(Epub 2018 Feb 2 PMID: 29398586)
11. Tang J, Liu X, Ma T, Lv X, Jiang W, Zhang J, Lu C, Chen H, Li
W, Li H, Xie H, Du C, Geng Q, Feng J, Tang W (2020) Applica-
tion of enhanced recovery after surgery during the perioperative
period in infants with Hirschsprung’s disease—a multi-center
randomized clinical trial. Clin Nutr 39(7):2062–2069. https://​
doi.​org/​10.​1016/j.​clnu.​2019.​10.​001 (Epub 2019 Oct 16 PMID:
31676258)
12. Zhao H, Cai D, Gao Z, Chen Q, Zhu J, Huang J (2019) Applica-
dren with congenital choledochal cyst. Zhejiang Da Xue Bao Yi
Xue Ban 48(5):474–480 (Chinese PMID: 31901019)
13. Xu L, Gong S, Yuan LK, Chen JY, Yang WY, Zhu XC, Yu SY,
Huang R, Tian S, Ding HY, He MD, Xiao SJ (2020) Enhanced
recovery after surgery for the treatment of congenital duodenal
obstruction. J Pediatr Surg 55(11):2403–2407. https://​doi.​org/​
10.​1016/j.​jpeds​urg.​2020.​04.​015 (Epub 2020 Apr 29 PMID:
32571537)
14. Hush SE, Chen JT, Brady CM, Soldanska M, Nusz DJ, Rhinehart
DL, Heiss K, Crowley C, Williams JK (2019) Implementation of
a modified enhanced recovery protocol in cleft palate repairs. J
Craniofac Surg 30(7):2154–2158. https://​doi.​org/​10.​1097/​SCS.​
00000​00000​005718 (PMID: 31283639)
15. Yalcin S, Walsh SM, Figueroa J, Heiss KF, Wulkan ML (2020)
Does ERAS impact outcomes of laparoscopic sleeve gastrectomy
in adolescents? Surg Obes Relat Dis 16(12):1920–1926. https://​
doi.​org/​10.​1016/j.​soard.​2020.​07.​016 (Epub 2020 Jul 23 PMID:
32847759)
16. Purcell LN, Marulanda K, Egberg M, Mangat S, McCauley C,
Chaumont N, Sadiq TS, Lupa C, McNaull P, McLean SE, Hayes-
Jordan A, Phillips MR (2021) An enhanced recovery after sur-
gery pathway in pediatric colorectal surgery improves patient
outcomes. J Pediatr Surg 56(1):115–120. https://d​ oi.o​ rg/1​ 0.1​ 016/j.​
jpeds​urg.​2020.​09.​028 (Epub 2020 Oct 6 PMID: 33131774)
17. Edney JC, Lam H, Raval MV, Heiss KF, Austin TM (2019)
Implementation of an enhanced recovery program in pediatric
laparoscopic colorectal patients does not worsen analgesia despite
reduced perioperative opioids: a retrospective, matched, non-infe-
riority study. Reg Anesth Pain Med 44(1):123–129. https://​doi.​
org/​10.​1136/​rapm-​2018-​000017 (PMID: 30640664)
18. Short HL, Heiss KF, Burch K, Travers C, Edney J, Venable C,
Raval MV (2018) Implementation of an enhanced recovery proto-
col in pediatric colorectal surgery. J Pediatr Surg 53(4):688–692.
https://​doi.​org/​10.​1016/j.​jpeds​urg.​2017.​05.​004 (Epub 2017 May
12 PMID: 28545764)
19. Phillips MR, Adamson WT, McLean SE, Hance L, Lupa MC,
Pittenger SL, Dave P, McNaull PP (2020) Implementation of a
pediatric enhanced recovery pathway decreases opioid utilization
and shortens time to full feeding. J Pediatr Surg 55(1):101–105.
https://​doi.​org/​10.​1016/j.​jpeds​urg.​2019.​09.​065 (Epub 2019 Nov
15. PMID: 31784102)
13

20. Tan Y, Shen Y, Li L, Yu J (2020) Protocol for enhanced recovery
after surgery with 3D laparoscopic excision for choledochal cysts
can benefit the recovery process. Pediatr Surg Int 36(5):643–648.
https://​doi.​org/​10.​1007/​s00383-​020-​04644-w (Epub 2020 Mar
26 PMID: 32219559)
21. Yeh A, Butler G, Strotmeyer S, Austin K, Visoiu M, Cladis F,
Malek M (2020) ERAS protocol for pediatric laparoscopic chol-
ecystectomy promotes safe and early discharge. J Pediatr Surg
55(1):96–100. https://​doi.​org/​10.​1016/j.​jpeds​urg.​2019.​09.​053
(Epub 2019 Oct 25 PMID: 31708204)
22. Holmes DM, Polites SF, Roskos PL, Moir CR (2019) Opioid use
and length of stay following minimally invasive pectus excavatum
repair in 436 patients - Benefits of an enhanced recovery pathway.
J Pediatr Surg 54(10):1976–1983. https://​doi.​org/​10.​1016/j.​jpeds​
urg.​2019.​02.​007 (Epub 2019 Mar 1 PMID: 30922685)
23. Gao R, Yang H, Li Y, Meng L, Li Y, Sun B, Zhang G, Yue M, Guo
F (2019) Enhanced recovery after surgery in pediatric gastrointes-
tinal surgery. J Int Med Res 47(10):4815–4826. https://d​ oi.o​ rg/1​ 0.​
1177/0​ 30006​ 05198​ 65350 (Epub 2019 Aug 4. PMID: 31379230;
PMCID: PMC6833409)
24. Haid B, Karl A, Koen M, Mottl W, Haid A, Oswald J (2018)
Enhanced recovery after surgery protocol for pediatric urological
augmentation and diversion surgery using small bowel. J Urol
200(5):1100–1106. https://​doi.​org/​10.​1016/j.​juro.​2018.​06.​011
(Epub 2018 Jun 7 PMID: 29886091)
25. Shah SK, Uray KS, Stewart RH, Laine GA, Cox CS Jr (2011)
Resuscitation-induced intestinal edema and related dysfunction:
state of the science. J Surg Res 166(1):120–130. https://d​ oi.o​ rg/1​ 0.​
1016/j.​jss.​2009.​09.​010 (Epub 2009 Sep 29. PMID: 19959186;
PMCID: PMC3709455)
13
View publication stats
Pediatric Surgery International
26. Lobo DN, Bostock KA, Neal KR, Perkins AC, Rowlands BJ,
Allison SP (2002) Effect of salt and water balance on recovery
of gastrointestinal function after elective colonic resection: a ran-
domised controlled trial. Lancet 359(9320):1812–1818
27. Gritsenko K, Khelemsky Y, Kaye AD, Vadivelu N, Urman RD
(2014) Multimodal therapy in perioperative analgesia. Best Pract
Res Clin Anaesthesiol 28(1):59–79. https://d​ oi.o​ rg/1​ 0.1​ 016/j.b​ pa.​
2014.​03.​001 (Epub 2014 Mar 15 PMID: 24815967)
28. Beverly A, Kaye AD, Ljungqvist O, Urman RD (2017) Essen-
tial elements of multimodal analgesia in enhanced recovery after
surgery (ERAS) guidelines. Anesthesiol Clin 35(2):e115–e143.
https://​doi.​org/​10.​1016/j.​anclin.​2017.​01.​018 (PMID: 28526156)
29. Oderda GM, Evans RS, Lloyd J, Lipman A, Chen C, Ashburn M,
Burke J, Samore M (2003) Cost of opioid-related adverse drug
events in surgical patients. J Pain Symptom Manage 25(3):276–
283. https://​doi.​org/​10.​1016/​s0885-​3924(02)​00691-7 (PMID:
12614962)
30. Shuman EK, Chenoweth CE (2018) Urinary catheter-associated
infections. Infect Dis Clin North Am 32(4):885–897. https://​
doi.​org/​10.​1016/j.​idc.​2018.​07.​002 (Epub 2018 Sep 18 PMID:
30241712)
31. Au AG, Shurraw S, Hoang H, Wang S, Wang X (2020) Effective-
ness of a simple intervention for prevention of catheter-associated
urinary tract infections on a medical hospital unit. J Infect Prev
21(6):221–227. https://​d oi.​o rg/​1 0.​1 177/​1 7571​7 7420​9 39242
(Epub 2020 Jul 20. PMID: 33408759; PMCID: PMC7745581)
Publisher's Note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.