Research review
Enhancing recovery in pediatric surgery: a review of the literature

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Abstract

Background

Enhanced recovery after surgery (ERAS), guidelines entail a strategy of perioperative management proven to hasten postoperative recovery and reduce complications in adult populations. Relatively few studies have investigated the applicability of this paradigm to pediatric populations. Our objective was to perform a systematic review of existing evidence regarding the use and efficacy of enhanced recovery protocols (ERPs) in the pediatric population.

Materials and methods

Data were collected through a PubMed/MEDLINE literature search. Study eligibility criteria included a pediatric population and implementation of at least four components of published ERAS Society recommendations.

Results

One retrospective and four prospective cohort studies evaluating children undergoing gastrointestinal, urologic, and thoracic surgeries were identified. The overall quality of reporting was fair with few studies acknowledging limitations and bias and inconsistent outcome reporting. Studies included six or fewer interventions compared to 20 recommended interventions in most adult ERAS Society guidelines. None of the studies were well controlled. Nevertheless, these studies suggest that ERPs applied to the appropriate pediatric surgical populations may be associated with decreased length of stay, decreased narcotic use, and no detectable increase in complications.

Conclusions

There is a paucity of high-quality literature evaluating implementation of ERPs in pediatric populations. The limited literature available indicates that ERPs would be safe and potentially effective. More studies are needed to assess the efficacy of ERPs in pediatric surgery.

Introduction

There is an increasing focus on providing high-value surgical care by improving outcomes while minimizing resource utilization and waste. Enhanced Recovery After Surgery (ERAS) Society guidelines were developed to embody this emphasis of optimized patient care [1], [2], [3], [4], [5]. Perioperative protocols based on these guidelines have been found to decrease hospital length of stay (LOS) and complications in diverse adult surgical populations [6], [7], [8], [9], [10], [11], [12]. Studies have also demonstrated that the decreased LOS and reduced morbidity associated with these protocols have led to decreased inhospital costs [10], [13], [14], [15]. Key elements of this paradigm-shifting approach to perioperative management were introduced as early as the 1980s and have been changing the standards of perioperative care since the turn of the century [16]. General tenets of ERAS include perioperative counseling, limited perioperative fasting, early enteral intake and mobilization, limited use of narcotics, and nonroutine use of surgical drains and tubes [1], [2], [3], [4], [5]. These interventions theoretically maintain physiological homeostasis and minimize surgical stress, thus facilitating a quicker return to baseline [17].

The ERAS Society has published perioperative guidelines for numerous adult surgical populations, including patients undergoing gastrectomy, cystectomy, pancreaticoduodenectomy, colon resection, and rectal and pelvic surgery [1], [2], [3], [4], [5]. The most widely adopted protocols typically contain over 20 elements and are unified in their inclusion of preoperative, intraoperative, and postoperative elements (Table 1). We encourage readers to view the published ERAS Society guidelines to learn more about their specific components, as they vary according to procedure [1], [2], [3], [4], [5].

Literature regarding similar, non-ERAS Society endorsed protocols, in the pediatric population is far less robust. Rather, there has been more widespread publication of enhanced recovery elements studied in isolation [18], [19], [20], [21], [22], [23], [24], [25], [26], [27]. For example, studies have focused on themes including earlier mobilization, regional and opiate-sparing analgesia, and selective use of drains and catheters [18], [19], [20], [21], [22], [23]. The outcomes of these limited studies were promising, with most interventions demonstrating positive results [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31].

Although there have been numerous pediatric studies demonstrating improved outcomes with isolated elements of adult ERAS protocols, there is a paucity of literature assessing the synchronous implementation of multiple elements of enhanced recovery protocols (ERPs) in the pediatric population, herein referred to through the non-trademarked, pediatric specific, acronym of “ERPs.” The objective of this systematic review was to explore the existing evidence of multifaceted ERPs that integrate general themes of ERAS Society guidelines, including perioperative counseling, minimally invasive techniques, early postoperative oral nutrition (<24 h), limited use of narcotics, and nonroutine use of surgical drains and tubes. Secondary objectives included highlighting safety and recovery outcomes after the implementation of ERPs in pediatric surgical cohorts, as measured by hospital LOS, pain control, and surgical complication rates attributable to the implementation of an ERP [1], [2], [3], [4], [5].

Section snippets

Methods

Articles for review were identified via PubMed/MEDLINE search following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Filters were set to retrieve articles available in English, with human patients from birth through 18 y of age. There were no restrictions on study type. Various search terms were used to capture publications that fall within the diverse realm of pediatric surgery and the variable permutations of ERPs. The included search phrases can be found

Results

Through systematic searches, 109 records were screened by abstract and title. Of those, 19 articles were reviewed in their entirety for inclusion. From those 19 articles, 14 were excluded for reasons summarized in Table 2. Five studies were identified as having implemented a multifaceted ERP entailing four or more elements, thus meeting our criteria for inclusion. These articles were assessed for quality and omissions in recommended reported items using the 22-point STROBE checklist [32]. A

Enhanced recovery protocols in pediatric surgery

As the United States' health care system embraces concepts such as cost-containment and value-based purchasing, improving outcomes while minimizing waste and resource utilization is crucial. Although ERAS Society guidelines, and various iterations of them, have gained acceptance and are being adopted across a variety of adult surgical indications, our literature review demonstrates a need for further study of whether enhanced recovery elements can be applied to pediatric surgery [1], [2], [3],

Conclusions

Based on success with adult patients and the limited data assembled for this review, ERPs for children appear promising and merit further investigation. There is a need to define modifications of existing adult pathways for children and to qualitatively assess the readiness of adoption of many aspects of ERAS in the care of children undergoing surgery. Larger, prospective studies using adequate controls and implementing multiple aspects of ERPs in the pediatric surgical population are needed.

Acknowledgment

The authors of this review have received support from the Emory + Children's Pediatric Research Trust, Children's Healthcare of Atlanta, and the Department of Surgery at Emory University.

Authors' contributions: M.V.R., K.F.H., M.L.B., and M.T.S. conceived and designed the work and assisted in development of the intellectual content within, and revision of, the work. H.L.S. and J.K.S. acquired, analyzed, and interpreted the data for the work with the assistance of M.V.R., K.F.H., M.L.B., and

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