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3 ScienceDirect 67
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7 journal homepage: www.JournalofSurgicalResearch.com 72
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Research review 76
12 77
13 Enhancing recovery in pediatric surgery: 78
14 79
15 a review of the literature 80
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17 82
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Q9 Julia K. Shinnick, BA,a Heather Short, MD,a Kurt F. Heiss, MD,a 84
20 Matthew T. Santore, MD,a Martin L. Blakely, MD, MSCR,b 85
21 and Mehul V. Raval, MD, MSa,* 86
22 87
a
23 Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children’s Healthcare of 88
24 Atlanta, Atlanta, Georgia 89
25 b
Department of Pediatric Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children’s Hospital at 90
26 Vanderbilt, Nashville, Tennessee 91
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article info abstract
30 95
31 96
Article history: Background: Enhanced recovery after surgery (ERAS), guidelines entail a strategy of peri-
32 97
Received 19 November 2015 operative management proven to hasten postoperative recovery and reduce complications
33 98
34 Received in revised form in adult populations. Relatively few studies have investigated the applicability of this 99
35 28 December 2015 paradigm to pediatric populations. Our objective was to perform a systematic review of 100
36 Accepted 31 December 2015 existing evidence regarding the use and efficacy of enhanced recovery protocols (ERPs) in 101
37 Available online xxx the pediatric population. 102
38 Materials and methods: Data were collected through a PubMed/MEDLINE literature search. 103
39 Keywords: Study eligibility criteria included a pediatric population and implementation of at least four 104
40 Pediatric surgery components of published ERAS Society recommendations. 105
41 Results: One retrospective and four prospective cohort studies evaluating children under-
106
Enhanced recovery protocols
42 107
Fast-track protocols going gastrointestinal, urologic, and thoracic surgeries were identified. The overall quality
43 108
Quality improvement of reporting was fair with few studies acknowledging limitations and bias and inconsistent
44 109
45 outcome reporting. Studies included six or fewer interventions compared to 20 recom- 110
46 mended interventions in most adult ERAS Society guidelines. None of the studies were well 111
47 controlled. Nevertheless, these studies suggest that ERPs applied to the appropriate pedi- 112
48 atric surgical populations may be associated with decreased length of stay, decreased 113
49 narcotic use, and no detectable increase in complications. 114
50 Conclusions: There is a paucity of high-quality literature evaluating implementation of ERPs 115
51 in pediatric populations. The limited literature available indicates that ERPs would be safe 116
52 and potentially effective. More studies are needed to assess the efficacy of ERPs in pediatric 117
53 118
surgery.
54 119
ª 2016 Elsevier Inc. All rights reserved.
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61 * Corresponding author. Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children’s 126
62 Healthcare of Atlanta, 1405 Clifton Road, 3rd Floor Surgical Suite, Atlanta, GA 30322-1101. Tel.: þ1404 785 0781; fax: þ1404 785 0800. 127
63 E-mail address: [email protected] (M.V. Raval). 128
64 0022-4804/$ e see front matter ª 2016 Elsevier Inc. All rights reserved. 129
65 http://dx.doi.org/10.1016/j.jss.2015.12.051 130

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131 196
132
1. Introduction adult ERAS protocols, there is a paucity of literature assessing
197
133 the synchronous implementation of multiple elements of 198
134 There is an increasing focus on providing high-value surgical enhanced recovery protocols (ERPs) in the pediatric popula- 199
135 care by improving outcomes while minimizing resource uti- tion, herein referred to through the non-trademarked, pedi- 200
136 lization and waste. Enhanced Recovery After Surgery (ERAS) atric specific, acronym of “ERPs.” The objective of this 201
137 Society guidelines were developed to embody this emphasis of systematic review was to explore the existing evidence of 202
138 optimized patient care [1e5]. Perioperative protocols based on multifaceted ERPs that integrate general themes of ERAS So- 203
139 these guidelines have been found to decrease hospital length ciety guidelines, including perioperative counseling, mini- 204
140 of stay (LOS) and complications in diverse adult surgical mally invasive techniques, early postoperative oral nutrition 205
141 206
populations [6e12]. Studies have also demonstrated that the (<24 h), limited use of narcotics, and nonroutine use of sur-
142 207
decreased LOS and reduced morbidity associated with these gical drains and tubes. Secondary objectives included high-
143 208
144 protocols have led to decreased inhospital costs [10,13e15]. lighting safety and recovery outcomes after the 209
145 Key elements of this paradigm-shifting approach to periop- implementation of ERPs in pediatric surgical cohorts, as 210
146 erative management were introduced as early as the 1980s measured by hospital LOS, pain control, and surgical compli- 211
147 and have been changing the standards of perioperative care cation rates attributable to the implementation of an 212
148 since the turn of the century [16]. General tenets of ERAS ERP [1e5]. 213
149 include perioperative counseling, limited perioperative fast- 214
150 ing, early enteral intake and mobilization, limited use of 215
151 narcotics, and nonroutine use of surgical drains and tubes 2. Methods 216
152 217
[1e5]. These interventions theoretically maintain physiolog-
153 218
ical homeostasis and minimize surgical stress, thus facili- Articles for review were identified via PubMed/MEDLINE
154 219
tating a quicker return to baseline [17]. search following the Preferred Reporting Items for Systematic
155 220
156 The ERAS Society has published perioperative guidelines Reviews and Meta-Analyses guidelines. Filters were set to 221
157 for numerous adult surgical populations, including patients retrieve articles available in English, with human patients 222
158 undergoing gastrectomy, cystectomy, pancreaticoduo- from birth through 18 y of age. There were no restrictions on 223
159 denectomy, colon resection, and rectal and pelvic surgery study type. Various search terms were used to capture publi- 224
160 [1e5]. The most widely adopted protocols typically contain cations that fall within the diverse realm of pediatric surgery 225
161 over 20 elements and are unified in their inclusion of preop- and the variable permutations of ERPs. The included search 226
162 erative, intraoperative, and postoperative elements (Table 1). phrases can be found in Appendix A. 227
163 We encourage readers to view the published ERAS Society 228
A single reviewer performed screening and eligibility
164 229
guidelines to learn more about their specific components, as analysis (J.K.S.). Ten percent of the articles at each level were
165 230
they vary according to procedure [1e5]. independently reviewed by a second reviewer (M.V.R.). If there
166 231
167 Literature regarding similar, non-ERAS Society endorsed was not complete agreement between the two reviewers, all 232
168 protocols, in the pediatric population is far less robust. Rather, articles included at that level were reviewed by the second 233
169 there has been more widespread publication of enhanced re- reviewer (M.V.R.). For articles where the two reviewers dis- 234
170 covery elements studied in isolation [18e27]. For example, agreed on whether to include the article, a third author was 235
171 studies have focused on themes including earlier mobiliza- consulted to help determine inclusion (H.S.). 236
172 tion, regional and opiate-sparing analgesia, and selective use Of the records retrieved through the initial search, a pre- 237
173 of drains and catheters [18e23]. The outcomes of these limited liminary screen of each title was performed. Keywords 238
174 studies were promising, with most interventions demon- including “ERAS,” “enhanced recovery,” “fast-track,” and 239
175 240
strating positive results [18e31]. “perioperative” were used to identify relevant articles for
176 241
Although there have been numerous pediatric studies further review. The most common reasons for articles to be
177 242
demonstrating improved outcomes with isolated elements of excluded at this level were inclusion of adult study
178 243
179 244
180 245
181 246
182 247
Table 1 e A list of the most common components of ERAS Society recommendations for perioperative care.1L5
183 Q3 248
184 Preoperative Intraoperative Postoperative 249
185 250
Preoperative counseling Short-acting anesthetics Epidural anesthesia/analgesia
186 Fluid and carbohydrate loading Epidural anesthesia/analgesia Nonroutine use of nasogastric tubes
251
187 Nonroutine bowel preparation Nonroutine use of tubes and drains Nausea and vomiting prophylaxis in high-risk patients 252
188 Avoidance of prolonged fasting Maintenance of normovolemia Maintenance of normovolemia 253
189 Antibiotic and antithrombotic prophylaxis Maintenance of normothermia Early removal of tubes and catheters 254
190 Early oral nutrition and mobilization 255
191 Opioid-sparing analgesia 256
192 Audit of compliance and outcomes 257
193 258
Please refer to the published guidelines for complete recommendations. Of note, the guidelines do not specify particular antibiotics to include
194 259
for antimicrobial prophylaxis.
195 260

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populations, a psychiatry or emergency medicine focus, and Control populations varied between studies, with the
261 326
262 studies with objectives outside the scope of this review. Of the German studies using the German reimbursement system to 327
263 relevant articles that were included in full-text review, as identify appropriate controls through the use of diagnosis- 328
264 depicted in Table 2, the most common reasons for exclusion related groups [33,34,36]. One of the German studies, by 329
265 were an adult study population and study interventions Schukfeh et al., took place at a private hospital and made 330
266 related to only singular elements of ERPs. additional comparisons to a cohort at an academic hospital 331
267 Q1 From each publication, methods including the elements of [36]. Mattioli et al.’s descriptive study did not have a control 332
268 the ERPs that were implemented, study and control pop- population [35]. Vrecenak and Mattei’s study included a 333
269 ulations, study duration, procedures included, and exclusion comparison population composed of patients seeking treat- 334
270 335
criteria, as well as results including hospital LOS, pain control, ment at the same hospital but who were managed tradition-
271 336
and complications. All publications were assessed for the ally per the discretion of their providers [37]. This was the only
272 337
quality of their reporting using the STrengthening the study designed to compare outcomes other than LOS to a
273 338
274 Reporting of OBservational studies in Epidemiology (STROBE) control population. 339
275 checklist to better assess the quality of the reporting of the Differences between patients included in the ERPs and 340
276 included studies [32]. Inclusion criteria consisted of imple- those who were excluded from them varied by study. Reis- 341
277 mentation of a multimodal ERP incorporating four or more mann et al.’s study in 2007 excluded patients with comorbid- 342
278 elements of an ERAS perioperative care protocol in a general ities that they believed would influence the applicability of 343
279 pediatric surgical population [1e5]. These criteria were their fast-track protocol, as well as patients 35-wk gestation 344
280 selected to ensure that included articles embodied a multi- in the first 6 mo of life, those with perforated appendicitis 345
281 faceted approach to enhancing perioperative care and would or nephroblastomas, and patients undergoing re- 346
282 347
be relevant to the general pediatric surgical population, which fundoplications or renal transplants. In addition, two pa-
283 348
is inherently diverse. tients were excluded from their analysis due to postoperative
284 349
285 Each publication was critically assessed for the potential of bleeding [33]. In 2009, Reismann et al. again excluded patients 350
286 selective reporting, as authors may be biased toward deemed to have comorbidities that would interfere with fast- 351
287 demonstrating the safety and applicability of ERPs. Likewise, track concepts, patients aged 4 wk, patients aged <6 mo who 352
288 the methods and results were scrutinized for potential were born at  35 wk gestational age, and reoperations [34]. 353
289 exclusion of assessments and results that might challenge the Further exclusion criteria included new surgical methods and 354
290 applicability of enhanced recovery strategies. Assessing bias participants in other clinical studies [34]. Schukfeh et al. 355
291 was done on an outcome level by considering likely publica- excluded patients for age < 4 wk and >16 y [36]. Mattioli et al. 356
292 tion bias toward positive results. included all patients who underwent laparoscopic colonic 357
293 358
resection during their study period [35]. Vrecenak and Mattei
294 359
performed their study retrospectively; thus, the patients
295 360
296
3. Results excluded were determined by individual practice patterns
361
297 [37]. 362
298 Through systematic searches, 109 records were screened by The studies took place from the years 2000 to 2012, and all 363
299 abstract and title. Of those, 19 articles were reviewed in their were nonrandomized cohort studies. Three of the studies 364
300 entirety for inclusion. From those 19 articles, 14 were excluded lasted 1 y, with Mattioli et al.’s study lasting 7 y, and Vrecenak 365
301 for reasons summarized in Table 2. Five studies were identi- and Mattei reviewing a 10-y period [35,37]. Studies by Mattioli 366
302 fied as having implemented a multifaceted ERP entailing four et al. and Vrecenak and Mattei included 46 and 45 patients, 367
303 or more elements, thus meeting our criteria for inclusion. respectively. All the other studies included over 100 patients. 368
304 These articles were assessed for quality and omissions in Of the studies that reported gender demographics of their 369
305 370
recommended reported items using the 22-point STROBE populations, study participants were predominantly male,
306 371
checklist [32]. A flow chart of this process is detailed in with female inclusion ranging from 22% to 40%. Of note, the
307 372
308 Figure 1. studies by Reismann et al., Reismann et al., and Schukfeh et al. 373
309 The included studies, with descriptions of the study type, are unified by contributions from many of the same authors 374
310 population, and limitations are summarized in Table 3 [33,34,36]. 375
311 [33e37]. Three of the studies took place in Germany Table 4 summarizes the enhanced recovery elements 376
312 [33,34,36], one in Italy [35], and one in the United States [37]. incorporated into each study. Most of the elements of ERAS 377
313 Two studies reported the age ranges of included patients. Society recommendations for perioperative care were not 378
314 Mattioli et al.’s patients’ ages ranged from 2.3 mo to 14 y, discussed in most studies [1e5]. Although the study by Mat- 379
315 whereas Vrecenak and Mattei’s ranged from 8 to 18 y [35,37]. tioli et al. is the only study that specifically mentioned incor- 380
316 381
The German studies exclusively reported mean ages, which porating antimicrobial prophylaxis as part of their protocol, it
317 382
ranged from 5.8 to 7.9 y [33,34,36]. Various procedures, such as is likely that antimicrobial prophylaxis was used in other
318 383
appendectomy, hypospadias repair, pyloromyotomy, pyelo- studies [35]. In addition, although the study by Mattioli et al. is
319 384
320 plasty, bowel anastomosis, fundoplication, nephrectomy, the only study that mentioned including a standardized pre- 385
321 colon resection, and ileocecectomy were included [33e37]. operative bowel preparation, other studies likely included 386
322 The studies by Reismann et al. and Schukfeh et al. initiated oral them to varying extents [35]. 387
323 nutrition and mobilization within 2 h of surgery, whereas Hospital LOS results for each study cohort versus controls 388
324 Vrecenak and Mattei initiated it within 24 h and Mattioli et al. are depicted in Figure 2. Reismann et al. found significantly 389
325 on postoperative day 1 [33e37]. decreased LOS in each of the procedures they included in 2007, 390

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 444
449
448

400
446
445

443
442

440

406

404
455
454
453
452

450

439
438

436

434

432

430
429
428

426
425

423
422

420

409
408

405

403
402

399
398

396
395
394
393
392
435

433

424

407
447

427

397
441

437

401

391
431

421
451

412
419

416
415
414
413

410
418
417

411

4
Table 2 e ERP articles excluded after full-text review.
Author, year Journal Title Reason for exclusion

West MA et al., 2013 Journal of Pediatric Surgery Potential benefits of fast-track concepts in pediatric No enhanced recovery intervention in the
colorectal surgery pediatric arm
Gastinger I et al., 2012 Polish Journal of Surgery Impact of fast-track concept elements in the classical Mean age was 57.5 y
pancreatic head resection (Kausch-Whipple procedure)
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Reismann et al., 2012 European Journal of Pediatric Surgery Feasibility of fast-track elements in pediatric surgery Looked at the applicability of individual
elements, rather than application of a
system

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Iodice FG et al., 2011 European Journal of Cardiothoracic Analgesia in fast-track pediatric cardiac patients Focused only on analgesia
Surgery
Howard et al., 2010 European Journal of Cardiothoracic Fast-track pediatric cardiac surgery: the feasibility and No clear description of the fast-track
Surgery benefits of a protocol for uncomplicated cases intervention, focused on early extubation
and early transfer out of intensive care
setting
Dingemann et al., 2010 World Journal of Urology Perioperative analgesia strategies in fast-track pediatric Focused only on analgesia
surgery of the kidney and renal pelvis: lessons learned
Jawahar and Scarisbrick, 2009 Association of periOperative Registered Parental perceptions in pediatric cardiac fast-track No focus on clinical outcomes
Nurses (AORN) Journal surgery
Kuzma, 2008 Clinical Nutrition Randomized clinical trial to compare the length of Focused only on early feeding and opioid-
hospital stay and morbidity for early feeding with sparing analgesia
opioid-sparing analgesia versus traditional care after
open appendectomy
Mastrigt et al., 2006 Critical Care Medicine Does fast-track treatment lead to a decrease of intensive Mostly adult patients
care unit and hospital LOS in coronary artery bypass
patients? A meta-regression of randomized clinical
trials
Biancofiore et al., 2005 European Journal of Anesthesiology Fast-track in liver transplantation: 5 y’ experience Mostly adult patients
Fernandes et al., 2004 Arquivos Brasileiros de Cardiologia The reduction in hospital stay and costs in the care of Mixed adult and pediatric patients
patients with congenital heart diseases undergoing
fast-track cardiac surgery
Grewal et al., 2004 Journal of the Society of Laparoscopic appendectomy in children can be done as Focused on operative technique
Laparoendoscopic Surgeons a fast-track or same-day surgery
Ono et al., 2003 Cardiology in the Young The clinical pathway for fast-track recovery of school Focused on operative technique with
activities in children after minimally invasive cardiac modified follow-up
surgery
Vricella et al., 2000 Annals of Thoracic Surgery Ultra fast-track in elective congenital cardiac surgery Focused on operative technique, early
extubation, and early discharge
500
506

504

499
498

496
495
494
493
492

490
489
488
487
486
485
484
483
482
481
480

468

466

464
520

509
508

505

503
502

469

465

463
462

460
459
458

456
507

497

467
491
501

461

457
479
478

475
477

470
473
472
471
476
512

474
519

516
515
514
513

510
518
517

511
 j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 6 ) 1 e1 2 5

521 586
522 587
523 588
524 589
525 590
526 591
527 592
528 593
529 594
530 595
531 596
532 597
533 598
534 599
535 600
536 601
537 602
538 603
539 604
540 605
541 606
542 607
543 608
544 609
545 610
546 611
547 612
548 613
549 614
550 615
551 616
552 617
553 618
554 619
555 620
556 621
557 622
558 Fig. 1 e Flow diagram of the record identification and screening process, as outlined by the Preferred Reporting Items for 623
559 Systematic Reviews and Meta-Analyses (PRISMA) 2009 guidelines. 624
560 625
561 626
562 627
563 and as a composite in 2009 [33,34]. Vrecenak and Mattei also 2.1 versus 3.7 d to full diet, P  0.01). The other studies did not 628
564 noted a significantly decreased hospital LOS in 2014 [37]. have appropriate control populations for such comparisons. 629
565 Schukfeh et al. found that only patients undergoing hypo- Of note, Reismann et al. modified their initial analgesia 630
566 631
spadias repair demonstrated a significantly decreased LOS protocol of no routine opioid use, with patient-controlled
567 632
when compared to controls from the German registry data- opiates as needed, to include limited use of piritramide and
568 633
base [36]. Furthermore, their university hospital controls patient-controlled nalbuphine [33]. This was in response to
569 634
570 found significantly decreased LOS only in fundoplications and postoperative patient-reported mean pain intensity scores 635
571 for all procedures as a composite. exceeding one-third of the maximum value of their desig- 636
572 Table 5 summarizes other results commonly reported be- nated scale, which was their threshold for inadequate anal- 637
573 tween studies. In 2007, Reismann et al. achieved full oral gesia. For Reismann et al.’s study in 2009 and Schukfeh et al.’s 638
574 nutrition after a mean of 15  13.9 h, whereas in 2014, study in 2014, the modified protocol with limited use of piri- 639
575 Schukfeh et al. reached this goal after a mean of 43.2  33.6 h tramide and patient-controlled nalbuphine was used [34,36]. 640
576 [33,36]. In 2009, Reismann et al. noted full oral nutrition for 90% With the exception of children aged >4 y on postoperative day 641
577 of patients on postoperative day 1, with 100% by day 3 [34]. 0 in 2009, subsequent average mean pain intensity scores 642
578 643
Vrecenak and Mattei found that their patients who received were deemed adequate. Importantly, Vrecenak and Mattei
579 644
oral nutrition immediately after operation had a significantly found that average narcotic use was significantly lower in
580 645
581 decreased LOS in comparison to oral nutrition initiated on their ERP patients compared to controls (1.4 mg versus 2.9 mg 646
582 postoperative day 1 (3.05 versus 4.24 d, P  0.01) [37]. Further- morphine equivalents/kg, P ¼ 0.03) [37]. 647
583 more, when compared to conventional groups, time to first Specific mobilization outcomes were not reported by Mat- 648
584 stool and time to full oral diet were significantly decreased in tioli et al. or Vrecenak and Mattei [35,37]. However, in 2007, 649
585 their enhanced recovery groups (2.2 versus 3.3 d to first stool, Reismann et al. achieved full mobilization after a mean of 650

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 700

668

666

664
689
688
687
686
685
684
683
682
681
680

669

665

663
662

660
706

704

699
698

696
695
694
693
692

690

667

659
658

656
655
654
653
652
709
708

705

703
702

679
678

675
707

697

677

670

661
691

673
672

657
701

671
676

651
712

674
715
714
713

710
711

6
Table 3 e Characteristics of the included studies addressing ERPs in a general pediatric surgical population.
Author, year Journal Study type and Population Mean age Procedures included Limitations
dates

Reismann et al. Journal of Pediatric Prospective 113 patients, 5.8  5.3 y Pyeloplasty, appendectomy, bowel Overlapping authors
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2007 Surgery June 2004eJune 70% male anastomosis, fundoplication, Control was LOS data from German
2005 hypospadias repair, full/partial reimbursement system
nephrectomy

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Reismann et al. Langenbeck’s Prospective 155 patients, 7.3  6.4 y All routine elective abdominal, Overlapping authors
2009 Archives of Surgery June 2006eJune 65% male thoracic, and urologic procedures Control was LOS data from German
2007 requiring hospital admission reimbursement system
28 patients were excluded after
operation due to impaired general
condition (n ¼ 25) and pain, catheters,
or drains (n ¼ 3)
Mattioli et al. Journal of Prospective 46 patients, 7.9 m (R 2.3-21.1 m) Laparoscopic colon resection No control population
2009 Laparoendoscopic 2000e2007 d 8 y (R 3-14)
and Advanced Surgical
Techniques. Part A
Schukfeh et al. European Journal of Prospective 143 patients, 7.9  5.0 y Appendectomy, hypospadias Overlapping authors
2014 Pediatric Surgery February 2011e 78% male repair, fundoplication, Took place at a private hospital with
January 2012 pyloromyotomy minimum LOS requirements for
reimbursement purposes
Controls included LOS data from
German reimbursement system and
data from a university hospital
Vrecenak and Journal of Pediatric Retrospective 45 patients, 14.6, range 8e18 y Isolated laparoscopic Retrospective
Mattei 2014 Surgery December 2000e 60% male ileocecectomy Controls were 26 conventionally
December 2010 managed patients who met the
inclusion criteria

R ¼ range; d ¼ not specified.

780

759
758

756
755
754
753
752

750
779
778

775
777

770

739
738

736

734

732

730
729
728

726
725

723
722

720
773
772

768

766

764

757

735

733

724
771

769

765

763
762

760

727
776

767

744

737
751

749
748

731

721
761

746
745

743
742

740
774

719

716
718
747

741

717
 j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 6 ) 1 e1 2 7

Q4
1.22  0.7 d, and Schukfeh et al. reached this goal after 2.3  2 d
781 846

no preoperative

None of the studies discussed inclusion of the following ERAS Society recommendations for perioperative care in elective colonic surgery: preoperative optimization, preoperative fasting limited to
clear fluids up to 2 h before the procedure and solid foods 6 h before the procedure, carbohydrate treatment, no preoperative bowel prep, thromboembolism prophylaxis, a multimodal approach to
postoperative nausea and vomiting for those at risk, intraoperative normothermia, maintenance of normovolemia, nonroutine drainage of peritoneal cavity after colonic anastomosis, routine
782 in 2014 [33,36]. The study by Reismann et al. in 2009 noted that 847

Selective or

bowel prep
783 full mobilization was reached by 82% of patients by post- 848
operative day 3, which was slightly greater than the 78% re-


784 849
785 ported by Schukfeh et al. in 2014 [34,36]. There were no 850
786 comparison populations for the aforementioned variables in 851
787 those studies. 852
788 There were no significant differences in complication rates 853
mobilization

789 that were attributable to ERPs in any of the studies. Authors 854
790 855
Early

defined complications as attributable to ERPs when medical

791 856
þ
þ
þ
þ

problems were associated with a delay in diagnosis or treat-

792 857
ment owing to early discharge. In 2007, Reismann et al. re-
793 858
794 ported one readmission for pain and one for occlusion of a 859
795 pigtail catheter. They also reported two postoperative com- 860
perioperative
Minimized

796 plications after hypospadias repair [33]. In 2009, Reismann 861

fasting

797 et al. reported four readmissions for reasons including pain 862
Table 4 e Elements of ERAS guidelines implemented by studies addressing general pediatric surgery included in this review.

þ
þ
þ
þ
þ

798 and a urinary tract infection on 2-wk follow-up [34]. Of Mat- 863
799 tioli et al.’s 46 patients, one was readmitted for fever and one 864
800 for rectal pouch dehiscence [35]. Nine of a total of 143 patients 865
801 suffered complications in Schukfeh et al.’s 2014 study, three of 866
802 867
Nonroutine
nasogastric
intubation

which were intraoperative gastric perforations [36]. On 2-wk

803 868
follow-up, six patients had been readmitted for reasons
þ
þ

þ
þ

804 869
805 including fever, infections, and vomiting [36]. Vrecenak and 870
806 Mattai had two readmissions and found that small bowel 871
* ¼ Use of blended and locoregional anesthesia systematically; þ ¼ present;  ¼ not present; blank ¼ no data provided.

807 obstructions were more common in their fast-track group, 872

808 with two occurring in the 6 mo after surgeries for Crohn’s 873
Modifications of
surgical access

809 disease. However, this difference did not reach statistical 874
810 significance (P ¼ 0.15) [37]. 875
þ
þ
þ
þ
þ

811 876
transurethral bladder drainage, efforts to prevent postoperative ileus, or postoperative glucose control.

812 877
813 878
814 879
4. Discussion
815 880
skin preparation
prophylaxis and

816 881
Antimicrobial

817 4.1. Enhanced recovery protocols in pediatric surgery 882

818 883
þ

819 As the United States’ health care system embraces concepts 884
820 such as cost-containment and value-based purchasing, 885
821 improving outcomes while minimizing waste and resource 886
822 utilization is crucial. Although ERAS Society guidelines, and 887
823 various iterations of them, have gained acceptance and are 888
Standardized

824 889
anesthetic

being adopted across a variety of adult surgical indications,

protocol

825 890
our literature review demonstrates a need for further study of
þ
þ

þ
þ

826 891
*

whether enhanced recovery elements can be applied to pe-

827 892
828 diatric surgery [1e5]. Although several studies have evaluated 893
829 individual aspects of ERPs, relatively few have addressed 894
830 multiple aspects of care pathways in a systematic or syn- 895
Preoperative
counseling

831 chronous fashion. 896

832 Of the five studies included in this review, the mean 897
þ
þ
þ
þ
þ

833 number of interventions in each study was 5.6 as compared to 898

834 an average of 23.8 interventions typically included in adult 899
835 ERAS Society position statements [1e5]. This may be in part 900
836 901
due to adult ERAS elements, such as thromboembolic pro-
Vrecenak and Mattei 2014

837 902
phylaxis, being viewed as less applicable for pediatric cases
838 903
Reismann et al. 2007
Reismann et al. 2009

[1e5]. Differences such as these are likely to become more

Schukfeh et al. 2014

839 904
Mattioli et al. 2009

840 pronounced as pediatric ERPs are fully developed and 905

841 customized for children, as the pediatric population has 906
842 unique perioperative considerations. The presence of distinct 907
843 perioperative needs within the pediatric surgical population 908
844 makes this topic an exciting and uncharted territory for 909
845 research. 910

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911 976
912 977
913 978
914 979
915 980
916 981
917 982
918 983
919 984
920 985
921 986
922 987
923 988
924 989
925 990
926 991
927 992
928 993
929 994
930 995
931 996
932 997
933 998
934 999
935 1000
936 1001
937 1002
938 1003
939 1004
940 1005
941 1006
942 1007
Fig. 2 e Mean hospital length of stay (in days) after implementation of an enhanced recovery protocol (ERP) versus controls.
943 1008
944 1009
945 1010
4.2. Further examination of hospital length of stay instance, Schukfeh et al.’s study, which took place 7 y later
946 1011
947 findings than Reismann et al.’s initial study, noted a more modest 1012
948 decrease in the overall LOS in their university hospital con- 1013
949 Results of this systematic review show that ERPs decreased trols when compared to the German reimbursement data [36]. 1014
950 LOS in most studies, including the one study that took place in During that time period, the landscape of surgery was rapidly 1015
951 the United States. Significant changes in LOS in enhanced changing with the increasing use of minimally invasive sur- 1016
952 recovery patients versus controls ranged from 1.3 to 13 d. gery (MIS) [34,36]. More ubiquitous use of MIS may partially 1017
953 However, drastic changes in LOS for some procedures should explain the lack of LOS differences observed in later studies, 1018
954 be subject to further examination. In 2007, Reismann et al. thus minimizing the effect of ERPs. It is not clear whether the 1019
955 1020
reported decreases in LOS, ranging from 2.6 d for appendec- German reimbursement data used for comparisons in the
956 1021
tomies, to 13 days for fundoplications [33]. Overall, four of the aforementioned studies adequately controlled for surgical
957 1022
six procedures in their study demonstrated a decrease in approach [33]. In addition, the hospital reimbursement sys-
958 1023
959 hospital stay of over a week [33]. These results reflect a com- tem may be responsible for the lack of improvement in LOS in 1024
960 parison between German reimbursement data for the pro- Schukfeh et al.’s study, as they acknowledged a minimum 1025
961 cedures of interest versus prospectively collected data from required LOS for full reimbursement, which may have pre- 1026
962 patients on an ERP. cluded true assessment of ERPs. 1027
963 Further examination reveals that Reismann et al.’s exclu- 1028
964 sion criteria may have played a role in self-selecting patients 4.3. Existing pediatric data for individual enhanced 1029
965 who would likely demonstrate a benefit from the ERPs. The recovery elements 1030
966 authors intentionally excluded patients deemed to have 1031
967 1032
comorbidities that would interfere with fast-track concepts Despite the paucity of studies regarding the implementation
968 1033
although the comorbidities they deemed relevant were not of pediatric ERPs, there are existing data regarding the safety
969 1034
970 clearly delineated [33]. It is also important to note that in the and efficacy of individual elements of adult ERAS Society 1035
971 2009 Reismann et al. study, 28 patients were excluded from the guidelines as applied to pediatric surgery. Studies have shown 1036
972 ERPs postoperatively but arguably should have been included that omission of preoperative bowel preparations in many 1037
973 using an intention-to-treat analysis [34]. pediatric procedures poses no greater risk of wound infection 1038
974 It is likely that there are many underlying factors contrib- [40e43]. Regional and patient-controlled analgesia have been 1039
975 uting to the early reports of drastically decreased LOS data. For demonstrated to be safe and efficacious, as has utilization of 1040

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 1044
1068

1066

1064

1049
1048
1069

1065

1063
1062

1060

1046
1045

1043
1042
1099
1098

1096
1095
1094
1093
1092

1090
1089
1088
1087
1086
1085
1084
1083
1082
1081
1080

1067

1059
1058

1056
1055
1054
1053
1052

1050
1079
1078

1075
1097

1077

1070

1061
1091

1073
1072

1057

1047
1071

1041
1076

1051
1100

1074
1104
1105

1103
1102
1101
Table 5 e Results of studies addressing multifaceted ERPs in general pediatric surgery. Q5
Hospital LOS Mean pain intensity Oral nutrition Mobilization Readmission Complications
mean  SD (d) (POD 0, 1, 2)

Reismann et al. Overall: CHIPPS scale Full oral nutrition after a Full mobilization 1 pyeloplasty requiring No complications attributable
2007 2.3 d  1.1 4.2  2.0 mean of 15  13.9 h after a mean of nephrostomy for to fast-track surgery**, 2
Appendectomy 2.2  2.1 29.5  16.6 h occlusion of a pigtail complications after hypospadias
3.7  2.4 2.0  2.4 catheter, repair (micturition pain, revision
Hypospadias VAS/SMILEY scale 1 hypospadias repair for bleeding)
repair 2.1  1 5.4  2.2 due to pain with
Nephrectomy 4.0  2.0 micturition a
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1.9  1.0 2.3  1.7

Pyeloplasty
1.9  0.9
Bowel anastomosis

j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 6 ) 1 e1 2
3.2  0.6
Fundoplication
3.2  0.8
Reismann et al. Overall: 4.6  2.9 CHIPPS scale Full oral nutrition for 90% Full mobilization 1 persistent abdominal No complications attributable to
2009 1.3  1.5 of patients on POD 1 and in 82% of patients pain after appendectomy fast-track surgery**, 4 minor
<1 100% by POD 3 by POD 3 1 UTI after pyeloplasty complications not associated with
<1 2 painful micturition fast-track surgery
VAS/SMILEY scale after hypospadias repair
3.7  2.2 necessitating suprapubic
<3 catheter insertion
<3
Mattioli et al. 95.7% of patients n/a Stool passage and oral All patients were 1 fever secondary to No complications other than the
2009 were discharged feeding were achieved mobilized before anastomotic leak two resulting in readmissions
before POD 1 in all cases discharge. 1 rectal pouch
POD 5 dehiscence
Schukfeh Overall: 5.8  3.4 CHIPPS scale Complete oral nutrition Full mobilization 2 fever No complications attributable to
et al. 2014 Appendectomy 1.7  2.1 after a mean of 1.8  1.4 d after 2.3  2 d, 2 abdominal wound fast-track surgery**, 9 complications
5.3  3.3 0.5  1.1 postoperatively full mobilization in infections after not attributed to fast-track surgery
Hypospadias repair n/a 78% of patients by appendectomy
6.2  1.1 VAS/SMILEY scale POD3 1 UTI after hypospadias
Pyloromyotomy 2.3  2.1 repair
6.3  4.9 1.7  1.8 1 vomiting after
Fundoplication n/a fundoplication
10.8  6.48
(continued)

9
1144

1129
1128

1126
1125

1123
1122

1120
1168

1166

1164

1149
1148

1124

1106
1169

1165

1163
1162

1160
1159
1158

1156
1155
1154
1153
1152

1150

1146
1145

1143
1142

1140
1139
1138

1136

1134

1132

1130

1127

1109
1108
1167

1135

1133

1107
1121
1161

1157

1137
1170

1147

1131
1141
1151

1112
1119

1116
1115
1114
1113

1110
1118
1117

1111
 10 j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 6 ) 1 e1 2

Q6
non-opiate pain medications [21,22]. Studies have demon-
1171 1236

Hospital LOS, pain intensity, oral nutrition, mobilization, readmission, and complication results for each of the studies were included to the extent that they were detailed in the articles. The VAS/
SMILEY scale was used to report pain intensity scores in children aged older than 4 y, the CHIPPS scale was used to report pain intensity scores in children aged younger than 4 y, in selected studies.
C ¼ controls; CHIPPS ¼ Children’s and Infants’ Postoperative Pain Scale; FT ¼ fast-track; Smiley ¼ Smiley Scale; VAS ¼ visual analog scale; * ¼ significant difference, ** ¼ fast-trackeassociated
1172 strated the utility of prophylactic ondansetron in high-risk 1237

nonsignificant increase in SBOs

pediatric populations to prevent postoperative nausea and
complications between groups,
1173 1238

in fast-track patients (P ¼ 0.15;

1174 vomiting, which is a major contributor to unanticipated hos- 1239
No significant difference in
Complications

1175 pital admissions [30,44,45]. 1240

1176 Furthermore, early enteral nutrition in a pediatric cohort 1241
1177 has been correlated with faster times to full feeds, with no 1242
1178 difference in readmissions [46]. Conversely, perioperative 1243
8.8% FT, 0% C)

1179 fluid overload has been identified as contributor to increase 1244

1180 1245
perioperative morbidity and the need for postoperative anti-
1181 1246
hypertensive medications [47,48]. Also, several studies have
1182 1247
shown that omission of catheters in select procedures is
1183 1248
1184 appropriate [18,19]. Furthermore, urinary catheter removal or 1249
1185 omission may facilitate early mobilization, which is associ- 1250
1186 ated with positive clinical outcomes on several fronts 1251
Readmission

1187 including venous thromboembolism prevention, prevention 1252

2 patients in both
treatment arms

1188 of atelectasis, and quicker return of bowel function [49]. 1253

1189 Several other elements typically found in adult ERAS So- 1254
1190 ciety guidelines are not well supported in the existing pedi- 1255
1191 atric surgery literature. These elements include elimination of 1256
1192 1257
routine nasogastric tubes, preventing postoperative ileus with
1193 1258
interventions including chewing gum or laxative use, the
1194 1259
1195 prevention of intraoperative hypothermia, and routine 1260
All patients were
mobilized before
Mobilization

1196 drainage of the peritoneal cavity after colonic anastomosis. 1261

1197 More studies are needed to assess the applicability of these 1262
discharge.

1198 adult recommendations in the pediatric population. 1263

1199 In 2012, Reismann et al. assessed the feasibility of select 1264
complications defined as medical problems with a delay in diagnosis or treatment owing to early discharge.

1200 enhanced recovery elements including anesthetic protocols, 1265

1201 early postoperative enteral nutrition, early mobilization, and 1266
1202 1267
3.3 d) and time to full PO diet

use of MIS among children undergoing a variety of thoracic,

significantly decreased in FT
Time to first stool (2.2 versus

1203 1268
urologic, oncologic, hepatobiliary, and gastrointestinal surgi-
PO nutrition immediately

(3.05 versus 4.24, P  0.01)

1204 1269
significantly decreased
Oral nutrition

cal procedures [27]. They found that most of the patients were
PO nutrition on POD 1
LOS in comparison to

(2.1 versus 3.7 d) were

after operation led to

1205 1270
able to achieve sufficient analgesia with no nausea or vomit-
1206 1271
groups (P  0.01)

1207 ing. Almost all patients were able to tolerate full enteral feeds 1272
1208 and ambulate within 48 h of surgery. 1273
1209 However, Reismann et al. identified situations where fast- 1274
1210 track elements were not feasible [27]. For example, analgesia 1275
1211 was inadequate in oncologic and ureteral reimplantation 1276
1212 procedures, and postoperative nausea and vomiting were 1277
1213 common after laparoscopic procedures and Kasai operations. 1278
Mean pain intensity

2.9 mg morphine/kg C;
morphine/kg FT versus

1214 1279
significantly lower in

Patients undergoing ureteral reimplantation and hypospadias

fast-track patients
(POD 0, 1, 2)

1215 1280
Narcotic use was

repair were not able to meet mobilization goals, and those

1216 1281
undergoing fundoplication and Kasai operation were unable
1217 1282
1218 to achieve early enteral intake goals [27]. Although this study 1283
P ¼ 0.03)
(1.4 mg

1219 assessed the applicability of many enhanced recovery ele- 1284

1220 ments, most of the components of the adult ERAS Society 1285
1221 Guidelines were not investigated. It is crucial to conduct 1286
1222 further studies to investigate whether additional enhanced 1287
mean  SD (d)

1223 recovery elements can be feasibly incorporated into pediatric 1288

Hospital LOS

1224 1289
Average of 3.7

surgery.
1225 1290
1226 1291
4.4. Limitations
1227 1292
Table 5 e (continued )

1228 1293
There are several limitations to this systematic review.
1229 1294
1230 Despite an extensive literature review, we were able to iden- 1295
Mattei 2014
Vrecenak and

1231 tify only five studies, none of which were randomized 1296
1232 controlled trials, and most of which had ill-suited or inade- 1297
1233 quate comparison populations. Study settings also varied in 1298
1234 terms of hospital ownership and geographic location, which 1299
1235 may contribute to variation in practice patterns and policies 1300

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effecting LOS. Three of the included studies have overlapping work. H.S. and J.K.S. acquired, analyzed, and interpreted the
1301 1366
1302 authors, thus potentially limiting the generalizability and data for the work with the assistance of M.V.R., K.F.H., M.L.B., 1367
1303 reproducibility of these findings. Despite the overlapping au- and M.T.S. H.S. and J.K.S. drafted the work. All the authors 1368
1304 thors, the studies took place over different years and do not have approved the article in its current state and have agreed 1369
1305 have overlapping data. Finally, the ERPs that were imple- to be accountable for all aspects of the work. 1370
1306 mented, and the quality of their reporting, were not uniform 1371
1307 between studies. Regardless of this heterogeneity, all the 1372
1308 included studies assessed multifaceted ERP entailing four or Supplementary data 1373
1309 more elements in an appropriately diverse pediatric surgical 1374
1310 1375
population. Supplementary data related to this article can be found at
1311 1376
It is also important to acknowledge Schukfeh et al.’s study http://dx.doi.org/10.1016/j.jss.2015.12.051.
1312 1377
in the capacity that it was the only one to report predomi-
1313 1378
1314 nantly negative results [36]. It is likely that publication bias 1379
1315 has prevented more reports demonstrating little or no efficacy Disclosure 1380
1316 of pediatric ERPs from surfacing. It is acknowledged that 1381
1317 studies with positive results are more likely to be published in The authors report no proprietary or commercial interest in 1382
1318 English-language journals, whereas negative results are more any product mentioned or concept discussed in this article. 1383
1319 likely to be published in noneEnglish-language journals. 1384
1320 Because many of the aforementioned studies took place in 1385
1321 Europe, it is possible that there are more data published in 1386
6. Uncited references Q8
1322 1387
noneEnglish-language journals.
1323 1388
Although a large body of literature supports the use of [38,39].
1324 1389
1325 ERAS Society guidelines in adults, it is important to remember 1390
1326 that adult protocols will likely need modifications before 1391
1327 successful application in pediatric patients [1e5]. Further- references 1392
1328 more, the ERP elements in this review are being viewed as 1393
1329 broad concepts that are open to further interpretation, rather 1394
1330 than specific recommendations. Exactly how these general [1] Gustafsson UO, Scott MJ, Schwenk W, et al. Guidelines for 1395
1331 themes will be applied to pediatric surgery is currently un- perioperative care in elective colonic surgery: Enhanced 1396
1332 Recovery After Surgery (ERAS) Society recommendations. 1397
known, and it would be inappropriate to make firm recom-
1333 World J Surg 2013;37:259. 1398
mendations based on such limited evidence. The overall [2] Mortensen K, Nilsson M, Slim K, et al. the Enhanced Recovery
1334 1399
consensus impression is that ERPs are likely safe and effec- After Surgery (ERAS) Group. Consensus guidelines for
1335 1400
tive; however, synthesizing these heterogeneous methodolo- enhanced recovery after gastrectomy: Enhanced Recovery
1336 1401
gies into one recommendation sacrifices important nuances After Surgery (ERAS) Society recommendations. Br J Surg
1337 1402
within each contribution. 2014;101:1209.
1338 1403
[3] Cerantola Y, Valerio M, Persson B, et al. Guidelines for
1339 1404
perioperative care after radical cystectomy for bladder
1340 1405
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1341 1406
5. Conclusions recommendations. Clin Nutr 2013;32:879.
1342 [4] Lassen K, Coolsen MME, Slim K, et al. Guidelines for 1407
1343 perioperative care for pancreaticoduodenectomy: Enhanced 1408
Based on success with adult patients and the limited data
1344 Recovery After Surgery (ERAS) Society recommendations. 1409
1345 assembled for this review, ERPs for children appear promising 1410
World J Surg 2013;37:240.
1346 and merit further investigation. There is a need to define [5] Nygren J, Thacker J, Carli F, et al. Guidelines for perioperative 1411
1347 modifications of existing adult pathways for children and to care in elective rectal/pelvic surgery: Enhanced Recovery 1412
1348 qualitatively assess the readiness of adoption of many aspects After Surgery (ERAS) Society recommendations. World J 1413
1349 of ERAS in the care of children undergoing surgery. Larger, Surg 2013;37:285. 1414
1350 prospective studies using adequate controls and implement- [6] Auyong DB, Allen CJ, Pahang JA, et al. Reduced length of 1415
1351 ing multiple aspects of ERPs in the pediatric surgical popula- hospitalization in primary total knee arthroplasty patients 1416
1352 using an updated enhanced recovery after orthopedic 1417
tion are needed.
1353 surgery (ERAS) pathway. J Arthroplasty 2015;30:1705. 1418
1354 [7] Miller TE, Thacker JK, White WD, et al. the Enhanced 1419
1355 Recovery Study Group. Reduced length of hospital stay in 1420
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1356 1421
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1357 1422
[8] Kagedan DJ, Ahmed M, Devitt KS, Wei AC. Enhanced
1358 1423
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1359 1424
Emory þ Children’s Pediatric Research Trust, Children’s evidence. HPB (Oxford) 2015;17:11.
1360 1425
[9] Tang J, Humes DJ, Gemmil E, et al. Reduction in length of stay
1361 Healthcare of Atlanta, and the Department of Surgery at 1426
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1362 Q2 Emory University.
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1432 1501
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1433 1502
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1434 1503
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1470 1539
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