Application of enhanced recovery after surgery during the perioperative period in infants with Hirschsprung's disease - A multi-center randomized clinical trial

Cost-effectiveness analysis of robot-assisted laparoscopic surgery for complex pediatric surgical conditions

BACKGROUND

Robotics has been used safely and successfully in a variety of adult surgeries and is gradually gaining ground in pediatrics. While the benefits of robotic-assisted surgery in disease treatment are well recognized, its high cost has led to questions. To investigate whether robotic-assisted laparoscopic surgery (RALS) is cost-effective compared to conventional laparoscopic surgery (LS) in pediatric surgery, we attempted to construct a model to perform an analysis of these two surgical approaches using Python statistical analysis software.

METHODS

We selected four common complex pediatric surgical conditions (choledochal cyst, Hirschsprung's disease, vesicoureteral reflux, and congenital hydronephrosis) from three systems (pediatric hepatobiliary, gastroenterology, and urology). Models were constructed using Python statistical software to compare hospital costs and surgical outcomes for RALS and LS. In addition, we performed a preferred strategy analysis for both surgical modalities while assessing model uncertainty using one-way sensitivity analysis.

RESULTS

For the four diseases, the operative time decreased sequentially. The total inpatient costs of RALS were 10,816.72, 9145.44, 8414.29, 7973.58 dollars, respectively, yielding 1.789, 1.712, 1.749, 1.792 quality adjustment life years (QALYs) over two years post-operatively. The incremental cost of RALS relative to LS for each disease was 3523.44, 3200.20, 3049.79, 3043.66 dollars, respectively, with an incremental utility of 0.060, 0.054, 0.051, 0.050 QALYs. The incremental cost-effectiveness ratios (ICERs) for RALS for each of the four diseases were 58,724.01, 59,262.95, 59,799.79, 60,873.20 dollars/QALY, all less than 100,000 dollars/QALY. The cost of robot consumables was the main incremental cost of RALS and had the most significant impact on the model.

CONCLUSION

For the four pediatric surgical conditions described above, RALS has higher inpatient costs than LS, but it has better postoperative outcomes, and all four RALS treatments are cost-effective. Children with complex diseases and long operative times appear to benefit more from RALS.

Meta-Analysis of Enhanced Recovery After Surgery Protocols for the Perioperative Management of Pediatric Colorectal Surgery

OBJECTIVE

This meta-analysis aimed to investigate the effects and safety of enhanced recovery after surgery (ERAS) for the management of pediatric colorectal surgery.

METHODS

We retrieved relevant studies from PubMed, EMBASE, the Cochrane Library, and China National Knowledgement Infrastructure (CNKI) from its inception until 20 May 2022. Meta-analysis was performed using RevMan 5.4, and power analysis was calculated using G∗Power 3.1.

RESULTS

Ten studies involving 1298 patients were included for meta-analysis. Meta-analysis suggested that ERAS protocol significantly lessened intraoperative fluids (mean difference [MD], -3.11; 95% confidence interval, -4.99 to -1.22) and postoperative opioid usage (MD, -0.58; 95% CI, -1.08 to -0.26), shortened time to bowel return (MD, -12.02; 95% CI, -20.03 to -4.02), first enteral nutrition (MD, -20.88; 95% CI, -28.34 to -13.42) and oral intake (MD, -1.40; 95% CI, -1.96 to -0.84), lowered readmission rate in 30 days (relative risk [RR], 0.61, 95% CI, 0.41 to 0.90), shortened length of hospital stay (MD, -1.50; 95% CI, -1.25 to -1.09), and reduced in-hospital costs (MD, -0.26; 95% CI, -0.34 to -0.18); however, there was a comparable rate of postoperative complications between the two groups. Sensitivity analysis significantly changed the result of the readmission rate in 30 days. The statistical power of all outcomes ranged from 26.84% to 99.44%.

CONCLUSIONS

Our findings demonstrate the beneficial role of the ERAS protocol in accelerating rehabilitation, shortening the length of hospital stay, and decreasing in-hospital costs among pediatric patients undergoing colorectal surgery.

LEVELS OF EVIDENCE

LEVEL V.

Utilization of an Enhanced Recovery After Surgery (ERAS) protocol for pediatric metabolic and bariatric surgery

INTRODUCTION

Enhanced recovery after surgery (ERAS) protocols for pediatric metabolic and bariatric surgery are limited. In 2018, an ERAS protocol for patients undergoing robotically assisted vertical sleeve gastrectomy (r-VSG) was instituted. This study's aim was to compare outcomes before and after ERAS initiation.

METHODS

A single institution retrospective review of patients undergoing r-VSG from July 2015 to July 2021 was performed. The multimodal ERAS protocol focused on limiting post-operative nausea and narcotic utilization. Subjects were categorized into non-ERAS (July 2015-July 2018) and ERAS (August 2018-July 2021) groups. In-hospital and 30-day outcomes were compared.

RESULTS

110 subjects (94 females) with a median age of 17.6 years (range 12.5-22.0 years) were included (60 non-ERAS, 50 ERAS). Demographics were similar except for a higher proportion of females in the non-ERAS group (97% vs 72%, p < 0.001). A significant decrease in narcotic use (p < 0.001) and higher utilization of acetaminophen (p < 0.001) and ketorolac (p < 0.001) was observed in the ERAS group. Additionally, median time to oral intake, a proxy for postoperative nausea and vomiting [2:00 h (1:15, 2:30) vs. 3:22 h (2:03, 6:15), p < 0.001] and hospital length of stay (LOS) [1.25 days (1.14, 1.34) vs. 2.16 days (1.48, 2.42), p < 0.001] were shorter in the ERAS group. Eleven subjects (10%; ERAS = 5, non-ERAS = 6) experienced post-discharge dehydration, prompting readmission 8 times for 7 (6%) individuals.

CONCLUSION

Utilization of ERAS led to a significant decrease narcotic utilization, time to first oral intake, and hospital LOS with no change in adverse events following pediatric metabolic and bariatric surgery. Larger studies, including comparative analysis of health care utilization, should be carried out.

LEVEL OF EVIDENCE

III.

TYPE OF STUDY

Treatment Study.

Key Strategies for Optimizing Pediatric Perioperative Nutrition-Insight from a Multidisciplinary Expert Panel

Adequate nutrition is an essential factor in healing and immune support in pediatric patients undergoing surgery, but its importance in this setting is not consistently recognized. Standardized institutional nutrition protocols are rarely available, and some clinicians may be unaware of the importance of assessing and optimizing nutritional status. Moreover, some clinicians may be unaware of updated recommendations that call for limited perioperative fasting. Enhanced recovery protocols have been used in adult patients undergoing surgery to ensure consistent attention to nutrition and other support strategies in adult patients before and after surgery, and these are now under evaluation for use in pediatric patients as well. To support better adoption of ideal nutrition delivery, a multidisciplinary panel of experts in the fields of pediatric anesthesiology, surgery, gastroenterology, cardiology, nutrition, and research have gathered and reviewed current evidence and best practices to support nutrition goals in this setting.

Enhanced recovery after surgery in pediatric urology: Current evidence and future practice

PURPOSE

To offer an up-to-date appraisal of the current status of enhanced recovery after surgery (ERAS) protocols in pediatric urology and to provide a guide for the clinical urologist.

MATERIALS AND METHODS

We performed a comprehensive literature search and scoping review on ERAS protocols in pediatric urology using Pubmed (from 1946), Cochrane library, and MEDLINE to December 2021 with the terms ''enhanced recovery'', ''protocolised care'', ''post-operative protocol", ''fast-track surgery'' and ''pediatric urology". Studies were excluded if they did not include perioperative intervention related to urological procedures, no full-text available and in non-English language.

RESULTS

To date, eight clinical studies (involving 1153 patients) have been published on ERAS protocols in pediatric urology. The patients involved ranged from neonates to adolescents, and the urological procedures included bladder augmentation, the Mitrofanoff procedure, laparoscopic pyeloplasty, laparoscopic nephrectomy, hypospadias repair, etc. Multidisciplinary components such as surgical and anesthetic considerations have been employed in ERAS protocols. The length of hospital stay was significantly lower in the ERAS groups with earlier enteral feeding resumption and return of bowel function in pediatric urology patients. The implementation of ERAS protocols does not result in higher complication and readmission rates; instead, some studies have even demonstrated a significant reduction in complication occurrence.

CONCLUSION

ERAS is novel to pediatric urology with a limited scale of published data in the literature. Initial clinical studies revealed that ERAS appears to be efficacious in the field of pediatric urology. Further prospective studies formulating a standardized multimodal protocol are encouraged to better understand key components of ERAS and incorporate ERAS into clinical practice to optimize surgical outcomes for pediatric urology procedures.

Evaluating caretaker satisfaction with same-day discharge after gastrostomy tube placement

BACKGROUND

Same-day discharge (SDD) after laparoscopic gastrostomy tube (G-tube) placement, using written and video-based preoperative education, has been our standard institutional practice since 2017. We aim to evaluate caretaker satisfaction with this protocol.

METHODS

All patients planned for SDD after G-tube placement from February 2021-February 2022 were identified. Chart review was performed to identify demographic information, successful same-day discharge or reason for postoperative admission, time to first postoperative feed, length of stay (LOS), and complications requiring emergency department evaluation, readmission, or reoperation. Telephone follow-up at two weeks postoperatively was conducted to evaluate satisfaction with the SDD protocol.

RESULTS

Forty-nine patients were eligible for SDD with a median age of 1.1 years [0.7, 4.4]. Forty-two (86%) patients were successfully discharged the same day with a median LOS of 7.5 h [6.7, 8.1], and 7 (14%) were admitted postoperatively for further education or emesis with a median LOS of 30.4 h [26.9, 31.2]. Median time to initiation of feeds was 2.3 h [1.7, 2.9]. 8 (16%) patients were evaluated in the emergency department within 30 days postoperatively, resulting in two re-admissions: one for peri‑stomal erythema and fever requiring oral antibiotics at 21 days and one for G-tube dislodgement requiring reoperation and replacement at 28 days. On two-week telephone follow-up, 42 caretakers (100%) felt that their education was adequate for same-day discharge and felt comfortable with the same-day discharge protocol. Six (14%) caretakers stated their child's pain was not well controlled at some point between discharge and survey follow-up, and three caretakers (7%) called a provider within the first 24 h for issues with pain. Forty-one caretakers (98%) expressed satisfaction going home the day of surgery.

CONCLUSION

Caretaker satisfaction and comfort with same-day discharge following laparoscopic G-tube placement are high, ascribed to comprehensive preoperative education and anticipatory guidance.

TYPE OF STUDY

Prognostic.

LEVEL OF EVIDENCE

Level 1.

Baseline assessment of enhanced recovery after pediatric surgery in mainland China

BACKGROUND

Enhanced recovery after surgery (ERAS) is a clinical pathway that optimizes perioperative management based on evidence-based medicine. ERAS has been gradually introduced to pediatric surgery in recent years. However, there are limited reports on its overall implementation. We aimed to determine the implementation of ERAS in patients who received pediatric surgery in mainland China.

METHODS

We designed a questionnaire involving 17 key ERAS elements and sent the questionnaire to 66 chiefs of pediatric surgery distributed throughout 31 provinces in mainland China to obtain a baseline assessment of the assimilation of ERAS protocols in the care of congenital biliary dilatation (CBD).

RESULTS

A total of 66 questionnaires were collected. The range of elements implemented at participating centers was 4-16, with a mean of 10.23. The least commonly practiced elements were administration of non-opioid preoperative analgesia (6 centers, 9.09%), prevention of postoperative nausea and vomiting [PONV] (9 centers, 13.64%), and postoperative pain management (26 centers, 39.39%).

CONCLUSIONS

The implementation of elements differed from center to center. Measures relying primarily on anesthesiologists had lower execution. The adherence to ERAS elements was often inhibited by a lack of institutional support, poor knowledge of ERAS protocols, and difficulties in coordinating multidisciplinary care, as well intransigence in changing surgical practices out of fear of liability for poor outcomes.

Implementation and outcomes of enhanced recovery protocols in pediatric surgery: a systematic review and meta-analysis

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 implementation 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.