Application of enhanced recovery after surgery in perioperative care of infants and children with Hirschsprung disease

Abstract

BACKGROUND

Enhanced recovery after surgery (ERAS) represents an innovative, protocol-driven perioperative care program designed to optimize patient outcomes. However, its application and efficacy in infants and children with Hirschsprung disease (HD) remain underexplored.

AIM

To delve into the impact of ERAS on perioperative recovery and the overall medical experience in HD infants and children.

METHODS

Thirty-eight infants and children with HD who received the Soave surgical procedure were enrolled in this case-control study. According to age- and sex-stratified single-blind randomized tables, 20 cases received ERAS treatment (ERAS group) and 18 cases received conventional treatment (control group). The two treatments were then compared in terms of perioperative recovery and medical experience.

RESULTS

Significant differences were observed in pain scores at awakening (4.2 ± 1.3 vs5.2 ± 1.2, t = 2.516, P = 0.017) and pain duration (85.69 ± 7.46 hours vs 67.00 ± 8.56 hours, t = 7.139, P < 0.001) between the ERAS and control group. The recovery of bowel movement was earlier in the ERAS group than in the control group (borborygmus time: 33.63 ± 9.83 hours vs 44.69 ± 16.85 hours, t = 2.501, P = 0.017; feeding time: 36.63 ± 9.55 hours vs 49.36 ± 16.99 hours, t = 2.884, P = 0.007; anal catheter indwelling time: 75.83 ± 13.80 hours vs 93.36 ± 20.65 hours, t = 3.104, P = 0.004), and fever duration (40.73 ± 14.42 hours vs 52.63 ± 18.69 hours, t = 2.211, P = 0.034). In the ERAS group, hospital stay was shorter (7.5 ± 0.9 days vs 8.3 ± 1.2 days) and the cost was lower (14203 ± 2381 yuan vs 16847 ± 3558 yuan). During the 1-month follow-up period, of the multiple postoperative complications observed, the occurrence of perianal dermatitis (P_Fisher = 0.016) and defecation dysfunction (P_Fisher = 0.027) were lower in the ERAS group than in the control group.

CONCLUSION

The ERAS protocol has the potential to profoundly enhance postoperative recovery and significantly elevate the overall comfort and quality of the medical experience, making it an indispensable approach that warrants widespread adoption. Continuous refinement through evidence-based practices is anticipated to further optimize its efficacy.

Key Words: Enhanced recovery after surgery; Hirschsprung disease; Infant and children; Perioperative period; Outcome; Complications

Core Tip: Nursing based on the concept of enhanced recovery after surgery (ERAS) effectively accelerates perioperative recovery and improves postoperative outcomes in children with Hirschsprung disease. Strategic implementation of the ERAS protocol throughout the preoperative, intraoperative, and postoperative phases is crucial for achieving expedited recovery. The ERAS protocol, which takes into account the needs and feelings of patients, can enhance patients’ medical experience by ensuring the provision of high-quality care.

INTRODUCTION

Hirschsprung disease (HD) is caused by failed migration of colonic ganglion cells, and is a common intestinal disease in infants, with an incidence of approximately 1/5000[1]. Lack of colonic ganglion cells causes persistent bowel spasms, resulting in fecal concentrations in the proximal colon. Thus, the proximal colon thickens and dilates with long-term stimulation by stool[2]. HD most commonly involves the rectosigmoid region or the entire colon, presenting with typical symptoms such as constipation, progressive abdominal distension, poor feeding, poor weight gain, and functional obstruction of the distal colon[3]. Therefore, HD infants and children should be treated promptly. The most effective treatment for HD is radical surgery, including the Swenson procedure (rectosigmoid colectomy), Duhamel procedure (colectomy combined with retrorectal colon pull-through), Soave procedure (endorectal pull-through), Rehbein procedure (colectomy combined with extraperitoneal colorectal anastomosis), Martin procedure (a modified Duhamel procedure), and heart shaped anastomosis[4]; the common goal is to resect the ganglionic segment and upstream transition area, and attach the ganglionic bowel immediately proximal to the anal canal. The Duhamel and Soave procedures are favorable for HD and comparable in efficiency and incidence of complications[5,6]. Both procedures have advantages and disadvantages, particularly postoperative complications[7-9]. The most frequent complications are anastomotic strictures, soiling or incontinence, constipation, and enterocolitis[10,11]. Postoperative enterocolitis may occur in 25%-37% of infants and children undergoing HD surgery during long-term recovery, causing serious morbidity and mortality[12]. Therefore, infants and children undergoing HD surgery should be closely monitored for enterocolitis over several years postoperatively.

Enhanced recovery after surgery (ERAS), also known as fast-track surgery or multimodal rehabilitation after surgery, is a multi-disciplinary cooperation model first proposed by Danish surgeons Wilmore and Kehlet[13] in 2001. It has gradually developed into a protocol-based perioperative care program[14]. Various ERAS guidelines have been established for several types of surgery, such as cardiac and thoracic surgery in adults[15,16], as well as transthoracic closure of ventricular septal defects and acute appendicitis in children[17,18]. Evidence-based practice based on ERAS protocols help optimize inpatient care and minimize discomfort. For long-term postoperative recovery in children with HD, the ERAS protocol decreases enterocolitis recurrence, improves anorectal function recovery, and enhances quality of life after radical colectomy[19,20]. The ERAS protocol has rarely been reported in infants and children undergoing HD surgery. Therefore, this study aimed to investigate the efficacy and safety of the ERAS protocol in HD infants and children undergoing pull-through procedures.

MATERIALS AND METHODS

Ethical review

This prospective case-control study received written approval from the Ethics Committee of Mianyang Central Hospital (approval No. P2021092, date August 27, 2021), and was performed in accordance with the Declaration of Helsinki. Subsequently, clinical trial registration was completed in the National Health Security Information Platform (https://www.medicalresearch.org.cn/index). Informed consent was obtained from the parents of all participants.

Patient characteristics

This case-control study enrolled 38 infants and children with HD who underwent the Soave procedure between January 2022 and September 2023 at the Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China (Table 1). Figure 1 shows the random enrollment process for the 38 HD infants and children. To ensure that the ERAS and control groups were matched in age and sex, we developed four age- and sex-stratified single-blind randomized tables, two for boys aged 1-3 years and 4-6 years and two for girls aged 1-3 years and 4-6 years, respectively. The appropriate randomized table was then selected based on the patient’s age and gender, and the patients were sequentially assigned to the two groups according to the random number corresponding to the enrollment order. Finally, 20 infants and children were enrolled in the ERAS group and received the ERAS protocol, and 18 infants and children were enrolled in the control group and received conventional treatment. Postoperative recovery and comfort were then prospectively observed and compared in these pediatric patients undergoing the two different perioperative treatments.

Figure 1 Enrollment process of infants and children with Hirschsprung disease. A total 49 infants with Hirschsprung disease (HD) were admitted to our hospital during the study period. Initially, 43 infants with HD, whose parents provided consent to participate in the study, were included. Owing to loss to follow-up, data from the remaining 38 infants with HD were included in the analysis. HD: Hirschsprung disease; ERAS: Enhanced recovery after surgery.

Table 1 Inclusion and exclusion criteria.

Inclusion criteria

Exclusion criteria

(1) Age less than 6 years old; (2) Diagnosis of HD according to the guidelines of the American Pediatric Surgical Association Hirschsprung Disease Interest Group[21], based on full-thickness biopsy findings of the absence of mucosal and submucosal ganglion cells away from the dentate line; (3) Pathological type includes only common type; (4) Barium enema showing significant dilation of the rectosigmoid colon and the existence of a stricture segment, and intraoperative findings showing obvious thickening of the dilated colon and dark red or purple in color; (5) Anorectal manometry stimulated by balloon inflation showing absence of the anorectal inhibitory reflex; (6) Characteristic clinical manifestations, including intractable constipation, abdominal distension, and delayed fecal discharge; and (7) Treatment with the Soave procedure via the laparoscope

(1) Systemic comorbidities, such as congenital heart disease, nephrotic syndrome, glomerulonephritis, pneumonia, and severe liver insufficiency; (2) Serious infection or blood or immune system diseases; (3) Severe hypoproteinemia, anemia, or inadequate remission after treatment; and (4) Refusal to participate in the ERAS study by the parents

HD: Hirschsprung disease; ERAS: Enhanced recovery after surgery.

HD treatment protocols

Establishment of multidisciplinary cooperation for HD: The HD multidisciplinary team comprised surgeons, anesthesiologists, and nurses (specialized nurses and responsible nurses). Surgeons implemented the HD surgical protocol, anesthesiologists performed intraoperative anesthesia, surgeons and specialized nurses executed postoperative analgesia management overseen by anesthesiologists. Specialized nurses formulated care procedures for ERAS or conventional treatment based on evidence, guided infants and children in postoperative activities, anus enlargement training, and biofeedback training. Responsible nurses performed perioperative care management of the infants and children.

Outline of the conventional treatment protocol: The conventional treatment protocol comprised the following: Routine psychological care and preoperative education; preoperative outpatient bowel preparation using backflow cleansing for 10-14 days (a bowel irrigation design to drain feces by an anal catheter, i.e. colonic irrigation using 50 mL normal saline for infants or 100 mL normal saline for children each time, with a total volume of 100-200 mL normal saline/kg weight, repeated 10 to 20 times within 30 minutes); no solid food for 24 hours and no liquid food for 6 hours preoperatively, except for oral sugar water and nutrient supplementation. The colonic catheter was removed after the last backflow bowel cleansing on the morning of surgery, and the patient received conventional general anesthesia following placement of a gastrointestinal catheter. The patient received intraoperative warming at room temperature and routine placement of urethral, orogastric, and anal canal drainage catheters. An empirical infusion replenishment strategy was adopted perioperatively and postoperative analgesia was provided by an analgesic pump device (2 μg Sufentanil/kg weight in 100 mL normal saline, for 48 hours). Strict postoperative fasting with intravenous infusion of partial parenteral nutrition for 5-7 days was carried out and a gradual change in the diet from liquid to a regular diet was initiated after intestinal function recovery. The patient underwent early activity management, that is, bed rest for at least one day followed by appropriate exercise if the patient was mentally stable.

Outline of the ERAS protocol: The ERAS protocol comprised the following: Preoperative education by a pediatric psychotherapist, with a focus on the psychology of infants and children and their families, to reduce stress and anxiety and enhance treatment cooperation. Preoperative outpatient bowel preparation was initiated using backflow cleansing for 7-10 days (irrigation design was identical to the conventional treatment). All patients received a liquid diet until 8 o’clock preoperatively with oral sugar water at a dosage of 5-10 mL/kg body weight up to a maximum volume of 400 mL, followed by clear liquid for 2 hours before the anesthesia. The colonic catheter was retained after the last backflow bowel cleansing on the morning of surgery and general anesthesia combined with sacral block anesthesia was administered. A gastrointestinal catheter was inserted after anesthesia and intraoperative warming at approximately 32 °C using a warm-blanket and placement of an anal canal drainage catheter was performed without urethral and orogastric drainage catheters. A target-oriented volume-limiting replenishment strategy was adopted perioperatively, and postoperative analgesia with oral nonsteroidal analgesics (4 mL/1-3 years old and 10-15 kg weight or 5 mL/4-6 years old and 16-21 kg weight ibuprofen suspension, per 6 hours or per 8 hours) and intravenous infusion of partial parenteral nutrition for 3 days, with appropriate sugar water on day 1, and a fluid diet on day 2. Gastrointestinal function recovery was promoted by sucking lollipops and gradually transitioning to regular feeding and early activity management with suitable exercise with parental aid on postoperative day 1.

Pain management

All clinical nurses received training on pain management and data collection. Pain assessment was conducted by responsible nurses at 8-10 am and 4-6 pm every day, for children aged 1-3 years using the FLACC scale and for those aged 4-6 years using the Wong-Baker scale. The FLACC scale assesses facial expression, leg movement, activity, crying, and consolability, with each component rated on a scale of 0 to 2. The Wong-Baker scale utilizes six distinct facial expressions, ranging from a smile to tears, to quantitatively describe varying levels of pain. Responsible nurses initially rated pain as 0, 2, 4, 6, 8, or 10 when the child was lying flat. If pain did not increase during turning, the final score was reduced by 1 from the initial rating; otherwise, it remained unchanged. After analgesia ceased, when the precise score was 1, the pain level was assessed every 4 hours to 6 hours; and when the precise score was 0 for two consecutive times, the patient was judged to have no pain.

Collection of clinical outcome data

Data on pain duration, fever duration, bowel sound recurrence time, regular diet time, catheter indwelling time, and hospital stay were extracted from medical records. Bowel sounds were auscultated for 1 to 2 minutes in the umbilical region, upper abdomen, and lower abdomen during the morning and afternoon. Body temperature was monitored as follows: Six times per day for temperatures exceeding 38.5 °C, four times per day for temperatures ranging from 37 °C to 38.5 °C, and twice per day for temperatures below 37 °C. Pain duration was defined as the time until the infant felt no pain after awakening. Fever duration was defined as the time until the infant temperature was above 37 °C after surgery. The bowel sound recurrence time was defined as the interval from awakening until bowel sounds occurred at a frequency exceedingly twice per minute. The regular diet time was defined as the duration from awakening until a fluid intake of 3 mL/kg weight. Catheter indwelling time was defined as the time from insertion of the anal canal drainage catheter to its removal.

Hospital costs were extracted from the hospital information system. A patient satisfaction survey was sent to the patient families after discharge. A comprehensive evaluation was conducted from multiple perspectives, including nurses (respect, listening, explanation, and responsiveness), doctors (respect, listening, and explanation), ward environment (cleanliness, quietness, and signage), treatment (pain management, medication names, functions, and side effects), admission and discharge processes (admission procedures, discharge procedures, cost transparency, and discharge guidance), and additional aspects (meal quality and patient interviews). Each item was assessed using a Likert-5 scale, with a maximum total score of 100 points. Satisfaction scores were standardized as the percentage of the cumulative score across all items relative to the total possible score.

Collection of postoperative complications data

Data on postoperative complications including nursing observations during hospitalization and telephone follow-up by the nurse supervisor after discharge (weekly, up to one month) were collected. The occurrence of various complications was assessed by a specialist clinician, such as anastomotic fistula, infection outside the intestinal tract, intestinal perforation, intestinal rupture, defecation dysfunction, ileus, and perianal dermatitis. Defecation dysfunction was defined as an obstacle in the excretion of feces caused by the dysfunction of pelvic floor muscle coordination or difficulty in defecation, and manifested as fecal incontinence or constipation. Defecation dysfunction was detected by digital rectal examination or anorectal manometry.

Postoperative discharge standard

Postoperative discharge standard was as follows: Unobstructed exhaust evacuation and defecation without abdominal signs or symptoms, such as abdominal pain or distension; good healing of the incision without evidence of inflammation. Anal canal drainage catheters were removed when normal exhaust and defecation occurred and orogastric drainage catheters were removed when drainage was less than 30-50 mL. Discharge also occurred when rehydration treatment was not required and on initiation of an appropriate diet that met physiological requirements.

Statistical analysis

Statistical analyses were performed using the SPSS software (version 19.0; SPSS Inc., Chicago, IL, United States) or MedCalc 18.2 software (MedCalc Software, Mariakerke, Belgium). Count data are expressed as n (%). Between-group differences in the count data were analyzed using the χ²-test (if the sample size was adequate) or Fisher’s exact test (if the sample size was small), and the strength and precision of the effects are expressed as the odds ratios (OR) and their 95% confidence intervals. All measurement data were confirmed to be normally distributed using the one-sample Kolmogorov-Smirnov test. Measurement data are expressed as mean ± SD. Between-group differences in measurement data were analyzed using an independent sample t-test. Statistical significance was set at P < 0.05.

RESULTS

Clinical features of infants and children in the ERAS and control groups

The infants and children in the ERAS and control groups did not differ in terms of basic information (age, sex, height, weight, or body mass index) or clinical manifestations (colon dilation or spasm, rectoanal inhibitory reflex, or ganglion cell loss, all P > 0.05) (Table 2).

Table 2 Basic data of infants and children with Hirschsprung disease in the enhanced recovery after surgery and control groups.

Item	ERAS (n = 20)	Control (n = 18)	χ2/t	P value
Age1, years	3.45 ± 1.60	3.05 ± 1.32	0.832	0.416
Sex, male/female	13/7	10/8	0.344	0.557
Weight1, kg	14.1 ± 2.6	15.9 ± 2.9	-1.939	0.060
Height1, m	1.06 ± 0.13	1.08 ± 0.12	-0.475	0.638
BMI1, kg/m2	12.88 ± 3.03	14.17 ± 4.44	-1.058	0.297
Colon dilation and spasm, n (%)	14 (70.0)	14 (77.8)	0.288	0.592
Rectoanal inhibitory reflex, n (%)	12 (60.0)	13 (72.2)	0.612	0.434
Ganglion cell loss	19 (95.0)	16 (88.9)	0.474	0.491

¹Independent-samples t-test was used for age, weight, height, and body mass index. χ²-test was used for the other variables. There were no statistically significant differences in these observation items between the enhanced recovery after surgery and control groups.

BMI: Body mass index; ERAS: Enhanced recovery after surgery.

Compliance with treatment protocols

During perioperative care, the following measures were used to improve adherence to the two treatment protocols: Outpatient/inpatient medical record and bedside labels to distinguish the two groups, preoperative enema phone reminders, strict record of fasting and water deprivation, intraoperative verification checklist (for intraoperative and postoperative anesthesia method, perioperative warming, various drainage catheters, and infusion replenishment), strict record of postoperative nutrition and early activity management. Table 3 shows compliance to the protocol in the two groups of infants and children. Among the 12 protocol elements, compliance rates in the control and ERAS groups were 77.8%-100.0% and 85.0%-100.0%, respectively.

Table 3 Compliance with treatment protocols in the enhanced recovery after surgery and control groups, n (%).

Protocol elements	Key, control group	Control group (n = 18)	Key, ERAS group	ERAS group (n = 20)
Preoperative education	Routine	18 (100.0)	20 (100.0)
Preoperative backflow bowel cleansing	10-14 days	17 (94.4)	7-10 days	19 (95.0)
Preoperative fasting	24 hours	18 (100.0)	8 hours	20 (100.0)
Preoperative fasting time for drinking	6 hours	16 (88.9)	2 hours	18 (90.0)
Colonic catheter after the last bowel cleansing	Pulled-up	17 (94.4)	Indwelled	17 (85.0)
Anesthesia	General anesthesia	16 (88.9)	Combined with sacral block anesthesia	20 (100.0)
Perioperative warming	Room temperature	15 (83.3)	Approximately 32 °C	19 (95.0)
Urethral, orogastric and anal canal drainage catheters	Routinely placed	18 (100.0)	Only anal canal drainage catheters to be placed	18 (90.0)
Infusion replenishment strategy	Empirical infusion replenishment strategy in accordance with requirements	16 (88.9)	Target-oriented volume-limiting replenishment strategy	20 (100.0)
Postoperative analgesia	Pumped opiate analgesics	14 (77.8)	Oral nonsteroidal analgesics	18 (90.0)
Postoperative nutrition	Fasting and intravenous infusion for 5-7 days followed by regular diet until intestinal function recovery	16 (88.9)	Intravenous infusion for 3 days with appropriate diet transition	20 (100.0)
Early activity management	Bedrest for at least 1 day	16 (88.9)	Suitable exercise on day 1	20 (100.0)

Count data in the enhanced recovery after surgery and control groups are expressed as number (percentage) of infants who complied with the respective treatment protocols. ERAS: Enhanced recovery after surgery.

Comparison of postoperative outcomes between the ERAS and control groups

All measured postoperative outcomes differed significantly between the ERAS and control groups (Table 4). The ERAS group had better family satisfaction scores than the control group (96.1% vs 93.8%, t = 2.338, P = 0.025). Furthermore the ERAS group showed better surgical outcomes compared to the control group in terms of pain score at awakening (4.2 vs 5.2, t = -2.516, P = 0.017), fever duration (40.7 hours vs 52.6 hours, t = -2.211, P = 0.034), bowel sound recurrence time (33.6 hours vs 44.7 hours, t = -2.501, P = 0.017), tolerance of regular diet time (36.6 hours vs 49.4 hours, t = -2.884, P = 0.007), catheter indwelling time (75.8 hours vs 93.4 hours, t = -3.104, P = 0.004), duration of hospital stay (7.5 days vs 8.3 days, t = -2.400, P = 0.022) and cost (14203 ± 2381 yuan vs 16847 ± 3558 yuan, t = -17.413, P < 0.001). However, their pain duration was prolonged (85.7 hours vs 67.0 hours, t = -7.184, P < 0.001). The statistical power ranged from 0.563 to 1.000.

Table 4 Differences in postoperative outcomes between the enhanced recovery after surgery and control groups.

Outcome	ERAS (n = 20)	Control (n = 18)	t	P value	Power
Pain score at awakening	4.2 ± 1.3	5.2 ± 1.2	-2.516	0.017	0.671
Pain duration, hours	85.7 ± 7.5	67.0 ± 8.6	7.184	< 0.001	1.000
Fever duration, hours	40.7 ± 14.4	52.6 ± 18.7	-2.211	0.034	0.563
Bowel sound recurrence time, hours	33.6 ± 9.8	44.7 ± 16.9	-2.501	0.017	0.654
Regular diet time, hours	36.6 ± 9.6	49.4 ± 17.0	-2.884	0.007	0.775
Catheter indwelling time, hours	75.8 ± 13.8	93.4 ± 20.6	-3.104	0.004	0.842
Length of hospital stay, days	7.5 ± 0.9	8.3 ± 1.2	-2.400	0.022	0.609
Cost, yuan	14203 ± 2381	16847 ± 3558	-17.413	< 0.001	0.732
Satisfaction, %	96.1 ± 2.6	93.8 ± 3.4	2.338	0.025	0.616

All postoperative outcomes differed significantly between the two groups. In the enhanced recovery after surgery group, family satisfaction was higher, but other outcomes were lower. This indicates that the enhanced recovery after surgery protocol was helpful in improving perioperative recovery and postoperative outcomes in infants and children with Hirschsprung disease. ERAS: Enhanced recovery after surgery.

Comparison of postoperative complications between the ERAS and control groups

Figure 2 shows the four postoperative complications associated with HD investigated in this study. Among them, the incidence of defecation dysfunction [10.0% vs 44.4%, P_Fisher = 0.027, OR = 0.14 (0.03, 0.79), P = 0.041], and perianal dermatitis [5.0% vs 38.9%, P_Fisher = 0.016, OR = 0.08 (0.01, 0.76), P = 0.031] in the ERAS group was lower than that in the control group; however, the incidence of enterocolitis was not significantly different between the two groups [0.0% vs 11.1%, P_Fisher = 0.218, OR= 0.18 (0.01, 4.01), P = 0.279]. In addition, the difference and risk analysis of ileus were contradictory [0.0% vs 27.8%, P_Fisher = 0.017, OR = 0.08 (0.01, 1.59), P = 0.098]. The power ranged from 0.435 to 0.858.

Figure 2 Differences in the incidence of postoperative complications between the enhanced recovery after surgery and control groups. The upper row shows the odds ratio and 95% confidence interval of risk analysis, and the middle row shows the P value of difference comparisons, the lower row shows the power of test. The incidence of enterocolitis did not differ between the two groups, and the risk of ileus was not significant; however, perianal dermatitis and defecation dysfunction were lower in the enhanced recovery after surgery group than in the control group (P < 0.05). Thus, the enhanced recovery after surgery protocol is helpful in reducing the incidence of some postoperative complications in infants and children with Hirschsprung disease. ^aP < 0.05, risk analysis. ERAS: Enhanced recovery after surgery; OR: Odds ratio.

DISCUSSION

Surgical treatment of HD has evolved with the introduction of minimally invasive techniques in recent decades. Various minimally invasive procedures have reduced the occurrence of postoperative complications, of which transanal endorectal pull-through (minimally invasive transanal Soave procedure) has the advantages of avoiding pneumoperitoneum, the transperitoneal approach, and laparoscopic instrumentation[21,22]. In this study, the minimally invasive transanal Soave procedure was the foundation of the ERAS concept, and the ERAS protocol had a continuation pattern to further promote the early recovery of infants and children with HD. ERAS is a 20-year-old multidisciplinary protocol that optimizes and integrates treatment plans to maximize collaboration between nursing, surgery, and anesthesia and to minimize trauma, surgical stress, and inflammation in patients[23]. It covers all aspects of the perioperative stage (preoperative preparation, intraoperative optimization, and postoperative care) and focuses on reducing trauma, surgical stress, and inflammation. This reduces the occurrence of surgical complications, accelerates postoperative recovery, and reduces postoperative morbidity and mortality[24]. This study focused on application of the ERAS concept in perioperative treatment of infants and children undergoing HD surgery. The ERAS protocol improved patient comfort, intestinal function recovery, and the perioperative patient experience.

Efficient bowel preparation is a prerequisite for successful surgery in HD infants and children. Preoperative colonic evacuation effectively eliminates accumulated waste, reduces abdominal distension, shrinks the expanded colon, improves the microbial ecological environment, reduces postoperative infection and related complications, and reduces surgical trauma[25,26]. Due to the loss of colonic ganglion cells resulting in abnormal defecation in infants and children with HD, bowel cleansing with megacolon enema differs from that of the normal colon. It has higher operational requirements to prevent intestinal perforation, rupture, and other complications[27]. The colonic irrigation technique we used was designed to clean the megacolon and improve the operative environment. Some studies have reported that, after daily bowel preparation using colonic irrigation with an anal catheter, the majority of patients can obtain ideal outcomes from single-stage Soave surgery[28], yet it has no impact on postoperative recovery and long-term defecation function[29]. Our study found that, none of the infants and children with HD in either group developed an anastomotic fistula, infection outside the intestinal tract, intestinal perforation, intestinal rupture, or other serious complications during the perioperative period. Although we reduced bowel preparation time in the ERAS group, the postoperative complications were still lower in the ERAS group than in the control group, including defecation dysfunction, ileus, and perianal dermatitis. Therefore, high-quality bowel preparation plays an important role in infants and children undergoing HD surgery.

Good preoperative and postoperative nutritional supplements can improve tolerance in infants and children with HD to surgery and anesthesia and quickly promote intestinal function recovery[28-30]. Our ERAS protocol shortened the fasting time preoperatively, that is, reduced hunger time. It has been reported that fasting for too long before anesthesia can lead not only to a decline in immunity, but also result in crying or irritability due to thirst and hunger, thus increasing the risk of perioperative dehydration, hypotension, hypoglycemia and other complications[31]. Moreover, our ERAS protocol advocated early eating and activity postoperatively by feeding infants and children with appropriate sugar water and lollipops on postoperative day 1. This practice can reduce abdominal distension caused by hunger crying, promote saliva secretion, enhance intestinal peristalsis, and promote intestinal function recovery[32]. In this study, the postoperative feeding time, catheter indwelling time, hospital stay, and cost were significantly lower in the ERAS group than in the control group. Thus, the ERAS protocol significantly improved parent satisfaction during the perioperative period.

With regard to analgesic management, the ERAS protocol uses sacral block combined with intravenous anesthesia to achieve rapid postoperative analgesia. It has the advantages of shortening postoperative recovery time, blocking sympathetic nerve conduction, and alleviating the stress response[33]. For postoperative analgesia, oral nonsteroidal analgesics are recommended to mitigate adverse effects associated with intravenous opioid analgesics in pediatric patients[34,35]. However, our study found that the ERAS group experienced a prolonged average pain duration compared with the control group, suggesting that oral nonsteroidal analgesics are still slightly less effective than intravenous opioid analgesics. Therefore, how to enhance the analgesic comfort of pediatric patients, including nonsteroidal analgesics dosage and a combination of multimodal analgesia, remains a key focus that the ERAS protocol should address. In addition, sucking lollipops is a complementary approach for pain relief. Lollipops stimulate the brain to produce a feeling of happiness, activate endogenous opioids, promote the release of 5-hydroxytryptamine and dopamine, and provide comfort and analgesia[36]. On the basis of a reduced pain score at awakening in the ERAS group, our protocol suggests a potential advantage of oral nonsteroidal analgesics combined with sucking lollipops for effective pain relief.

Additionally, it should be noted that the control group and ERAS group were not matched in terms of the placement of urethral catheters and gastric tubes. The placement of these medical devices serves to prevent accidental injury to the urethra and alleviate burden on the gastrointestinal tract[37], which are commonly employed preventive measures in traditional intestinal surgery. In accordance with recent expert consensus and recommendations, minimizing the use of urethral catheters and gastric tubes has been shown to facilitate faster postoperative recovery[38]. Consequently, we have excluded the placement of these from our ERAS protocol. In addition, early dietary and physical activity management in the ERAS group significantly facilitated the recovery of gastrointestinal function. These approaches expedited early removal of the anal drainage catheters, which further supported the restoration of gastrointestinal function, ultimately reducing the occurrence of gastrointestinal and perianal related complications.

This study has some limitations. As the incidence of HD is approximately 1 in 1500 to 5000 live births, we only enrolled 38 cases of HD during a limited period. In the statistical analysis, based on the number of cases in this study, the power ranged from 0.563 to 1.000. Therefore, these results should be further verified by large-scale studies. Additionally, the pain score is based on a visual scale, thereby introducing subjective influence that cannot be disregarded, thus is the main bias of analgesic management in this study.

CONCLUSION

Successful implementation of ERAS requires multidisciplinary cooperation among surgeons, anesthesiologists, and nurses. The ERAS protocol has clear medical goals and treatment plans that are based on evidence-based medicine. The crucial aspects of the ERAS concept are to adopt optimized anesthesia and minimally invasive techniques to shorten preoperative fasting time, continue heat preservation, not routinely place gastrointestinal catheters during the operation, and advocate early diet and exercise training postoperatively. This reduces the incidence of postoperative complications and improves the clinical diagnosis and treatment outcomes. Additionally, in comparison to the control group, the observed trend of longer pain duration in the ERAS group is inconsistent with the primary goal of the ERAS protocol, which is to enhance patient comfort. Therefore, it is necessary to conduct further research into optimizing postoperative analgesic management in patients receiving ERAS.