Abstract
Background
The implementation of enhanced recovery after surgery (ERAS) pathway has resulted in shorter length of stay (LOS), fewer complications, and lowering of medical costs. We aimed to investigate if ERAS protocol implementation in patients with complicated appendicitis reduces the LOS after laparoscopic appendectomy.
Methods
In this randomized controlled trial, 38 patients were randomly assigned to laparoscopic appendectomy with ERAS protocol (LE) or with conventional care (LC). The primary outcome was the hospital LOS. The secondary outcomes included time to resume diet, postoperative complications, readmissions, and reoperation rates.
Results
From April 2019 to December 2019, 19 patients in the LE group and 19 in the LC were included. There were no significant differences in preoperative data. Regarding the primary outcome of the study, the ERAS protocol did not significantly reduce the postoperative LOS in comparison with conventional care (63.8 ± 62.10 h vs. 95.3 ± 135.78 h, p=0.366). There was a significant reduction in time to resume diet (367.3 vs. 696.3 min, p=0.003). We did not find differences in terms of postoperative complications, pain control, readmission, and reoperation rates.
Conclusions
Laparoscopic appendectomy with ERAS protocol was not superior to laparoscopic appendectomy with conventional care for the treatment of complicated appendicitis in terms of hospital LOS. However, postoperative morbidity, readmission, and reoperation rates were similar in both groups, making ERAS implementation a safe and feasible alternative to conventional care.
Similar content being viewed by others
References
Gorter RR, Eker HH, Gorter-Stam MA, Abis GS, Acharya A, Ankersmit M, et al. Diagnosis and management of acute appendicitis. EAES consensus development conference 2015. Surg Endosc. 2016;30:4668–90.
Athanasiou C, Lockwood S, Markides GA. Systematic review and meta-analysis of laparoscopic versus open appendicectomy in adults with complicated appendicitis: an update of the literature. World J Surg. 2017;41:3083–99.
Bailey K, Choynowski M, Kabir SMU, Lawler J, Badrin A, Sugrue M. Meta-analysis of unplanned readmission to hospital post-appendectomy: an opportunity for a new benchmark. ANZ J Surg. 2019;89:1386–91.
Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N, et al. Guidelines for perioperative care in elective colonic surgery: enhanced recovery after surgery (ERAS) society recommendations. World J Surg. 2013;37:259–84.
Hajibandeh S, Hajibandeh S, Bill V, Satyadas T. Meta-analysis of enhanced recovery after surgery (ERAS) protocols in emergency abdominal surgery. World J Surg. 2020;44:1336–48.
Cash CL, Frazee RC, Abernathy SW, Childs EW, Davis ML, Hendricks JC, et al. A prospective treatment protocol for outpatient laparoscopic appendectomy for acute appendicitis. J Am Coll Surg. 2012;215:101–5.
Trejo-Avila ME, Romero-Loera S, Cárdenas-Lailson E, Blas-Franco M, Delano-Alonso R, Valenzuela-Salazar C, et al. Enhanced recovery after surgery protocol allows ambulatory laparoscopic appendectomy in uncomplicated acute appendicitis: a prospective, randomized trial. Surg Endosc. 2019;33:429–36.
Scott A, Shekherdimian S, Rouch JD, Sacks GD, Dawes AJ, Lui WY, et al. Same-day discharge in laparoscopic acute non-perforated appendectomy. J Am Coll Surg. 2017;224:43–8.
Cross W, Chandru Kowdley G. Laparoscopic appendectomy for acute appendicitis: a safe same-day surgery procedure? Am Surg. 2013;79:802–5.
Akkoyun I. Outpatient laparoscopic appendectomy in children: a single center experience with 92 cases. Surg Laparosc Endosc Percutan Tech. 2013;23:49–50.
Alkhoury F, Burnweit C, Malvezzi L, Knight C, Diana J, Pasaron R, et al. A prospective study of safety and satisfaction with same-day discharge after laparoscopic appendectomy for acute appendicitis. J Pediatr Surg. 2012;47:313–6.
Jain A, Mercado PD, Grafton KP, Dorazio RA. Outpatient laparoscopic appendectomy. Surg Endosc. 1995;9:424–5.
Grewal H, Sweat J, Vazquez D. Laparoscopic appendectomy in children can be done as a fast-track or same-day surgery. JSLS. 2004;8:151–4.
Trejo-Avila M, Cárdenas-Lailson E, Valenzuela-Salazar C, Herrera-Esquivel J, Moreno-Portillo M. Ambulatory versus conventional laparoscopic appendectomy: a systematic review and meta-analysis. Int J Color Dis. 2019;34:1359–68.
Lasso-Betancor CE, Ruiz-Hierro C, Vargas-Cruz V, Orti-Rodriguez RJ, Vazquez-Rueda F, Paredes-Esteban RM. Implementation of “fast-track” treatment in paediatric complicated appendicitis. Cir Pediatr. 2013;26:63–8.
Frazee R, Abernathy S, Davis M, Isbell T, Regner J, Smith R. Fast track pathway for perforated appendicitis. Am J Surg. 2017;213:739–41.
Charlson M, Szatrowski TP, Peterson J, Gold J. Validation of a combined comorbidity index. J Clin Epidemiol. 1994;47:1245–51.
Bolmers MDM, de Jonge J, van Rossem CC, van Geloven AAW, Bemelman WA, Snapshot Appendicitis Collaborative Study group. Discrepancies between intraoperative and histological evaluation of the appendix in acute appendicitis. J Gastrointest Surg. 2019.
Van Rossem CC, Bolmers M, Schreinemacher MHF, Van Geloven AAW, Bemelman WA. Prospective nationwide outcome audit of surgery for suspected acute appendicitis. Br J Surg. 2016;103:144–51.
Dhupar R, Evankovich J, Ochoa LG, Hughes SJ. Outcomes of operative management of appendicitis. Surg Infect. 2012;13:141–6.
Sauerland S, Jaschinski T, Neugebauer EA. Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev. 2010;10:CD001546.
Hamill JK, Rahiri JL, Gunaratna G, Hill AG. Interventions to optimize recovery after laparoscopic appendectomy: a scoping review. Surg Endosc. 2016;31:2357–65.
Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth. 1997;78:606–17.
Garulli G, Lucchi A, Berti P, Gabbianelli C, Siani LM. “Ultra” E.R.A.S. in laparoscopic colectomy for cancer: discharge after the first flatus? A prospective, randomized trial. Surg Endosc. 2016;31:1806–13.
Kehlet H. Surgical stress and postoperative outcome from here to where? Reg Anesth Pain Med. 2006;31:47–52.
Gignoux B, Blanchet MC, Lanz T, Vulliez A, Saffarini M, Bothorel H, et al. Should ambulatory appendectomy become the standard treatment for acute appendicitis? World J Emerg Surg. 2018;13:28.
Markides G, Subar D, Riyad K. Laparoscopic versus open appendectomy in adults with complicated appendicitis: systematic review and meta-analysis. World J Surg. 2010;34:2026–40.
Wei B, Qi CL, Chen TF, Zheng ZH, Huang JL, Hu BG, et al. Laparoscopic versus open appendectomy for acute appendicitis: a metaanalysis. Surg Endosc. 2011;25:1199–208.
Yu MC, Feng YJ, Wang W, Fan W, Cheng HT, Xu J. Is laparoscopic appendectomy feasible for complicated appendicitis? A systematic review and meta-analysis. Int J Surg. 2017;40:187–97.
Joliat GR, Hübner M, Roulin D, Demartines N. Cost analysis of enhanced recovery programs in colorectal, pancreatic, and hepatic surgery: a systematic review. World J Surg. 2020;44:647–55.
Bernard ET, Davenport DL, Collins CM, Benton BA, Bernard AC. Time is money: quantifying savings in outpatient appendectomy. Trauma Surg Acute Care Open. 2018;3:e000222.
Di Saverio S, Podda M, De Simone B, Ceresoli M, Augustin G, Gori A, et al. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World J Emerg Surg. 2020;15:27.
Mohsina S, Shanmugam D, Sureshkumar S, Kundra P, Mahalakshmy T, Kate V. Adapted ERAS pathway vs. standard care in patients with perforated duodenal ulcer: a randomized controlled trial. J Gastrointest Surg. 2018;22:107–16.
Lemanu DP, Singh PP, Berridge K, Burr M, Birch C, Babor R, et al. Randomized clinical trial of enhanced recovery versus standard care after laparoscopic sleeve gastrectomy. Br J Surg. 2013;100:482–9.
Spanjersberg WR, Reurings J, Keus F, van Laarhoven CJ. Fast track surgery versus conventional recovery strategies for colorectal surgery. Cochrane Database Syst Rev. 2011;2:CD007635.
Ljungqvist O, Scott M, Fearon KC. Enhanced recovery after surgery: a review. JAMA Surg. 2017;152:292–8.
Acknowledgements
We would like to thank Dr. Judith Rodriguez for the supervision and corrections to the protocol.
Author information
Authors and Affiliations
Contributions
ANV, MTA, and ECL were involved in study conception and design. ANV did data acquisition. ECL and MTA performed statistical analyses, drafted the manuscript, contributed to study concept, critically revised the manuscript, performed overall supervision, and contributed to the final approval of the manuscript. CVS, JHE, and MMP interpreted the data, drafted the manuscript, critically revised the manuscript, and contributed to the final approval of the manuscript.
Corresponding author
Ethics declarations
Ethics Approval and Consent to Participate
All procedures were performed in accordance with the ethical standards of the institutional research committee. The present study was approved by the institutional research and ethical board of our hospital (Registration Number: 04-18-2019).
Informed Consent
Informed consent for participation was obtained from all patients included in the study.
Conflict of Interest
The authors declare no competing interests.
Additional information
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Núñez-Venzor, A., Trejo-Avila, M., Cárdenas-Lailson, E. et al. Effect of Enhanced Recovery After Surgery on Laparoscopic Appendectomy Outcomes in Patients with Complicated Appendicitis: a Randomized Controlled Trial. SN Compr. Clin. Med. 3, 646–653 (2021). https://doi.org/10.1007/s42399-021-00788-5
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s42399-021-00788-5