Impact of Adherence to Enhanced Recovery After Surgery (ERAS) Elements and Patient Presentation on Outcomes Following Pediatric Choledochal Cyst Excision

Background: Enhanced recovery after surgery (ERAS) protocols can optimize outcomes following gastrointestinal procedures. The benefits of these interventions have not been reported following choledochal cyst (CDC) excision in children. This study investigated the impact of adherence to ERAS elements and patient presentation on postoperative outcomes.

Methods: A retrospective review of 59 consecutive patients having open CDC excision with Roux-Y hepaticojejunostomy between 2000-2020 at a single institution was performed. Patients were divided into two groups: ERAS-adherent (ERAS) and ERAS-nonadherent (NO ERAS). The ERAS group consisted of patients whose perioperative care consisted of at least 3 of the following five elements: use of preoperative bowel preparation, reduced preoperative fasting, no preoperative narcotic administration, use of regional anesthesia, and use of preoperative antibiotics within one of hour of incision. To understand the impact of patient presentation on perioperative outcomes, the same patient cohort was then divided into the ELECTIVE group, which comprised patients scheduled from the clinic for CDC excision, and the ACUTE group, which consisted of patients who had surgery within the same admission for CDC-related symptoms. Patient characteristics, intraoperative data, and perioperative outcomes were compared between the two sets of patient groups.

Results: ERAS patients (n=22; 37%) were more likely than their NO ERAS counterparts (n=37; 63%) to undergo an elective operation (86% vs 51%; p= 0.01) and be asymptomatic (27% vs 5%; p=0.04) at diagnosis. If preoperative symptoms were present, ERAS patients were less likely to be diagnosed with cholangitis (0% vs 15%; p= 0.03). Adherence to ERAS elements did not associate with quicker oral intake, return of bowel function, or less postoperative complications, but did associate with decreased days of narcotic use (2.1 vs 3.8 days; p=0.03) and hospital length of stay (6.1 vs 13.8 days; p =0.02)
Elective patients (n=38; 64%) were older, had more Todani-type 1 CDC, and more commonly adhered to ERAS elements. Acute patients (n=21; 36%) were younger, had more Todani-type IVA CDC, followed fewer ERAS elements, and experienced increased intraoperative blood loss and transfusions. No significant differences emerged regarding postoperative complications. Multivariate analysis showed that elective cyst excision (p=0.008; p= 0.04), type 1 CDC (p=0.03; p=0.04), and adherence to 60% of ERAS elements (p=0.002; p=0.02) associated independently with decreased hospital stay and less opioid use.

Conclusion: Adherence to 60% ERAS elements and elective surgery were associated with shortened hospital stay and decreased narcotic use following CDC excision with Roux-Y hepaticojejunostomy among children. Better compliance with standard ERAS elements emerged for children having elective procedures. These findings suggest that an interval CDC excision with Roux-Y hepaticojejunostomy may be considered for patients who present with CDC-related symptoms.