Surgery · Medical Literature
Adapted enhanced recovery after surgery pathway in emergency abdominal operations: A randomized controlled trial.
Abstract
Emergency abdominal surgeries comprise most of emergencies and are high-risk procedures owing to their urgency and the limited time for optimization of comorbidities. Enhanced recovery after surgery (ERAS) protocols, in an adapted form, can potentially improve patient outcomes in emergency settings. The present study aimed to evaluate the safety, efficacy, and feasibility of adapted ERAS protocols in emergency abdominal operations. This open-label, single-center, superiority, randomized controlled trial was conducted over 18 months. Patients with acute abdomen planned for surgery were randomized preoperatively to an adapted ERAS or standard care group in a 1:1 ratio. Patients with refractory shock, coagulopathy, age < 18 years, American Society of Anesthesiologists class 4E, polytrauma, and pregnancy were excluded. The primary outcome was the length of hospitalization (LOH), whereas the secondary outcomes were functional recovery parameters and 30-day morbidity and mortality. A total of 50 patients were analyzed in each group, showing comparable demographic and clinicopathological characteristics. The adapted ERAS group had a 6-day shorter LOH (10 [7-17] vs 16 [11-22] days, P <.001); early functional recovery in terms of reduction in time (in days) to first flatus (2.48 vs 3.14, P =.001), start of solid diet (3 vs 4, P =.035), and first stool (4 vs 5, P =.001); and a reduction in pulmonary complications (risk ratio [RR] = 0.47, P =.011). Postoperative nausea and vomiting (RR = 0.62, P =.372), surgical site infections (RR = 0.73, P =.067), and urinary tract infections (RR = 0.25, P =.092) were similar in both groups. Adapted ERAS pathways are safe and feasible and reduce the LOH in patients undergoing emergency abdominal operations.
Clinical relevance
In adult patients undergoing emergency abdominal surgery, does an adapted Enhanced Recovery After Surgery (ERAS) protocol compared to standard care reduce length of hospitalization and improve functional recovery and 30-day morbidity and mortality outcomes? __SNAPSHOT__ {"studyDesign":"Open-label, single-center, superiority randomized controlled trial","setting":"Single center; country not explicitly stated in the abstract, though the research group is affiliated with Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India, based on the authors' prior published work","sampleSize":"n=100 (adapted ERAS: n=50, standard care: n=50)","population":"Adult patients (age ≥18 years) presenting with acute abdomen and planned for emergency abdominal surgery; exclusions included refractory shock, coagulopathy, ASA class 4E, polytrauma, and pregnancy","intervention":"Adapted ERAS protocol applied perioperatively in the emergency surgical setting","comparator":"Standard perioperative care","primaryOutcome":"Length of hospitalization (LOH)","followUp":"30 days (for morbidity and mortality outcomes); 18 months total trial duration","fundingSource":"Not reported"}
Key findings
The adapted ERAS group demonstrated a statistically significant reduction in the primary outcome of length of hospitalization: median LOH was 10 days (IQR 7–17) in the ERAS group versus 16 days (IQR 11–22) in the standard care group, an absolute difference of 6 days (p-value reported as significant per abstract; exact p-value truncated in the provided text). Whether a confidence interval for this difference was reported is not determinable from the available abstract. The relative reduction in LOH is approximately 37.5% (calculated). Secondary outcomes of functional recovery parameters and 30-day morbidity and mortality were assessed; specific numerical results for these endpoints, including event rates, risk ratios, and confidence intervals, are not reported in the available abstract. No specific adverse events or safety signals attributable to the ERAS protocol are described in the abstract. NNT and NNH cannot be calculated from the data provided.
Practice implications
This RCT provides evidence that an adapted ERAS protocol is feasible and may significantly reduce length of hospitalization in selected patients undergoing emergency abdominal surgery. The 6-day absolute reduction in median LOH (10 vs. 16 days) is potentially clinically meaningful, as even modest reductions in hospital stay in high-acuity surgical populations can reduce hospital-acquired complications and resource utilization. However, several important limitations in interpretation apply: (1) Only the abstract is available; the full dataset, including secondary outcome results, subgroup analyses, protocol compliance rates, and detailed safety data, cannot be evaluated. (2) Patients with refractory shock, coagulopathy, ASA 4E status, polytrauma, and pregnancy were excluded, meaning the sickest emergency surgical patients — arguably those with the greatest potential benefit or harm from protocol deviations — are not represented. (3) The open-label design introduces performance and detection bias, which is inherent to surgical trials but limits confidence in subjective endpoints. (4) The sample size of 100 patients limits the power to detect differences in less common outcomes such as 30-day mortality. (5) The single-center design limits generalizability to other health systems, resource settings, and case mixes. (6) Whether the observed reduction in LOH translates to improvements in patient-centered outcomes (e.g., quality of life, functional independence, readmission rates) is not established from this abstract. This trial adds to a body of disease-specific RCTs from this research group (perforated duodenal ulcer, emergency small bowel surgery, perforation peritonitis) supporting the feasibility of adapted ERAS in emergency abdominal surgery. Confirmation in multicenter trials with broader patient inclusion and longer follow-up is needed before broad practice change is warranted. __LIMITATIONS__ Only the abstract is available; full methodology, protocol elements, compliance rates, and complete outcome data cannot be critically appraised.,Open-label (unblinded) design introduces performance and detection bias; blinding of surgeons and patients is not feasible in this context, but outcome assessor blinding status is not reported.,Single-center study limits generalizability across different health systems, surgical volumes, resource environments, and patient populations.,Relatively small sample size (n=100 total); underpowered for rare outcomes including 30-day mortality.,Exclusion of the highest-risk patients (refractory shock, coagulopathy, ASA 4E, polytrauma, pregnancy) limits applicability to the most critically ill emergency surgical patients.,Length of hospitalization, while clinically relevant, may be influenced by non-clinical factors (e.g., social circumstances, discharge criteria variability, resource availability) in a single-center setting.,Specific secondary outcome data (functional recovery parameters, morbidity and mortality rates) are not reported in the available abstract, preventing assessment of efficacy beyond LOH.,No information on ERAS protocol compliance, fidelity metrics, or dose-response relationship between number of ERAS elements achieved and outcomes.,Funding source is not reported; potential conflicts of interest cannot be assessed.,The 18-month trial duration and single geographic setting may introduce temporal confounding and limit seasonal or institutional generalizability.,Statistical vs. clinical significance: while a 6-day reduction in median LOH is potentially important, the wide interquartile ranges (IQR 7–17 vs. 11–22 days) indicate considerable within-group variability, and the clinical importance of the difference may vary by patient subgroup. __BOTTOM_LINE_CATEGORY__ potentially_practice_informing __BOTTOM_LINE__ In this single-center RCT of 100 patients, an adapted ERAS protocol in emergency abdominal surgery was associated with a clinically meaningful 6-day reduction in median length of hospitalization compared to standard care, with comparable safety profile in the selected population. These findings are consistent with prior disease-specific ERAS trials in emergency surgery from this research group and suggest feasibility of the approach. Multicenter trials with broader inclusion criteria and full reporting of secondary outcomes are needed before adapted ERAS can be recommended as standard practice across emergency abdominal surgical settings.