ADAPTED ERAS PATHWAY VS. STANDARD CARE IN PATIENTS UNDERGOING EMERGENCY SMALL BOWEL SURGERY- A RANDOMIZED CONTROLLED TRIAL.
Vikram Kate*1, Saurabh Kumar2, Sathasivam Sureshkumar2, Subair Mohsina2, Thulasingam Mahalakshmy3, Pankaj Kundra4
1Department of General & Gastrointestinal Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India; 2Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India; 3Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India; 4Department of Anesthesia and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
Introduction: Emergency laparotomy for small bowel pathologies comprise a significant number of all emergency surgeries. The management of these patients is carried out by varied procedures by open or laparoscopic techniques. Application of evidence-based adapted enhanced recovery after surgery (ERAS) protocol has the potential for improvising the outcomes by enhancing recovery in these patients. However, randomized studies on the role of ERAS in emergency surgery are sparse, especially on small bowel surgery. This study was carried out to evaluate the safety, feasibility, and efficacy of these adapted pathways in patients undergoing emergency small bowel surgery.
Methods:
This was a single-center, prospective, open-labeled, superiority, randomized controlled trial (RCT) that was carried out from April 2017 to December 2018. All consecutive patients planned for emergency small bowel surgery based on clinical and adjunctive investigations were included as per the inclusion criteria. Patients with refractory shock, ASA class ≥3, polytrauma patients with associated other intra-abdominal organ injuries, duodenal ulcer perforations and pregnant patients were excluded. Block randomization was done with block sizes of 4 and 6. Eligible patients were randomly assigned in a 1:1 ratio using a serially numbered opaque sealed envelope to receive either standard care or adapted ERAS pathway groups (Table 1). Intra-operatively, patients who required any other procedure than simple closure of small bowel perforation or small bowel resection were excluded from the analysis. The primary outcome was the length of hospitalization (LOH). Secondary outcomes were functional recovery parameters and morbidity. The study was registered at www.ctri.gov.in (CTRI no: CTRI/2017/04/008294).
Results:
A total of 82 patients were included in the study as a standard care group with 40 patients and adapted the ERAS group with 42 patients. The two groups were comparable in terms of all demographics and clinicopathological characteristics. LOH in adapted ERAS group was significantly shorter (2.83±0.56, p<0.001) when compared to the standard care group(Table 2). Patients in the adapted ERAS group had significantly earlier recovery (days) for the time to first flatus (1.25±0.24, p<0.001), first stool (1.8±0.27, p<0.001), first fluid diet (1.48±0.18, p<0.001) and solid diet (2.11±0.17, p<0.001). The urinary catheter (0.86±0.17, p<0.001) and abdominal drain (2.61±0.22, p<0.001) were also removed significantly early in the adapted ERAS group as compared to the standard care group. Postoperative nausea, vomiting, pulmonary complications, urinary tract infections, and surgical site infections were comparable.
Conclusion:
Adapted ERAS pathways are safe and feasible in select patients undergoing emergency small bowel surgery without an increase in the rate of complications
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