Application evidence-based accelerated rehabilitation surgery nursing in the perioperative period of open abdominal gastrointestinal perforation repair: Retrospective analysis

Abstract

BACKGROUND

Acute gastrointestinal perforation is a life-threatening surgical emergency requiring rapid intervention. Although enhanced recovery after surgery (ERAS) is well known in elective procedures, its efficacy in emergency open repair remains poorly studied due to severe systemic inflammation and limited preoperative preparation time.

AIM

To evaluate the impact of evidence-based ERAS nursing on perioperative outcomes in patients undergoing open surgical repair for gastrointestinal perforation.

METHODS

A retrospective study was conducted on 100 patients who underwent open surgical repair of gastrointestinal perforation at the First Affiliated Hospital of Soochow University from June 2023 to May 2025. Patients were divided into a control group (n = 50) that received standard nursing care and an observation group (n = 50) that received evidence-based ERAS nursing. The study compared intraoperative parameters, perioperative recovery metrics (time to first postoperative ambulation, first flatus, and first oral liquid intake; postoperative hospital stay; and Numerical Rating Scale pain score on postoperative day 3), as well as operative duration, intraoperative blood loss, and postoperative complications. Systemic inflammatory markers, including white blood cell (white blood cell count, C-reactive protein), and serum albumin, were measured before surgery and on days 1 and days 3 after surgery. Patient satisfaction with nursing care was also evaluated between groups.

RESULTS

Compared with the control group, patients in the observation group showed significantly improved postoperative recovery outcomes (all P < 0.05). Specifically, the observation group achieved earlier postoperative ambulation (12.36 ± 4.15 hours vs 26.85 ± 8.74 hours), earlier first flatus (42.18 ± 10.22 hours vs 65.43 ± 15.67 hours), and earlier initiation of oral liquid intake (20.54 ± 6.33 hours vs 48.72 ± 12.41 hours). Postoperative hospital stay was significantly shorter in the observation group (7.25 ± 1.86 days vs 10.83 ± 2.95 days, P < 0.001). The postoperative day 3 Numerical Rating Scale pain score was also significantly lower (2.45 ± 0.87 vs 4.62 ± 1.23, P < 0.001). In addition, the overall postoperative complication rate was significantly reduced in the observation group compared with the control group (12.0% vs 34.0%, P = 0.009). On postoperative day 3, white blood cell count and C-reactive protein levels decreased more markedly, whereas serum albumin recovery was significantly better in the observation group (all P < 0.05). Patient satisfaction scores were significantly higher in all evaluated domains in the observation group (all P < 0.05).

CONCLUSION

The study concluded that evidence-based ERAS nursing strategies substantially improve postoperative recovery, reduce hospitalization duration and the frequency of postoperative complications, and reduce postoperative inflammatory responses in patients undergoing open surgical repair for gastrointestinal perforation. The results showed significant clinical relevance and broad applicability of ERAS nursing in this patient population. These findings suggest important implications for future clinical practice and healthcare delivery.

Key Words: Evidence-based practice; Enhanced recovery after surgery nursing; Open surgical repair for gastrointestinal perforation; Perioperative period

Core Tip: The results of this study demonstrate the feasibility of implementing enhanced recovery after surgery (ERAS) nursing in emergency gastrointestinal perforation repair, with observable clinical impact. ERAS nursing effectively optimizes stress responses, facilitates early functional recovery, reduces postoperative complications, and improves patient-centered outcomes through integrated multidisciplinary perioperative management strategies. These results support wider implementation of ERAS principles in nursing practice for emergency abdominal surgery.

INTRODUCTION

Acute gastrointestinal perforation is a surgical emergency that is frequently encountered and is characterized by an abrupt onset and a severe clinical presentation[1]. Previous studies have identified several risk factors for its development, including reduced skeletal muscle mass, increased visceral adiposity, a history of prior abdominal surgery, external abdominal pressure, and elevated D-dimer levels[2]. If not managed in a timely and appropriate manner, the condition may rapidly progress to generalized peritonitis and septic shock. It is reported that approximately 27.8% of affected patients progress to septic shock, which poses a significant risk to survival[3,4].

Currently, the primary treatment for this condition is exploratory laparotomy with perforation repair. Despite surgical intervention, traditional perioperative care remains predominantly focused on operative management. As a result, physiological and psychological stress responses are often not comprehensively controlled during the perioperative period. This may contribute to a high incidence of postoperative complications, delayed gastrointestinal recovery, and prolonged hospital stay. These outcomes are associated with increased patient discomfort, more healthcare resource utilization, reduced treatment efficacy, and adverse long-term consequences. Therefore, the concept of enhanced recovery after surgery (ERAS) has been progressively integrated into clinical practice in response to evolving approaches in surgical care[5]. The ERAS framework comprises a set of perioperative strategies designed to reduce surgical stress, enhance organ function, and accelerate postoperative recovery[6].

These strategies are multidisciplinary and evidence-based. Key components include structured preoperative counseling and risk assessment, optimized anaesthesia, improved surgical techniques, multimodal pain control, early postoperative feeding, and ambulation. There is strong evidence that ERAS pathways shorten hospital stays. They also decrease postoperative complications.

They also improve patient satisfaction in elective gastrointestinal surgeries, particularly in colorectal and gastric procedures[7,8]. However, evidence supporting the application of ERAS principles in emergency gastrointestinal perforation repair remains limited. Patients in such cases often have severe infections and metabolic disturbances, and there is limited preparation time, which can hinder the implementation of standard ERAS principles.

This indicates the need for further research to evaluate the feasibility and benefits of ERAS-based nursing care in emergency gastrointestinal perforations. Accordingly, this study was conducted to observe the outcomes of ERAS nursing interventions and to obtain objective data to improve the management of this high-risk patient group.

MATERIALS AND METHODS

A retrospective study was conducted on 100 patients who underwent emergency open surgical repair for gastrointestinal perforation at the First Affiliated Hospital of Soochow University between June 2023 and May 2025. Based on the perioperative nursing strategy, the patients were divided into two groups: A conventional care group (n = 50) and an ERAS-based nursing group (n = 50). Group allocation was based on the nursing protocol implemented during hospitalization, which was designed to ensure the smooth and efficient management of patients. Comparative analysis of baseline demographic and clinical characteristics revealed no statistically significant differences between the two groups (P > 0.05), indicating comparability at baseline.

Eligibility criteria

Inclusion criteria: Patients were eligible for inclusion if they met all of the following criteria: (1) Gastrointestinal perforation confirmed preoperatively by imaging (e.g., abdominal computed tomography scan or upright abdominal X-ray) and/or intraoperative findings, requiring emergency open surgery[9]; (2) Standard open exploratory laparotomy with perforation repair, peritoneal lavage, and drainage; (3) Age ≥ 18 years; (4) Completion of full intraoperative and postoperative treatment and nursing care at the study hospital, with complete and traceable electronic medical and nursing records; and (5) Approval of the hospital ethics committee with a waiver of informed consent for this retrospective study.

Exclusion criteria: Patients were excluded if they had any of the following conditions: (1) Undergoing laparoscopic procedures, bowel resection with anastomosis, stoma formation, or other complex repair surgeries; (2) Severe comorbid cardiac, pulmonary, hepatic, or renal dysfunctions, or uncontrolled coagulation disorders; (3) Perforation related to malignancy that required extensive oncological surgery; (4) Pre-existing chronic intestinal obstruction, extensive intra-abdominal adhesions, or neurological or musculoskeletal issues that limit postoperative mobility; and (5) History of psychiatric disorders, cognitive impairments, or inability to participate in perioperative nursing care and assessments.

Nursing intervention protocols

Conventional perioperative nursing care: Patients in the control group received routine perioperative nursing care, including preoperative, intraoperative, and postoperative management, in accordance with hospital protocols and regulations. Preoperatively, patients underwent a 12-hour fasting period and a 6-hour fluid restriction, along with basic health education and psychological support. During surgery, nursing staff assisted with the procedure and continuously monitored vital signs. Postoperatively, patients were monitored with electrocardiography, and oral intake was gradually increased as bowel function resumed. Analgesia was administered as needed. Bed mobility and ambulation were progressively encouraged as tolerated. Drainage tubes were managed and removed according to standard clinical criteria. All nursing interventions were performed in accordance with established departmental guidelines.

Evidence-based ERAS nursing care: The observation group received ERAS nursing care developed by the researchers through an evidence-based approach. The Patient/Problem, Intervention, Comparison, Outcome model was used to formulate the structured clinical questions, and systematic literature searches were conducted in PubMed/MEDLINE, EMBASE, and the Cochrane Library. Chinese databases, including CNKI and Wanfang Data, were also used to capture high-quality international and regional evidence. The searches combined medical subject headings terms with free-text keywords. In PubMed, for example, the query was: [“Gastrointestinal Perforation/Surgery”(MeSH) OR “Digestive System Surgical Procedures”(MeSH)]. The search terms are “Early Feeding” (Mesh) OR “Early Ambulation”(Mesh) OR “Enhanced Recovery After Surgery”(Mesh). AND [“Randomised Controlled Trial”(pt) OR “Meta-Analysis”(pt) OR “Systematic Review”(pt)]. The search period covered the previous 10 years. Priority was given to studies published within the past 5 years. The quality of all retrieved evidence was thoroughly assessed and critically appraised. Based on the synthesised evidence, a multidisciplinary team including surgeons, anaesthetists, dietitians, head nurses, and clinical nursing experts conducted structured discussions to develop and finalise the ERAS nursing intervention protocol.

Preoperative assessment and intervention: (1) After admission, a comprehensive multidisciplinary assessment was conducted involving the responsible nurse, surgeon, anesthesiologist, and dietitian. Nutritional risk was determined using the Nutritional Risk Screening 2002 tool[10,11]. Patients scoring ≥ 3 were promptly provided with preoperative nutritional support in accordance with guidelines from the European Society for Clinical Nutrition and Metabolism; (2) Individualized, evidence-based preoperative education and psychological care were provided using a structured foresee-train-participate approach. Nurses used educational booklets, videos, and face-to-face explanations to inform patients and their families about the surgical procedure, expected pain-control strategies, planned early mobilization, and the role of respiratory exercises. A range of psychological care services was provided to reduce anxiety and negative emotions, including emotional counseling, sharing experiences, and relaxation guidance; (3) Preoperative fasting followed established international guidelines of the American Society of Anesthesiologists and the Society for the Advancement of Accelerated Recovery in Surgery. Patients were advised to avoid solid foods for six hours before surgery and were encouraged to drink clear, carbohydrate-rich fluids up to two hours before anaesthesia. They could consume a 5% glucose solution at 10 mL/kg, with a maximum of 50 mL; and (4) Routine mechanical bowel preparation was skipped, and prophylactic intravenous antibiotics were administered 30-60 minutes before incision. Patients were also trained in deep breathing and effective coughing techniques to improve postoperative respiratory function.

Intraoperative interventions: (1) Standardized intraoperative strategies were implemented to optimize anesthesia, physiologic stability, and surgical outcomes. General anesthesia was induced with a rapid-sequence intravenous protocol using propofol, sufentanil, and rocuronium bromide. After induction and before skin incision, ultrasound-guided bilateral transversus abdominals plane blocks were administered with 0.33% ropivacaine (20 mL/side) to enhance perioperative analgesia. Anesthesia was maintained with a combined intravenous-inhalational technique, consisting of continuous propofol and remifentanil infusions with 1%-2% sevoflurane inhalation, while maintaining the bispectral index between 40 and 60; (2) Active measures were implemented to maintain intraoperative normothermia. The operating room temperature was set to 24 °C and adjusted to 22 °C after anesthesia induction. Forced-air warming blankets were used on non-operative body regions immediately after patient positioning. All intravenous infusions and peritoneal lavage solutions were pre-warmed to 37 °C. Core body temperature was continuously monitored via a nasopharyngeal probe to maintain intraoperative temperature at < 36.0 °C; (3) Goal-directed fluid therapy was guided by continuous stroke volume variation (SVV) monitoring. Ringer’s lactate solution was administered at a baseline rate of 5-7 mL/kg/hour after induction, with intraoperative adjustments based on SVV values. When SVV exceeded 13%, infusion rates were reduced, and volume expansion was provided. In comparison, when SVV fell to below 10%, infusion rates were increased to maintain SVV within the target range of 10%-13% and limit total crystalloid administration to 15-20 mL/kg; and (4) The attending lead surgeon determined drain placement intraoperatively, which was performed only in cases meeting one or more of the following criteria: (1) Perforation duration > 24 hours with severe intra-abdominal contamination and abundant fibrinous exudate; (2) Edematous and fragile tissue at the repair site with a high risk of leakage; and (3) Severe preoperative malnutrition (serum albumin < 30 g/L). When indicated, a 16-Fr silicone drain was placed through a separate abdominal incision and connected to low-pressure drainage. To reduce postoperative nausea and vomiting, prophylactic antiemetic therapy consisting of intravenous tolanoxin and dexamethasone (5 mg each) was administered at the onset of fascial closure.

Postoperative care and rehabilitation: A standardized postoperative management protocol was implemented to promote recovery and reduce complications. Pain intensity was assessed immediately upon return to the ward using the Numerical Rating Scale (NRS). Starting on the first postoperative day, postoperative analgesia was administered as follows: Sustained-release paracetamol tablets (650 mg, orally every 8 hours) or celecoxib capsules (200 mg, orally once daily) were routinely prescribed. When the NRS pain score was ≥ 4, flurbiprofen axetil (50 mg) was administered intravenously immediately. If complete pain relief was not achieved, tramadol hydrochloride injection (50 mg) was administered as prescribed by the physician.

For patients identified preoperatively as having low pain tolerance, a pre-programmed intravenous patient-controlled analgesia pump was initiated with sufentanil (100 μg) and tropanol (10 mg), diluted with saline (100 mL). The pump was set to a continuous background infusion of 2 mL/hour, a single bolus dose of 0.5 mL, and a 15-minute lockout interval. Pain intensity was routinely evaluated using the NRS and recorded twice daily at 8:00 am and 8:00 pm.

Approximately 2 hours after returning to the ward, patients were assisted with in-bed ankle pump exercises, including flexion, extension, and circumduction, performing 10 repetitions per set for a total of 5 sets daily. At 6 hours postoperatively, patients were supported to sit at the bedside with legs dangling for 10-15 minutes per session, twice daily. On the first postoperative morning, patients were aided to stand at the bedside and ambulate within the ward for 5-10 minutes per session, once in the morning and once in the afternoon, with support from nursing staff or family members. Starting on the second postoperative day, patients were encouraged to walk daily within the ward, targeting a total daily activity duration of at least 4 hours (at least 20 minutes for each session).

Drainage tubes were checked daily for color, consistency, and volume. Tubes were removed if the output remained < 50 mL/day within 24-48 hours postoperatively, the fluid was clear and pale, and the patient had no fever or increasing abdominal pain. Urethral catheters were initially clamped on the morning of the first postoperative day and removed once proper bladder filling and voluntary urination were confirmed. For elderly male patients, catheter-clamping training lasting 2-4 hours was provided before removal for safe bladder function.

Oral intake was initiated 4-6 hours postoperatively, once patients were fully alert and free of nausea or vomiting, starting with 5-10 mL of lukewarm water. On the first postoperative day, patients received a clear liquid diet (e.g., rice water, fat-free broth), in 50-100 mL portions every 2-3 hours. If tolerated without abdominal discomfort or nausea, patients progressed to a semi-liquid diet (e.g., congee, soft noodles) on the second postoperative day. From the third day onward, diets slowly progressed to soft foods and then to regular meals, depending on individual tolerance. Patients who had preoperative malnutrition (NRS 2002 score ≥ 3) or could not meet at least 60% of their daily caloric requirements for > 3 days received supplemental nutrition, specifically, 400-600 kcal of whole-protein enteral formula administered between meals.

Prophylactic antiemetic therapy included 5 mg intravenous tolanoxom daily for the first two postoperative days. In cases of vomiting, the underlying cause was promptly assessed, the patient’s head was turned to one side, oral secretions were cleared, and 10 mg of metoclopramide was administered intramuscularly as prescribed.

Intravenous fluid administration was limited to a maximum of 1500 mL per day, primarily with balanced electrolyte solutions, and infusion rates were maintained at 80-100 mL/hour. Capillary blood glucose was monitored on the morning after the operation. Patients with diabetes or a blood glucose level of > 10.0 mmol/L were initiated on subcutaneous insulin therapy as prescribed, to achieve an optimal glycemic control range of 7.8-10.0 mmol/L.

We actively monitored postoperative complications and implemented preventive measures. Daily inspections were conducted to check for signs of bleeding or exudate, and the initial dressing change was performed on the third day after surgery. Subcutaneous closure was performed using absorbable sutures, which did not require removal. To reduce the risk of pulmonary infection, patients were instructed and supervised in deep-breathing exercises using an incentive spirometer. They were required to perform 10-15 breaths per session, 4-6 times daily, starting from the first postoperative day.

Clear discharge criteria were established, including tolerance of a semi-liquid or soft diet, independent ambulation, adequate pain control with oral analgesics (NRS < 3), absence of fever, and no complications requiring intravenous therapy. At discharge, patients and their families were provided written instructions regarding dietary progression, wound care, permitted and restricted activities, scheduled follow-up visits, and emergency contact information to ensure safe recovery at home.

Observation indicators

The study compared intraoperative variables and postoperative recovery indicators between the observation and control groups. These included time to first ambulation, time to first passage of anal flatus, time to first oral intubation of liquid diet, length of postoperative hospital stay, NRS pain score on postoperative day 3, duration of surgery, and intraoperative blood loss. The pain intensity of each patient was assessed using the NRS, a scale that ranges from 0 (no pain) to 10 (severe pain)[12].

Postoperative complications were recorded and compared between the two groups, including surgical site infection, intra-abdominal infection or abscess, pulmonary infection, intestinal obstruction, and anastomotic leakage. Pulmonary infection was defined by clinical symptoms such as fever, purulent or yellow sputum, dyspnea, or chest pain, along with clinical examination findings and confirmatory investigations, including elevated neutrophil counts and new infiltrates on chest X-ray[13].

The systemic inflammatory response was examined by measuring white blood cell (WBC) count and C-reactive protein (CRP) levels preoperatively and on postoperative days 1 and 3. Venous blood samples (5 mL) were collected after overnight fasting and then centrifuged at 3000 rpm for 10 minutes in a centrifuge with a radius of 10.5 cm. Serum samples were analyzed using a fully automated biochemical analyzer (Hitachi Instruments Suzhou Co., Ltd., Model 7060C; National Medical Device Approval No. 2002-3400349). Nutritional status was evaluated by measuring serum albumin levels using the immunoturbidimetric method.

Patient satisfaction was assessed using a hospital-designed questionnaire covering five domains: Health education, psychological care, technical procedures, care environment, and overall subjective experience. Patients rated each domain on a scale of 0 to 10, with 0 indicating dissatisfaction and higher scores reflecting greater satisfaction and improved experience.

Statistical analysis

Data were statistically analyzed using SPSS 27.0. Continuous variables are expressed as mean ± SD and compared using independent-sample t-tests. Categorical variables are presented as frequencies or percentages and analyzed using χ² tests. Preoperative and postoperative inflammatory and nutritional indicators at different time points were compared using repeated measures analysis of variance. A two-sided P value < 0.05 was considered statistically significant.

RESULTS

Baseline characteristics of patients

Comparative analysis of baseline demographic and clinical characteristics revealed no statistically significant differences between the two groups (P > 0.05) (Table 1).

Table 1 Intergroup comparison of baseline demographic and clinical characteristics, n (%)/mean ± SD.

Observation items	Observation group (n = 50)	Control group (n = 50)	t/χ2	P value
Demographic data
Age (years)	45.34 ± 12.67	46.21 ± 11.89	0.354	0.724
Gender			0.170	0.680
Male	32 (64.00)	30 (60.00)
Female	18 (36.00)	20 (40.00)
BMI (kg/m2)	21.15 ± 1.42	21.27 ± 1.18	0.460	0.647
Preoperative clinical data
Etiology of perforation			0.229	0.973
Gastroduodenal ulcer perforation	35 (70.00)	33 (66.00)
Colorectal cancer perforation	8 (16.00)	9 (18.00)
Traumatic perforation	4 (8.00)	5 (10.00)
Others	3 (6.00)	3 (6.00)
Time from perforation to surgery (hours)	8.45 ± 2.21	8.56 ± 2.05	0.151	0.881
Preoperative septic shock	7 (14.00)	9 (18.00)	0.298	0.585
Intraoperative conditions
Perforation site			0.105	0.949
Stomach/duodenum	36 (72.00)	35 (70.00)
Jejunum and ileum	5 (10.00)	6 (12.00)
Colon and rectum	9 (18.00)	9 (18.00)
Degree of peritoneal contamination (by SAPS classification)			0.220	0.896
Grade I (mild)	15 (30.00)	13 (26.00)
Grade II (moderate)	25 (50.00)	27 (54.00)
Grade III (severe)	10 (20.00)	10 (20.00)

BMI: Body mass index; SAPS: Simplified Acute Physiology Score.

Intergroup differences in intraoperative parameters and perioperative recovery outcomes

Compared with the control group, patients in the observation group achieved significantly earlier postoperative ambulation, first flatus, and initiation of oral liquid intake (all P < 0.001): Postoperative ambulation (12.36 ± 4.15 hours vs 26.85 ± 8.74 hours), first flatus (42.18 ± 10.22 hours vs 65.43 ± 15.67 hours), and initiation of oral liquid intake (20.54 ± 6.33 hours vs 48.72 ± 12.41 hours). Furthermore, the observation group had a significantly shorter postoperative hospital stay (7.25 ± 1.86 days vs 10.83 ± 2.95 days) and significantly lower postoperative day 3 NRS pain scores (2.45 ± 0.87 vs 4.62 ± 1.23) (all P < 0.001). However, no statistically significant differences were observed in operative duration or intraoperative blood loss between the two groups (P > 0.05). Detailed data are presented in Table 2.

Table 2 Intergroup comparison of intraoperative indicators and perioperative rehabilitation outcomes, mean ± SD.

Group	Time to first postoperative ambulation (hour)	Time to first postoperative flatus (hour)	Time to first postoperative oral liquid diet (hour)	Postoperative length of hospital stay (day)	NRS score on the 3rd postoperative day (points)	Operation duration (minute)	Intraoperative blood loss (mL)
Observation group (n = 50)	12.36 ± 4.15	42.18 ± 10.22	20.54 ± 6.33	7.25 ± 1.86	2.45 ± 0.87	115.34 ± 25.67	85.56 ± 20.12
Control group (n = 50)	26.85 ± 8.74	65.43 ± 15.67	48.72 ± 12.41	10.83 ± 2.95	4.62 ± 1.23	118.45 ± 28.91	88.23 ± 25.44
t	10.590	8.788	14.303	7.259	10.185	0.569	0.582
P value	0.000	0.000	0.000	0.000	0.000	0.571	0.562

NRS: Numerical Rating Scale.

Comparison of postoperative complications

The total postoperative complication rate was significantly lower in the observation group than in the control group (12.00% vs 34.00%, χ² = 6.832, P = 0.009). A comprehensive comparison of complication types is provided in Table 3.

Table 3 Intergroup comparison of postoperative complication rates, n (%).

Group	Incision infection	Peritoneal infection/abscess	Pulmonary infection	Intestinal obstruction	Anastomotic leakage	Total complications
Observation group (n = 50)	3 (6.00)	1 (2.00)	1 (2.00)	1 (2.00)	0 (0.00)	6 (12.00)
Control group (n = 50)	8 (16.00)	5 (10.00)	4 (8.00)	3 (6.00)	1 (2.00)	17 (34.00)
χ2	-	-	-	-	-	6.832
P value	-	-	-	-	-	0.009

A comparison of the inflammatory and nutritional indicators before and after surgery

On postoperative day 3, WBC and CRP levels decreased more significantly in the observation group than in the control group, whereas serum albumin recovery was higher in the observation group (all P < 0.05). The summarized results are presented in Table 4.

Table 4 Intergroup comparison of preoperative and postoperative inflammatory and nutritional parameters, mean ± SD.

Indicator	Group	Preoperative	Postoperative day 1	Postoperative day 3	Intragroup F/P value	Intergroup interaction F/P value
WBC (× 109/L)	Observation group	12.35 ± 3.21	13.88 ± 3.75	9.12 ± 2.54	28.76/< 0.001	5.34/0.023
	Control group	12.89 ± 3.54	15.67 ± 4.12	11.45 ± 3.33	18.92/< 0.001	-
CRP (mg/L)	Observation group	25.43 ± 15.67	68.54 ± 22.31	35.21 ± 18.76	67.89/< 0.001	8.91/0.004
	Control group	26.12 ± 16.05	85.79 ± 30.45	52.67 ± 25.43	59.34/< 0.001	-
Serum albumin (g/L)	Observation group	38.45 ± 4.12	32.15 ± 3.78	35.86 ± 3.95	31.45/< 0.001	4.56/0.036
	Control group	37.89 ± 4.33	30.02 ± 4.21	32.45 ± 4.10	25.78/< 0.001	-

WBC: White blood cell; CRP: C-reactive protein.

Comparison of patient satisfaction between groups

A structured self-reported satisfaction questionnaire demonstrated higher scores in the observation group across all assessed domains, including health education, psychological support, procedural proficiency, ward environment, and overall satisfaction. As shown in Table 5, statistically significant differences were observed between the groups (P < 0.05).

Table 5 Intergroup comparison of nursing care satisfaction, mean ± SD.

Group	Health education	Psychological care	Technical skills	Care environment	Overall subjective evaluation
Observation group (n = 50)	8.14 ± 0.67	8.05 ± 0.75	8.18 ± 0.84	8.07 ± 0.77	8.23 ± 0.76
Control group (n = 50)	7.64 ± 1.15	7.64 ± 1.07	7.53 ± 1.29	7.55 ± 1.24	7.43 ± 1.74
t	2.656	2.219	2.986	2.519	2.979
P value	0.009	0.029	0.004	0.013	0.004

DISCUSSION

Gastrointestinal perforation is a common gastrointestinal emergency, and surgery is the primary treatment. However, postoperative complications may delay recovery and prolong hospital discharge. Recently, ERAS protocols have shown significant benefits in elective procedures, including reduced length of hospital stay, lower complication rates, and improved overall outcomes through multimodal perioperative strategies[14,15]. However, further clinical evidence is needed to establish the efficacy of ERAS in emergency surgery, particularly in patients undergoing open repair for gastrointestinal perforation.

This study found that patients in the observation group recovered significantly faster than those in the control group, due to evidence-based ERAS nursing care. This included earlier postoperative ambulation, earlier first flatus, earlier initiation of oral liquid intake, and a shorter overall length of postoperative hospital stay. Moreover, on postoperative day 3, pain scores were significantly lower in the observation group (P < 0.05). The incidence of postoperative complications was also lower in the observation group (12.0% vs 34.0%, P < 0.05). These results suggest that structured ERAS interventions can effectively accelerate postoperative recovery, reduce complications, and shorten hospitalization in patients undergoing open repair of gastrointestinal perforation. The results are consistent with those of Mishra et al[16], who reported that ERAS implementation significantly reduced hospital stay, promoted earlier ambulation, enabled earlier initiation of a clear liquid diet, and decreased rates of surgical site infections and pulmonary complications. These outcomes may reflect the coordinated use of preoperative[17], intraoperative, and postoperative ERAS measures. Preoperatively, multidisciplinary evaluation and individualized nutritional optimization support physiological preparation and reduce anxiety. Intraoperative interventions, including perioperative temperature management and goal-directed fluid therapy, help minimize surgical stress and tissue edema. Transversus abdominis plane blocks provide effective regional analgesia, facilitating earlier mobilization. Postoperatively, multimodal analgesia enables early ambulation and oral intake. Early mobilization promotes gastrointestinal motility and accelerates flatus passage, while early oral feeding helps preserve mucosal integrity and restore bowel function. Other measures, such as fluid restriction, antiemetic therapy, and close monitoring, further support a stable recovery environment, reducing complications and shortening hospital stay[18]. The ERAS pathway replaces the traditional “pain-bed rest-fasting-complications” cycle with a “analgesia-mobility-nutrition-recovery” framework, improving postoperative outcomes[19].

This study also demonstrated significant differences in the temporal trends of WBC counts and CRP levels between the two groups, indicating a significant interaction between time and intervention. These findings suggest that the ERAS protocol effectively attenuates the systemic inflammatory response to surgical trauma, a key determinant of postoperative recovery and clinical outcomes. This is consistent with Tian et al[20], who reported faster recovery and significant reductions in WBC and CRP levels in patients managed under ERAS protocols. Before surgery, interventions such as nutritional optimization and psychological preparation enhance physiological and psychological reserves, thus reducing baseline stress responses. During surgery, strict temperature management preserves immune cell function and limits the release of stress hormones associated with hypothermia. Goal-directed fluid therapy prevents tissue oedema[21]. Postoperatively, multimodal analgesia incorporating regional nerve blocks provides effective pain control and attenuates continuous activation of the hypothalamic-pituitary-adrenal axis via nociceptive pathways. This inhibits excessive stress and inflammatory responses at their origin[22,23]. Furthermore, early oral nutrition supports the integrity of the intestinal mucosal barrier, thereby limiting bacterial and endotoxin translocation - key triggers of systemic inflammation. Similarly, early mobilization promotes lymphatic circulation and the removal of inflammatory mediators through skeletal muscle activity. The more favourable trajectories of WBC and CRP levels observed in the ERAS group reflect the synergistic impact of ERAS strategies in reducing surgical stress, optimizing the metabolic environment, and accelerating the resolution of inflammatory processes.

In this study, patients in the observation group achieved significantly higher scores than those in the control group across all domains of the self-designed satisfaction questionnaire, including health education, psychological care, technical competence, ward environment, and overall subjective assessment (P < 0.05). This improvement may be due to the ERAS procedure, which improves patients’ overall care experience by integrating patient-centred, evidence-based nursing strategies. In the case of health education, for example, the ERAS approach replaces the delivery of non-specific, conventional information with a structured ‘anticipation-training-engagement’ model. Various educational tools are used to provide patients and their families with comprehensive explanations of surgical procedures, pain management strategies, and early mobilization plans. This approach transforms patients from passive recipients of care into informed, active participants in their own recovery, thereby enhancing their understanding, confidence, and perceived safety. In case of psychological support, the ERAS program incorporates systematic emotional counseling, experience sharing, and guided relaxation techniques to effectively reduce perioperative anxiety and uncertainty, while strengthening psychological adaptability. In nursing practice, standardized medication protocols, precise fluid balance monitoring, and intraoperative temperature regulation can reduce postoperative pain and stress. These measures reflect a high level of clinical precision and professional nursing practice[24,25]. Furthermore, close multidisciplinary collaboration across the preoperative, intraoperative, and postoperative phases fosters a more structured, responsive, and supportive care environment. These interventions significantly shorten recovery time and enhance patient satisfaction. These measures aim to alleviate pain, promote early mobilization and oral intake, accelerate functional recovery, and provide clear discharge guidance.

However, this study has several limitations. First, the relatively small sample size and single-center retrospective design may limit the generalizability of the findings. Second, the retrospective design introduces an unavoidable risk of selection bias. Therefore, further multicenter, prospective, randomized controlled trials with larger sample sizes are needed to confirm the clinical efficacy and long-term benefits of ERAS nursing strategies in emergency gastrointestinal perforation surgery. Third, age-related factors may influence postoperative recovery, inflammatory response, nutritional status, and tolerance to early mobilization. Elderly patients often present with multiple comorbidities and reduced physiological reserve, which may affect ERAS implementation and outcomes. Although no significant age differences were observed between the groups in this study, future research should include stratified age subgroup analyses to further evaluate the safety and effectiveness of ERAS nursing strategies in older populations.

CONCLUSION

In summary, evidence-based ERAS nursing interventions significantly improve postoperative recovery, reduce length of hospital stay, and decrease complication rates and inflammatory responses in patients undergoing open repair for gastrointestinal perforation. These results highlight the clinical relevance and potential benefits of implementing ERAS-based nursing approaches in acute surgical settings.