Enhanced recovery after surgery protocol implementation in pediatric Meckel’s diverticulum resection: A clinical outcome study

Table 1 Comparison of preoperative characteristics between the two groups, n (%)/median (25^th percentile, 75^th percentile)/mean ± SD

Parameter	ERAS group (n = 40)	TRAD group (n = 38)	P value	Hedges (g)	Odds ratio	95%CI
Gender			0.406		0.66	0.25-1.75
Male	26 (65.00)	28 (73.68)
Female	14 (35.00)	10 (26.32)
Age (months)	60.00 (34.75, 90.00)	84.00 (39.00, 91.75)	0.331	-0.22		-19.68 to 6.40
Weight (kg)	21.35 (15.75, 26.25)	25.00 (15.75, 27.00)	0.420	-0.18		-4.60 to 1.65
ASA physical status			0.493		1.37	0.56-3.33
Ⅱ	21 (52.50)	17 (44.74)
Ⅲ	19 (47.50)	21 (55.26)
Laboratory indicators
WBC (× 109/L)	8.39 (6.71, 14.44)	9.75 (5.89, 14.82)	0.951	-0.01		-2.62 to 1.84
NEUT (× 109/L)	4.58 (2.70, 11.91)	6.60 (3.20, 12.50)	0.460	-0.17		-0.17 to -3.16
CRP (mg/L)	4.50 (2.50, 19.20)	6.50 (4.10, 21.50)	0.265	-0.71		-21.22 to 10.49
Hb (g/L)	123.53 ± 15.62	117.03 ± 15.16	0.068	-0.44		-0.39 to 13.38
PAB (g/L)	0.24 ± 0.04	0.25 ± 0.04	0.223	-0.28		-0.03 to 0.01
Glu (mmol/L)	5.38 (5.01, 6.91)	4.60 (4.09, 5.33)	< 0.001	-1.02		0.64-1.67

ASA: American Society of Anesthesiologists; WBC: White blood cell; NEUT: Neutrophil; CRP: C-reactive protein; Hb: Hemoglobin; PAB: Prealbumin; Glu: Blood glucose; ERAS: Enhanced recovery after surgery; TRAD: Traditional care group; CI: Confidence interval.

Table 2 Comparison of intraoperative characteristics between the two groups, n (%)/median (25^th percentile, 75^th percentile)/mean ± SD

Parameter	ERAS group (n = 40)	TRAD group (n = 38)	P value	Hedges (g)	Odds ratio	95%CI
Operation time (minutes)	92.20 ± 21.35	88.11 ± 17.99	0.364	0.20		-4.83 to 13.02
Blood loss (mL)	10.00 (5.00, 10.00)	10.00 (5.00, 10.00)	0.911	-0.02		-2.42 to 2.94
Surgical approach			0.632		1.24	0.51, 3.04
Wedge resection	19 (47.50)	16 (42.10)
Segmental resection	21 (52.50)	22 (57.90)
Diverticulum location (cm)	44.50 ± 18.87	47.76 ± 22.57	0.490	-0.16		-12.63 to 6.10
Infusion speed (mL/kg/hour)	5.00 (5.00, 6.00)	8.00 (7.00, 8.75)	< 0.001	-1.65		-2.95 to -1.53
Combined anesthesia	32 (80.00)	9 (23.68)	< 0.001		12.89	4.39-37.83
Catheter utilization
NGTs	19 (47.50)	30 (78.95)	0.004		0.24	0.09-0.65
Urinary catheters	5 (12.50)	12 (31.58)	0.041		0.31	0.10-0.99
Abdominal drains	7 (17.50)	17 (44.74)	0.009		0.26	0.09-0.74

NGT: Nasogastric tube; ERAS: Enhanced recovery after surgery; TRAD: Traditional care group; CI: Confidence interval.

Table 3 Analysis the intra-individual correlation of pain between the two groups

Variable	β (95%CI)	t value	P value
Group (ERAS vs TRAD)	-1.34 (-1.66 to -1.02)	-8.251	< 0.001
Time (continuous)	-0.03 (-0.04 to -0.02)	-7.075	< 0.001
Group time	0.02 (0.01-0.03)	2.751	0.006

ERAS: Enhanced recovery after surgery; TRAD: Traditional care group; CI: Confidence interval.

Table 4 Comparison of postoperative recovery indicators, median (25^th percentile, 75^th percentile)

Parameter	ERAS group (n = 40)	TRAD group (n = 38)	P value	Hedges (g)	95%CI
FLACC pain scores
2 hours	2.00 (1.75, 3.00)	3.00 (2.00, 4.00)	< 0.001	-1.09	-1.32 to -0.58
6 hours	3.00 (2.75, 4.00)	4.00 (4.00, 4.00)	< 0.001	-1.89	-1.49 to -0.89
12 hours	4.00 (3.00, 4.00)	5.00 (5.00, 6.00)	< 0.001	-2.22	-2.14 to -1.41
24 hours	3.00 (3.00, 4.00)	4.00 (4.00, 5.00)	< 0.001	-1.09	-1.19 to -0.49
36 hours	3.00 (2.75, 3.00)	4.00 (3.00, 4.00)	< 0.001	-0.83	-0.92 to -0.28
48 hours	2.00 (1.00, 2.00)	2.00 (2.00, 3.00)	< 0.001	-0.87	-0.85 to -0.28
Oral analgesics (administrations)	4.00 (3.75, 5.00)	2.00 (1.00, 3.75)	< 0.001	-1.33	1.17-2.32
Postoperative LOS	8.00 (6.00, 8.00)	9.50 (8.00, 11.00)	< 0.001	-1.16	-4.06 to -1.63
Wedge resection	8.00 (7.00, 9.00)	9.00 (7.00, 11.00)	0.354	-0.31	-2.77 to 0.31
Segmental resection	6.98 (6.00, 8.00)	10.00 (9.00, 11.05)	< 0.001	-2.10	-5.88 to -2.39

FLACC: Face, Legs, Activity, Cry, Consolability; LOS: Length of stay; ERAS: Enhanced recovery after surgery; TRAD: Traditional care group; CI: Confidence interval.

Table 5 Effects of treatment groups on length of stay before and after covariate adjustment via inverse probability weighting

Variable	β (95%CI)	t value	P value
Group (ERAS vs TRAD)1	-2.88 (-4.06 to -1.70)	-4.794	< 0.001
Group (ERAS vs TRAD)2	-2.89 (-4.06 to -1.71)	-4.823	< 0.001

¹Before inverse probability weighting: Effect of treatment groups on length of stay.

²After inverse probability weighting: Effect of treatment groups on length of stay.

Covariates included in the models: Age, weight, American Society of Anesthesiologists classification, surgical approach, and surgical indication/disease severity. ERAS: Enhanced recovery after surgery; TRAD: Traditional care group; CI: Confidence interval.

Table 6 Comparison of postoperative outcomes of the two groups, n (%)/median (25^th percentile, 75^th percentile)/mean ± SD

Parameter	ERAS group (n = 40)	TRAD group (n = 38)	P value	Hedges (g)	Odds ratio	95%CI
Recovery parameters (days)
Time to ambulation	1.00 (1.00, 2.00)	3.00 (2.00, 3.00)	< 0.001	-1.59		-1.50 to -0.85
First flatus	2.00 (1.00, 2.00)	3.00 (2.00, 3.75)	< 0.001	-1.12		-1.30 to -0.58
TEN achievements	5.00 (5.00, 6.00)	6.50 (6.00, 8.00)	< 0.001	-1.36		-2.22 to -1.10
IV duration	6.00 (5.00, 6.00)	8.00 (7.00, 9.00)	< 0.001	-1.92		-3.09 to -1.68
Catheter duration (days)
NGTs	2.00 (1.50, 3.00)	3.00 (3.00, 4.00)	< 0.001	-1.44		-2.26 to -0.84
Urinary catheters	1.00 (1.00, 2.00)	3.00 (2.00, 3.00)	0.016	-1.38		-2.11 to -0.42
Abdominal drains	2.71 ± 0.76	4.72 ± 1.23	0.001	-1.73		-3.04 to -0.97
Complications	7 (17.50)	5 (13.16)	0.595		1.40	0.40-4.86
Nausea/vomiting	3 (7.50)	2 (5.26)	1		1.46	0.23-9.26
Abdominal distension	5 (12.50)	4 (10.53)	1		1.21	0.30-4.91
Cough/sputum production	2 (5.00)	2 (5.26)	1		0.95	0.13-7.09
Umbilical infection	1 (2.50)	0 (0.00)	1		2.92	0.12-74.02
Residual abdominal infection	1 (2.50)	1 (2.63)	1		0.97	0.06-16.15
Anastomotic leakage	0 (0.00)	1 (2.63)	0.487		0.31	0.01-7.81
Clavien-Dindo classification			1		0.89	0.09-9.16
Grade I	4 (10.00)	3 (7.90)
Grade II	3 (7.50)	2 (5.26)
Parental satisfaction	37 (92.50)	33 (86.84)	0.476		1.87	0.41-8.43
30-day readmission	1 (2.50)	1 (2.63)	1		0.95	0.06-15.73
Incomplete obstruction	1 (2.50)	0 (0.00)	1		2.92	0.12-74.02
Residual abdominal infection	0 (0.00)	1 (2.63)	0.487		0.31	0.01-7.81
Laboratory parameters
WBC (× 109/L)	9.66 ± 3.02	10.62 ± 4.01	0.336		-0.26	-2.93 to 1.02
NEUT (× 109/L)	5.98 ± 2.02	8.01 ± 3.98	0.015		-0.60	-3.63 to -0.41
CRP (mg/L)	13.67 (7.85, 22.11)	19.63 (7.10, 32.69)	0.20		-0.35	-21.83 to 0.05
Hb (g/L)	117.82 ± 13.51	114.46 ± 12.60	0.348		0.26	-3.75 to 10.46
PAB (g/L)	0.18 (0.15, 0.21)	0.15 (0.13, 0.18)	0.01		-0.60	0.01-0.04
Glu (mmol/L)	5.53 (4.79, 6.43)	6.46 (5.35, 8.81)	0.023		-0.60	-2.25 to -0.03

TEN: Total enteral nutrition; IV: Intravenous; NGT: Nasogastric tube; WBC: White blood cell; NEUT: Neutrophil; CRP: C-reactive protein; Hb: Hemoglobin; PAB: Prealbumin; Glu: Blood glucose; ERAS: Enhanced recovery after surgery; TRAD: Traditional care group; CI: Confidence interval.