Application of enhanced recovery after surgery in the perioperative period of pediatric enterostomy closure

Table 1 Demographic and clinical characteristics of study cohorts, n (%)

Characteristic	ERAS group (n = 31)	TRAD group (n = 30)	P value
Gender			0.717
Male	21 (67.74)	19 (63.33)
Female	10 (32.26)	11 (36.67)
Age (months)	10.30 (6.75, 16.50)	8.95 (6.00, 11.88)	0.398
Weight (kg)	9.00 (7.00, 10.00)	8.00 (6.33, 9.23)	0.251
ASA physical status			1.000
II	26 (83.87)	26 (86.67)
III	5 (16.13)	4 (13.33)
STAMP score			0.823
≥ 4 (malnourished)	8 (25.81)	7 (23.33)
< 4 (normal)	23 (74.19)	23 (76.67)
Enterostomy site			0.716
Small bowel	20 (64.52)	18 (60.00)
Colon	11 (35.48)	12 (40.00)
Stoma closure interval (days)	178.00 (120.00, 225.50)	166.50 (119.50, 229.75)	0.948
Causes of enterostomy
Necrotizing enterocolitis	11 (35.48)	8 (26.67)	0.457
Hirschsprung’s disease	8 (25.81)	7 (23.33)	0.823
Meconium peritonitis	1 (3.23)	3 (10.00)	0.581
Adhesive bowel obstruction	3 (9.68)	2 (6.67)	1.000
Intussusception	1 (3.23)	0 (0.00)	1.000
Incarcerated hernia	0 (0.00)	1 (3.33)	0.492
Intestinal atresia	1 (3.23)	3 (10.00)	0.581
Anal atresia	3 (9.68)	4 (13.33)	0.963
Intestinal torsion	1 (3.23)	2 (6.67)	0.977
Trauma		2 (6.45)	0 (0.00)

Median (25^th percentile, 75^th percentile) for non-parametric continuous variables. ASA: American Society of Anesthesiologists; STAMP: Screening Tool for the Assessment of Malnutrition in Pediatrics; ERAS: Enhanced recovery after surgery; TRAD: Traditional care.

Table 2 Comparison of intraoperative and postoperative outcomes, n (%)/mean ± SD

Parameter	ERAS group (n = 31)	TRAD group (n = 30)	P value
Intraoperative data
Operation time (minutes)	85.58 ± 19.10	88.27 ± 23.54	0.626
Estimated blood loss (mL)	10.00 (10.00, 12.50)	10.00 (10.00, 20.00)	0.329
Fluid infusion speed (mL/kg/hour)	5.94 ± 1.21	8.63 ± 2.19	< 0.001
Combined anesthesia	25 (80.65)	7 (23.33)	< 0.001
Catheters utilization
NGTs	13 (41.94)	23 (76.67)	0.006
Urinary catheters	6 (19.36)	13 (43.33)	0.043
Abdominal drains	5 (16.13)	12 (40.00)	0.038
Catheters duration
NGTs (days)	2.00 (2.00, 3.00)	3.00 (3.00, 4.00)	< 0.001
Urinary catheters (days)	1.00 (1.00, 1.75)	3.00 (2.00, 3.00)	0.003
Abdominal drains (days)	2.00 (2.00, 3.00)	4.50 (4.00, 5.25)	0.003
Recovery outcomes
Active ambulation (days)	1.00 (1.00, 1.00)	3.00 (2.00, 3.00)	< 0.001
First flatus (days)	2.00 (1.00, 2.00)	3.00 (2.00, 3.75)	< 0.001
Liquid diet initiation (days)	2.00 (2.00, 3.00)	4.00 (3.00, 4.00)	< 0.001
IV infusion duration (days)	5.23 ± 0.76	7.33 ± 1.94	< 0.001
TEN achievement (days)	5.68 ± 0.79	8.37 ± 1.94	< 0.001
Complications	6 (19.36)	5 (16.67)	0.785
Abdominal distension	5 (16.13)	3 (10.00)	0.742
Nausea/vomiting	3 (9.68)	2 (6.67)	1.000
Cough with sputum production	1 (3.23)	2 (6.67)	0.977
Incision infection	2 (6.45)	1 (3.33)	1.000
Incomplete bowel obstruction	0 (0.00)	1 (3.33)	0.492
By severity (Clavien-Dindo)
Grade I	4 (12.90)	2 (6.67)	0.698
Grade II	2 (6.45)	3 (10.00)	0.969
Hospitalization cost (yuan)	14542.87 ± 4322.97	19030.64 ± 5541.51	< 0.001
30-day outcomes
Weight restoration	25 (80.65)	22 (73.33)	0.497
Readmissions	1 (3.23)	1 (3.33)	1.000
Wound infection	1 (3.23)	0 (0.00)	1.000
Partial obstruction	0 (0.00)	1 (3.33)	0.492

Median (25^th percentile, 75^th percentile) for non-parametric continuous variables. IV: Intravenous; NGT: Nasogastric tube; TEN: Total enteral nutrition; ERAS: Enhanced recovery after surgery; TRAD: Traditional care.

Table 3 Multivariable linear regression analysis of factors influencing caregiver satisfaction rate and postoperative length of stay

Variable	Caregiver satisfaction rate		Postoperative LOS
	β (95%CI)	P value	β (95%CI)	P value
ERAS group vs TRAD group	0.24 (0.06, 0.42)	0.011	-2.29 (-3.28, -1.30)	< 0.001
Age (continuous, per month)	0.01 (-0.01, 0.02)	0.226	-0.05 (-1.00, -0.01)	0.006
Body weight (continuous, per kg)	-0.02 (-0.07, 0.02)	0.336	0.15 (-0.09, 0.39)	0.222
Operative duration (continuous, per minute)	0 (-0.01, 0.01)	0.650	0.01 (-0.02, 0.03)	0.682
Enterostomy site (ref: Small bowel)	0.11 (-0.09, 0.32)	0.257	0.73 (-0.35, 1.80)	0.181
Postoperative complications (ref: No)	-0.20 (-0.45, 0.05)	0.112	0.94 (-0.42, 2.29)	0.170
Preoperative nutritional status (ref: STAMP score < 4)	-0.03 (-0.25, 0.19)	0.780	1.03 (-0.17, 2.23)	0.091
Anesthetic technique (ref: Alone)	-0.02 (-0.21, 0.18)	0.864	-0.98 (-2.02, 0.06)	0.063
Social support level (ref. Inadequate)	0.11 (-0.19, 0.41)	0.473	-1.22 (-2.86, 0.42)	0.141

Statistical significance was set at P < 0.05. The model is adjusted for age, body weight, operative duration, enterostomy site (small bowel vs colon), postoperative complications (yes vs no), preoperative nutritional status, anesthetic technique, and social support level to control for potential confounding. For continuous variables (age, body weight, operative duration), β coefficients represent the change in caregiver satisfaction rate per 1-unit increase in the variable. CI: Confidence interval; LOS: Length of stay; ERAS: Enhanced recovery after surgery; STAMP: Screening Tool for the Assessment of Malnutrition in Pediatrics; TRAD: Traditional care.

Table 4 Comparison of perioperative laboratory indicators, n (%)/mean ± SD

Parameter	ERAS group (n = 31)	TRAD group (n = 30)	P value
Blood glucose (mmol/L)
Anesthesia induction	6.09 (5.04, 6.84)	4.70 (4.17, 5.11)	< 0.001
POD2	5.35 (4.91, 6.63)	6.22 (5.46, 9.23)	0.045
WBC count (× 109/L)
Admission	8.08 ± 1.97	8.95 ± 2.09	0.100
POD2	10.90 ± 3.28	11.44 ± 2.77	0.489
NEUT count (× 109/L)
Admission	4.81 ± 1.26	5.19 ± 1.42	0.266
POD2	5.57 ± 1.46	7.63 ± 1.93	< 0.001
CRP (mg/L)
POD2	10.05 (4.75, 28.34)	27.14 (11.90, 39.86)	0.019
Hemoglobin (g/L)
Admission	117.13 ± 11.35	119.63 ± 12.36	0.413
POD2	109.58 ± 12.63	106.13 ± 14.63	0.328
Albumin (g/L)
Admission	42.09 ± 3.01	42.89 ± 4.78	0.444
POD2	36.56 ± 4.47	34.69 ± 4.89	0.125
Prealbumin (g/L)
Admission	0.22 ± 0.03	0.21 ± 0.03	0.320
POD2	0.18 ± 0.03	0.16 ± 0.03	0.003
Sodium (mmol/L)
Admission	135.94 ± 3.39	134.23 ± 4.01	0.078
POD2	134.77 ± 3.66	133.27 ± 3.50	0.106

Median (25^th percentile, 75^th percentile) for non-parametric continuous variables. WBC: White blood cell; NEUT: Neutrophil; CRP: C-reactive protein; POD: Postoperative day; ERAS: Enhanced recovery after surgery; TRAD: Traditional care.