Length of stay in enhanced recovery after surgery in children

Editor, Enhanced recovery after surgery (ERAS) has become standard management for many surgical patients.1 Recent evidence suggests that ERAS may be applied to paediatric surgery, and that it may have similar beneficial effects in terms of recovery, duration of hospital stay and the reduced postoperative complications observed in adults.2 Consequently, we undertook this meta-analysis. The primary endpoint of this meta-analysis was hospital length of stay (HLOS), the secondary outcome was the presence of postoperative complications. This meta-analysis was registered (PROSPERO database # CRD42020172990) and performed according to Systematic Review guidelines as previously described.3 Literature searches included PubMed, Embase, the Cochrane Central Register of Controlled Trials, the Clinical Trials Register and the Directory of Open Access Journals using the following key words ‘children’ or ‘infants’ and ‘ERAS’ or ‘Enhanced Recovery After Surgery’ or ‘rehabilitation’ or ‘fast-track’. The most recent search was February 2020. Inclusion criteria were: age less than 18 years and standardised ERAS protocols. Cardiac surgery was excluded. Quality assessment used: the Cochrane Collaborative Group Criteria for Randomized Studies and Risk of Bias In Nonrandomized Studies.4 Extracted data consisted of: ERAS protocol components, patient ages, type(s) of surgery(ies), American Society of Anesthesiologists status (ASA), HLOS (days) and incidence of postoperative complications. Risk ratio (RR) and the mean difference were computed. Heterogeneity was assessed using Cochran's heterogeneity statistic (Q) and the I2 statistic; I2 above 40% was considered meaningful heterogeneity and indicated use of a random effects model. Subgroup analyses investigated effects of type of surgery and patients’ age on the primary outcome. Level of evidence was analysed using the GRADE methodology. Overall, 15 articles were included (including 1769 patients). Most procedures were abdominal and/or urological surgeries and three were orthopaedics. Only one study was randomised with a high risk of bias (Supplemental files 1, https://links.lww.com/EJA/A405 and 2, https://links.lww.com/EJA/A406). The remaining studies were observational with 13 exhibiting a moderate risk and 1 exhibiting a serious risk of bias (Supplemental files 1, https://links.lww.com/EJA/A405 and 2, https://links.lww.com/EJA/A406). ERAS was associated with (Supplemental file 3, https://links.lww.com/EJA/A407) a reduction of HLOS [six studies: mean difference = −1.7 (95% confidence interval; CI, −2.7 to −0.66); I2 = 99%, P < 0.0001; GRADE: very low] and postoperative complications [11 studies: RR = 0.6 (95% CI, 0.46 to 0.81); I2 = 0%; P = 0.58; GRADE: low]. Type of surgery (classified as abdominal/urological versus orthopaedics) and age (<14 months versus heterogeneous ages) have no influence on HLOS. Results of the current meta-analysis appear to indicate that ERAS in children potentially has the same advantages of those observed in adults. Recent meta-analyses in adult patients have shown a mean decrease in HLOS of 2.5 and 1.4 days after major abdominal5 and orthopaedic6 surgeries. Children have generally better health status in comparison to adults, and are therefore, less likely to suffer from peri-operative complications.7 As a result, any observed effects of ERAS in children will tend to be smaller when compared with adults. Articles included were mostly observational. ERAS involves significant group changes of practice in complex healthcare systems.1 This makes it methodologically very difficult to perform a randomised trial where caregivers are required to apply different protocols simultaneously. This explains the high volume of publications using a before--after methodology. In addition, many items of ERAS are parts of recent advances in the peri-operative management in children making difficult evaluating the effect of ERAS. Perhaps one way of improving results in this field would be to attempt international multicentre trials. ERAS seems to be evolving more slowly in paediatric surgical patients in comparison to adults. This may result from a resistance to change,1 the lack of knowledge of the benefits of ERAS2 a reduced perception of ERAS relevance given shorter baseline HLOS in children and the previous application of ERAS items in paediatrics. The current meta-analysis exhibits some limitations. The number of included studies was small and quality of evidence far from optimal. Secondly, results exhibited high heterogeneity. Finally, items of ERAS were very heterogeneous between studies (Supplemental file 4, https://links.lww.com/EJA/A408). In conclusion, the current meta-analysis sheds light on the benefits of ERAS in children in terms of HLOS and postoperative complication rates. More studies are required to confirm these results. ERAS programmes should be encouraged in children.