Cumulative Implementation of Postoperative Enhanced Recovery After Surgery (Eras) Elements and Postoperative Length of Stay After Emergency Laparotomy for Perforated Appendicitis: A Retrospective Analytical Crosssectional Study in an Indonesian Tertiary Referral Hospital

Background: Perforated appendicitis often requires emergency laparotomy and prolongs hospitalisation. Enhanced Recovery After Surgery (ERAS) shortens stay in elective surgery, but appendicectomy is excluded from ERAS Society emergency laparotomy guidelines, and evidence from low- and middle-income settings is limited. Objective: To describe the implementation of seven postoperative ERAS elements and to analyse the association between the number of elements implemented and postoperative length of stay (LOS) in adults undergoing emergency laparotomy for perforated appendicitis. Methods: Retrospective analytical cross-sectional study of medical records at Dr. Saiful Anwar General Hospital, Malang, Indonesia (2023–2025). Adults aged 18–59 years with clinically and intraoperatively confirmed perforated appendicitis were consecutively sampled. The exposure was the number (0–7) of elements implemented: antiemetic prophylaxis, opioid avoidance, early oral nutrition, early mobilisation, and early removal of nasogastric tube, drain and urinary catheter. Spearman's correlation was the primary analysis; adjusted analyses were exploratory. Results: Sixty patients were analysed (mean age 33.2 ± 11.5 years; 68.3% male; ASA III–IV 43.3%). Median postoperative LOS was 3 days (interquartile range [IQR] 3–5; mean 3.68 ± 1.66). Early nutrition (80.0%), nasogastric tube removal (76.7%) and mobilisation (75.0%) were most frequently implemented; early urinary catheter removal was least frequent (20.0%). No patient received all seven elements (median 4; IQR 3–5). The number of elements correlated inversely with LOS (ρ = −0.455; 95% CI −0.635 to −0.227; p < 0.001). The association persisted after adjustment for ASA class, age and sex (partial ρ = −0.369; p = 0.005); each additional element was associated with a 0.46-day shorter stay (95% CI 0.04–0.88). Conclusion: Greater cumulative implementation of postoperative ERAS elements was moderately associated with shorter postoperative stay after emergency laparotomy for perforated appendicitis. Early removal of urinary catheters and drains represents the principal opportunity for improvement, supporting a multidisciplinary, checklist-based emergency ERAS protocol.