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

Abstract

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols have improved perioperative outcomes in adults. However, we know less about their use in pediatric enterostomy closure and this area still has no specific guidelines.

AIM

To see how well ERAS pathways, when adjusted for children, work during the whole perioperative period of enterostomy closure surgery.

METHODS

This is a single-center retrospective analysis conducted in a tertiary pediatric surgery department. It included 61 children who received enterostomy closure from January 2017 to December 2024, covering both the periods before and after ERAS protocol application. Patients were divided into two groups in this study. A total of 31 children treated by standardized pediatric ERAS protocols between 2021 and 2024 were assigned to the ERAS group. The other 30 patients received routine traditional perioperative management from 2017 to 2020 were comprised the traditional (TRAD) group. The main observational indicators included postoperative length of stay (LOS), pain scores within 48 hours after surgery and parental satisfaction. Secondary outcomes included perioperative metabolic, nutritional and inflammatory indicators, as well as the recovery of gastrointestinal function recovery metrics, indwelling catheter utilization/durations, surgical complications, hospitalization costs, 30-day unplanned readmission rate, and preoperative weight restoration at 30 days postoperatively.

RESULTS

Compared with the TRAD group, children in the ERAS group had a shorter median postoperative LOS (8.00 days vs 10.00 days, P < 0.001) and markedly lower Face, Legs, Activity, Cry, Consolability pain assessment scale pain scores within 48 hours after surgery (P < 0.001). In addition, parental satisfaction was significantly higher in the ERAS group (96.77% vs 73.33%, P < 0.05). The ERAS children had higher blood glucose at anesthesia induction, which decreased significantly by postoperative day 2 (both P < 0.05). They also showed higher serum prealbumin and lower C-reactive protein and neutrophil levels (all P < 0.05). ERAS significantly accelerated gastrointestinal recovery in children. Patients had earlier intestinal exhaust, sooner resumption of liquid and full enteral feeding, and required shorter intravenous infusion time (all P < 0.001). ERAS decreased perioperative catheter use, with shorter indwelling time and lower utilization of nasogastric tubes, urinary catheters and abdominal drains (all P < 0.05). The ERAS group had significantly lower mean hospitalization costs (¥14542.87 vs ¥19030.64, P < 0.001). Safety was comparable between the two groups, with no significant differences in surgical complication rates (19.36% vs 16.67%), 30-day unplanned readmissions (3.23% vs 3.33%), or 30-day preoperative weight recovery (80.65% vs 73.33%) (all P > 0.05).

CONCLUSION

ERAS protocols tailored for children are safe and practical for perioperative care in pediatric enterostomy closure. Adopting this approach helps enhance postoperative recovery, optimize nutritional and inflammatory indicators, and improve parental satisfaction, while maintaining overall patient safety. We therefore recommend routine clinical application of ERAS protocols for this high-risk pediatric surgical population.

Key Words: Enhanced recovery after surgery; Enterostomy closure; Perioperative care; Multimodal analgesia; Surgical rehabilitation

Core Tip: Our findings confirm that enhanced recovery after surgery (ERAS) application is safe and clinically beneficial for preschool children undergoing enterostomy closure. The clinical benefits were more prominent in colostomy reversal compared with small bowel stoma closure. It may be because colostomy patients follow ERAS protocols more steadily. Also, when patients stuck more closely to the ERAS guidelines, their recovery after surgery went better. This link shows a clear dose response pattern.

INTRODUCTION

Closing an enterostomy is a common second surgery on the gut. Its goal is to reconnect the bowel that had been brought out to the skin, so the digestive tract can work again[1]. Doctors do this operation often in clinical practice. Still, the rate of complications is around 32%, which is quite high[2]. So, we should not think of it as just a simple intestinal reconnection. Classified as a Class II-III surgical wound, enterostomy closure carries clear postoperative risks. Some common complications are anastomotic leakage, intestinal blockage, and infection at the surgical site. This type of infection often slows down wound healing. There are also more serious problems, like wound dehiscence and incisional hernia. These issues not only hurt children’s physical and mental health but also put a heavy financial load on their families. So, in clinical practice, it is essential to develop practical strategies to standardize perioperative care and reduce the incidence of postoperative complications.

The enhanced recovery after surgery (ERAS), was first put forward by a Danish surgeon named Henrik Kehlet. It uses a multimodal, evidence-based approach to guide perioperative care. The goal is to reduce surgical stress, lower the risk of complications, and help patients get better faster after surgery[3]. ERAS protocols were first made for adult patients. Since then, they have shown good results in many types of surgery, including colorectal, urologic, cardiothoracic, and orthopedic procedures[4-7].

So far, there is still no single ERAS guide for children who need enterostomy closure. Young patients tend to have low blood volume and poor temperature regulation. Their immune systems are not fully mature, and they need a lot of nutrition. They also have trouble speaking about how they feel, and their ability to digest and absorb food is weak. All these natural traits work together to slow down their recovery after surgery. To fill this clinical gap, our team formulated and applied a tailored ERAS protocol for pediatric enterostomy closure based on previous research evidence[8,9]. We then compared its clinical performance with traditional perioperative care in this high-risk pediatric group.

MATERIALS AND METHODS

Study population

A retrospective analysis was conducted on pediatric patients who underwent enterostomy closure at the Department of Pediatric Surgery, The First Affiliated Hospital of USTC (Anhui Provincial Hospital), between January 2017 and December 2024.

Inclusion criteria: (1) Duration of prior enterostomy ≥ 2 months; (2) Body weight ≥ 4 kg; (3) Preoperative hemoglobin level ≥ 90 g/L; (4) Complete medical records available for review; (5) No concurrent major surgical procedures performed; and (6) Availability of 30 ± 2 days of postoperative follow-up data.

Exclusion criteria: (1) Age > 96 months; (2) Presence of significant systemic comorbidities (e.g., cardiac, renal, or hepatic impairment; primary immunodeficiency); (3) Concurrent participation in other clinical trials; and (4) Requirement for perioperative critical care interventions (e.g., blood transfusion, admission to the pediatric intensive care unit).

A total of 61 consecutive eligible patients were stratified into two groups based on the perioperative care regimen received: The traditional (TRAD) group (n = 30, 2017-2020): Managed with conventional perioperative care protocols; the ERAS group (n = 31, 2021-2024): Treated per a standardized pediatric-specific ERAS protocol.

The study was approved by the hospital’s Institutional Review Board (approval No. 2025-RE-386). All surgeries and anesthesia were performed by a fixed multidisciplinary team (MDT) to ensure consistent clinical management. Before we started collecting any raw data, we took off all patient identifiers and made the data unlinked to any individual. We did this to lower the risk of detection bias. Because this study used a retrospective observational design and all patient data were fully anonymized, the Institutional Review Board did not require informed consent. Figure 1 gives an overview of how patients were selected for the study.

Figure 1 Patient selection process. PICU: Pediatric intensive care unit; ERAS: Enhanced recovery after surgery; TRAD: Traditional care.

Quality control

We set up a special MDT to carry out the ERAS protocols. This team had two senior pediatric surgeons, each with at least ten years of experience. There was also one professional clinical dietitian, two attending anesthesiologists, and six specialist nurses. Two of these nurses worked in the operating room, and the other four worked on the general ward. We used a three-tier quality control system to keep the ERAS protocol running in a standard and reliable way: (1) Hospital information system (HIS) monitoring: We set up the HIS to automatically find patients in the ERAS group. Through the surgery scheduling module, the system sent real-time reminders. This helped make sure all perioperative ERAS care steps were done on time and correctly; (2) MDT oversight: The MDT met every two weeks to check how well the protocol was being followed. They looked for any problems in how it was carried out and came up with specific fixes to close those gaps; and (3) Research nurse auditing: Specially trained research nurses performed daily checklist audits to confirm that every enrolled patient fully complied with all ERAS management measures.

Perioperative management

Preoperative measures: (1) Patient assessment and nutritional optimization: Pediatric surgeons completed thorough preoperative evaluations. They assessed stoma-related conditions such as peristomal skin integrity and proximal and distal bowel function, along with systemic indicators including nutritional status and peripheral inflammatory markers, to confirm patients were fit for surgery. All patients completed nutritional screening with the Screening Tool for the Assessment of Malnutrition in Pediatrics (STAMP) during preoperative outpatient visits. Those at high nutritional risk, defined as a STAMP score of 4 or higher, received two weeks of preoperative nutritional optimization. A clinical dietitian supervised their oral high-calorie nutrition supplementation throughout the intervention; (2) Preoperative counseling and psychological preparation (ERAS group): Our team provided individualized preoperative counseling for families of patients during outpatient visits. Counseling contents included: (a) Verification of primary disease diagnoses and detailed introduction of surgical plans; (b) Explanation of core surgical procedures; (c) Introduction of anticipated postoperative recovery progress; and (d) Clear explanation of hospital discharge standards. To help children feel less anxious before surgery, pediatric nurses used play therapy that was suited to each child's age. This helped the children become more familiar with the hospital setting. At the same time, the nurses brought parents into the care process. That way, parents could give their children enough emotional support; and (3) On the day of surgery, patients in the ERAS group followed a set list of steps to prepare before the operation: (a) They got one warm saline enema in the morning, only to clean the distal bowel; (b) They received an intravenous (IV) dose of cefuroxime at 50 mg/kg, given 30 minutes before the first cut. The same antibiotic was used to prevent infection in both groups; (c) They followed a stepwise fasting plan before surgery. Solid food and formula were allowed up to 6 hours before anesthesia. Breast milk could be given up to 4 hours before. Also, up to 2 hours before anesthesia, they could drink 5 mL/kg of an oral glucose solution. This helped ease hunger and prevent dehydration before the operation; and (d) After anesthesia was started, the team put in a nasogastric tube (NGT) and a urinary catheter only when needed, based on what the surgery required at that time[10]. TRAD group: These patients received the conventional care before surgery, which included the following: (a) Before the operation, the attending doctors talked with the patients and their families. They covered only the basic course of the illness, general surgical principles, and potential postoperative complications. They did not give any structured advice on how to recover; (b) There was no formal psychological preparation designed for the child’s age; (c) Bowel preparation lasted three days. The team used warm saline to flush both the distal and the proximal parts of the bowel; (d) Patients were told to have nothing by mouth for eight hours before surgery. This included no clear fluids in the last two hours before the operation; and (e) A NGT was placed while the patient was awake and still in the inpatient ward, regardless of individual surgical indication.

Intraoperative measures: (1) ERAS group interventions included: (a) Anesthesia regimen: Combined general endotracheal anesthesia with caudal epidural blockade for multimodal intraoperative and postoperative analgesia; (b) Perioperative thermoregulation: Operating room temperature maintained at ≥ 25 °C, supplemented with forced-air warming blankets, pre-warmed skin antiseptic solutions, and heated IV fluid administration to prevent perioperative hypothermia; (c) Goal-directed fluid therapy[11]: Fluid administration titrated based on real-time hemodynamic monitoring (heart rate, invasive/non-invasive blood pressure, hourly urine output) to avoid iatrogenic fluid overload; (d) Selective drainage: Abdominal drains placed only for cases with high anastomotic tension or compromised bowel perfusion; and (e) Local analgesia: Prophylactic infiltration of 0.5% ropivacaine at the surgical incision site prior to wound closure for postoperative pain control[12]; and (2) TRAD group interventions were as follows: (a) Anesthesia regimen: Used sole general endotracheal anesthesia without additional regional analgesia; (b) Fluid management: Given routine IV fluids according to standard maintenance needs and estimated surgical loss, without goal-directed hemodynamic adjustment; (c) Thermoregulation: Adopted no active warming strategies, only passive insulation was provided with the operating room temperature kept at 21-23 °C; and (d) Drainage: Received routine abdominal drain placement for all patients, independent of anastomotic conditions.

Postoperative measures: (1) The ERAS group followed these protocols: (a) Antibiotic management: After the operation, patients received cefuroxime sodium through an IV for 24 hours. This followed the hospital's rules on antibiotics and was the same as what the TRAD group received; (b) Multimodal pain management: We checked pain after surgery with a tool called the Face, Legs, Activity, Cry, Consolability pain assessment scale (FLACC) scale. This looks at the face, legs, activity, crying, and ability to be comforted. We did these checks at set times during the first 48 hours after surgery. We used a stepwise plan that combined different pain relief methods[13]. Some steps did not involve drugs. For example, we used cartoons or music to distract children in a way that fit their age. For babies under 12 months old, we gave a pacifier with 24% sucrose. We also gave regular oral analgesics (acetaminophen or ibuprofen) every six hours. We kept this up until the FLACC score stayed at 3 or lower for two checks in a row; (c) Catheter and drain management: Right after surgery, we took out the urinary catheters. NGTs were kept in only if the amount of fluid drawn from the stomach each day went above 50 mL and that fluid looked yellow-green. Otherwise, we removed the NGT within 48 hours. For abdominal drains, we took them out once the fluid coming out had a steady amount and appearance, and there was no fresh blood or pus; (d) Early mobilization: Starting 6 hours after surgery, children began doing leg and arm movements while lying in bed. Older children walked with help from their family members. Infants and young toddlers did guide limb exercises with help from their caregivers[14]. Activity intensity was gradually raised according to each child’s tolerance level; and (e) Nutritional advancement: On postoperative day (POD) 1, children started with small amounts of water or a 10% glucose solution. Then, as they could handle it, we slowly moved them to formula or breast milk. We also adjusted the amount of IV fluids based on what they took in by mouth, so they could prevent fluid overload; (2) The TRAD group received conventional care after surgery: (a) Pain control: Children got a single dose of oral acetaminophen or ibuprofen only when their FLACC score reached 4 or higher. There was no set schedule for giving pain medicine; (b) Tube and drain care: Urinary catheters were stayed in until POD3; NGTs were kept in place for three to five days, until the fluid removed from the stomach looked clear and had no color; abdominal drains were taken out only when the amount of fluid coming out each day dropped below 20 mL; (c) Activity: For the first three days after surgery, patients were kept on bed rest; (d) Nutrition: Feeding by mouth was delayed until the child passed gas or had a bowel movement. Then, they slowly moved from clear liquids to solid foods; and (e) Fluid management: Weight-based IV fluid administration continued until full oral/enteral intake was restored; and (3) Post-discharge assessment: Prior to hospital discharge, guardians completed a standardized satisfaction questionnaire to evaluate the quality of perioperative medical services. Satisfaction rates were calculated using the formula: [(number of “satisfied” responses + number of “basically satisfied” responses)/total number of respondents] × 100%[15]. All patients underwent a mandatory postoperative follow-up visit at the outpatient clinic at 30 ± 2 days after surgery to assess long-term recovery endpoints.

Discharge criteria and clinical data collection

Discharge eligibility was determined by predefined standardized criteria, requiring patients to meet all of the following benchmarks: (1) Tolerance of full oral intake for ≥ 24 consecutive hours without emesis, with normalized GI motility and urinary function; (2) Uncomplicated surgical wound healing (no signs of infection or dehiscence), with no need for specialized wound care or indwelling drainage devices; (3) Sustained normothermia (axillary temperature ≤ 37.3 °C) for 48 hours, absence of clinically significant respiratory symptoms (cough frequency ≤ 2 episodes per hour), and resolution of all perioperative complications; and (4) Normalized routine laboratory results (complete blood count and basic metabolic panel) and unremarkable postoperative abdominal ultrasound findings (no evidence of anastomotic leakage, intra-abdominal fluid collection, or bowel obstruction).

Clinical data collection: Comprehensive data were retrospectively extracted from electronic medical records for all eligible patients, covering six core domains of clinical outcomes and perioperative parameters: (1) Baseline characteristics: Demographics (age, sex, body weight), underlying primary diagnoses (e.g., congenital intestinal atresia, necrotizing enterocolitis), duration of prior enterostomy, and preoperative nutritional status (STAMP score, serum albumin/prealbumin levels); (2) Intraoperative parameters: Total operative duration, estimated intraoperative blood loss, volume of intraoperative fluid administration, anesthesia type, and indwelling drain utilization; (3) Postoperative recovery metrics: Serial FLACC pain scores (at 6 hours, 12 hours, 24 hours, 36 hours, and 48 hours postoperatively), dynamic inflammatory markers [C-reactive protein (CRP), white blood cell (WBC) count], serial nutritional and electrolyte parameters (serum albumin, prealbumin, sodium), glycemic variability (serum glucose levels at anesthesia induction and POD2, GI recovery endpoints [time to first flatus, first oral intake, and total EN (TEN)]; and time to first assisted ambulation; (4) Perioperative care utilization data: Intraoperative fluid infusion rate; total duration of postoperative IV fluid therapy; utilization rates and indwelling durations of NGTs, urinary catheters, and abdominal drains; (5) Safety and long-term recovery outcomes: Incidence of procedure-related complications (classified per the Clavien-Dindo grading system), 30-day unplanned readmission rate, and proportion of patients who regained preoperative baseline body weight at the 30 ± 2 days follow-up visit; and (6) Healthcare utilization and caregiver-reported outcomes: Total hospitalization costs, postoperative length of stay (LOS), and caregiver satisfaction scores (derived from the standardized post-discharge questionnaire).

Statistical analysis

All statistical analyses were performed using IBM SPSS Statistics version 26.0 (IBM Corporation, Armonk, NY, United States). Normality of continuous data was first assessed via the Shapiro-Wilk test. Continuous variables with a normal distribution were presented as mean ± SD and compared between groups using the independent samples t-test. Non-normally distributed continuous variables were reported as median (interquartile range) and analyzed using the Mann-Whitney U test. Categorical variables were summarized as n (%) and compared using the Pearson’s χ² test or Fisher’s exact test, depending on the expected cell frequencies. Statistical significance was defined as a two-tailed P value < 0.05 for all comparisons.

Given the retrospective design of this study, a priori sample size calculation was not feasible. Instead, we conducted a post-hoc power analysis using G*Power software (version 3.1.9.7) to evaluate the statistical power of the observed significant differences in our primary outcome-postoperative LOS.

RESULTS

Baseline characteristics

The study included 31 patients in the ERAS group and 30 in the TRAD group. Baseline characteristics were well balanced between groups, with no statistically significant differences observed in key variables: Median age (10.30 months vs 8.95 months, P = 0.398), median body weight (9.00 kg vs 8.00 kg, P = 0.251), malnutrition risk (25.81% vs 23.33%, P = 0.823), and enterostomy site distribution (small bowel: 38 cases; colon: 23 cases). Admission nutritional parameters were also comparable across groups (all P > 0.05). All patients classified as high nutritional risk (STAMP score ≥ 4) received standardized preoperative nutritional optimization. The primary indications for enterostomy creation were similar between groups, with detailed distributions summarized in Table 1.

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.

Intraoperative outcomes

All surgical procedures were completed successfully without intraoperative adverse events. Compared with the TRAD group, the ERAS cohort showed two notable intraoperative differences with statistical significance: (1) More restrictive IV fluid infusion (5.94 ± 1.21 mL/kg/hour vs 8.63 ± 2.19 mL/kg/hour, P < 0.001); and (2) Much higher adoption of combined anesthesia (general anesthesia plus caudal block) with local anesthetic infiltration (80.65% vs 23.33%, P < 0.001). Additionally, the ERAS group had markedly lower rates of postoperative catheter use for all measured indicators (all P < 0.05) (Table 2).

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.

Postoperative outcomes

Catheter retention time and postoperative recovery: The ERAS group had notably shorter indwelling times for all catheters. Median duration was 2.00 days vs 3.00 days for NGTs, 1.00 days vs 3.00 days for urinary catheters, and 2.00 days vs 4.50 days for abdominal drains (all P < 0.01; Table 2).

Comparative analysis showed the ERAS group achieved markedly faster postoperative recovery than the TRAD group (all P < 0.001). Key improvements included earlier ambulation (median 1.00 days vs 3.00 days), quicker GI recovery (median time to first flatus: 2.00 days vs 3.00 days), earlier liquid diet initiation (median: 2.00 days vs 4.00 days), shorter IV fluid support time (5.23 ± 0.76 days vs 7.33 ± 1.94 days), and faster achievement of TEN (5.68 ± 0.79 days vs 8.37 ± 1.94 days). These results further confirm that the ERAS protocol markedly improves postoperative recovery, especially by accelerating GI functional restoration (Table 2).

Complications, readmission, and costs: The complications we tracked included abdominal distension, feeling sick or throwing up, productive cough, infection of the cut, and a partial blockage of the bowel. All these problems were rated using the Clavien-Dindo system, which is a standard way to grade how serious they are[16]. No statistically significant between-group differences were observed in the incidence of grade I or II complications (both P > 0.05), and neither group experienced grade III or higher complications. Furthermore, 30-day unplanned readmission rates and the proportion of patients who regained preoperative weight at 30 ± 2 days postoperatively were comparable between groups (both P > 0.05).

Each group had one readmission case: Wound infection in the ERAS group and partial intestinal obstruction in the TRAD group, both of which were successfully managed with conservative treatment. Notably, the ERAS protocol was associated with a significant reduction in mean hospitalization costs compared with conventional care (¥14542.87 vs ¥19030.64, P < 0.001; Table 2).

Pain management, postoperative LOS, and caregiver satisfaction: Quantitative pain assessment via the FLACC scale demonstrated that the ERAS group had significantly lower pain scores across all 48-hour postoperative time points (all P < 0.001; Figure 2A). Although ERAS patients required more frequent oral analgesic doses (median: 4.00 doses vs 2.00 doses, P < 0.001; Figure 2B), the protocol achieved superior pain control-validating the efficacy of its multimodal analgesia strategy.

Figure 2 Comparative analysis of postoperative pain management, length of stay, and caregiver satisfaction between the enhanced recovery after surgery and traditional care groups. A: Postoperative pain assessment via the Face, Legs, Activity, Cry, Consolability pain assessment scale (FLACC) scale. The enhanced recovery after surgery (ERAS) group (n = 31) exhibited significantly lower FLACC scores than the traditional care (TRAD) group (n = 30) at all predefined timepoints within 48 hours postoperatively; B: Frequency of oral analgesic administration. The ERAS cohort required significantly more oral analgesic doses than the TRAD cohort (median: 4.00 doses vs 2.00 doses), consistent with the protocol’s multimodal analgesia strategy; C: Postoperative length of stay (LOS). Median LOS was significantly shortened in the ERAS group compared to the TRAD group (8.00 days vs 10.00 days). Subgroup analysis revealed a more pronounced LOS reduction in colostomy patients (ERAS: n = 11; TRAD: n = 12; 3.50-day reduction) than in small bowel stoma patients (2.00-day reduction); D: Caregiver satisfaction rate. The ERAS group had a significantly higher caregiver satisfaction rate than the TRAD group (96.77% vs 73.33%). ^aP < 0.05, ^bP < 0.01, ^cP < 0.001. Statistical analyses were performed using Mann-Whitney U tests (continuous variables) or χ² tests (categorical variables). FLACC: Face, Legs, Activity, Cry, Consolability pain assessment scale; ERAS: Enhanced recovery after surgery; TRAD: Traditional care; LOS: Length of stay.

The ERAS pathway helped shorten postoperative LOS by 2 days (8.00 days vs 10.00 days, P < 0.001). When we looked closer at different types of patients, we found that those with a colostomy stayed 3.5 days less, and those with a small bowel stoma stayed 2 days less. This suggests that ERAS works better for colostomy closure procedures (Figure 2C).

Families were much more satisfied with the care in the ERAS group (96.77% vs 73.33%, P < 0.05; Figure 2D). You can find all the detailed results in Supplementary Table 1.

To mitigate potential confounding, a supplementary multivariable linear regression model was constructed, adjusting for key covariates including age, body weight, enterostomy site (small bowel vs colon), operative duration, postoperative complications, preoperative nutritional status, anesthetic technique, and social support level. As shown in Table 3, after adjusting for potential confounders, the ERAS group was independently associated with significantly higher caregiver satisfaction levels [β = 0.24, 95% confidence interval (CI): 0.06-0.42; P = 0.011] and shorter postoperative LOS (β = -2.29, 95%CI: -3.28 to -1.30; P < 0.001) compared with the TRAD group. Additionally, each one-month increase in patient age was independently associated with a 0.05-day reduction in postoperative LOS (β = -0.05, 95%CI: -1.00 to -0.01; P = 0.006).

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.

Perioperative laboratory indicators

Admission laboratory assessments showed no significant between-group differences inflammatory markers [WBC count, CRP level, and neutrophil (NEUT) count] or nutritional indicators (serum sodium, hemoglobin, albumin, and prealbumin levels; all P > 0.05). However, the ERAS group had significantly higher blood glucose levels at anesthesia induction (P < 0.001; Table 4).

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.

By POD2, WBC count, serum sodium, hemoglobin, and albumin levels remained comparable between groups (all P > 0.05). Notably, the ERAS group exhibited: (1) Significantly higher serum prealbumin levels (P < 0.01); (2) Improved glycemic control (lower blood glucose levels, P < 0.05); and (3) Attenuated inflammatory responses (reduced NEUT count and CRP level, both P < 0.05) relative to the TRAD group (Table 4).

DISCUSSION

ERAS protocols optimize perioperative recovery through multidisciplinary, patient-centered strategies that mitigate surgical stress and expedite physiological restoration[17]. ERAS has been shown to work well in adults. But in children, especially infants, it is still not used much. This is largely due to insufficient targeted evidence, as well as the need to accommodate children’s unique physiological and psychological developmental characteristics. Children respond more strongly to surgical stress than adults do. That means they need ERAS plans that are specially adjusted for them, not just copied from adult care. This need is very clear in children having enterostomy reversal. Up to now, there are still no standard ERAS guidelines made just for this procedure.

Our study fills this gap in clinical care. We used an ERAS plan made just for children having enterostomy closure. Compared to conventional care, this plan safely cut the median postoperative LOS by 2 days (8.00 days vs 10.00 days). It did not raise the overall risk of complications. A post-hoc power check confirmed that our findings are reliable. The difference in LOS gave a Cohen’s d value of about 0.95, which means the effect seen in the clinic is large. We used a two-tailed t-test with an alpha level of 0.05. With 31 patients in the ERAS group and 30 in the TRAD group, the statistical power came out to 96.5%. That is well above the usual standard of 80%. These results confirm that our total sample of 61 patients gave us enough statistical power to pick up real differences between the two groups for the main outcome we were looking at. This adds support to the trustworthiness of our findings. We should point out that this was a retrospective study, so we did not do an initial sample size calculation beforehand. That is typical for this type of research. Therefore, the effect size we observed should be interpreted with some caution.

One thing that stands out is that parents in the ERAS group were much more satisfied with the care (96.77% vs 73.33%, P < 0.05). This shows that the ERAS plan helps patients recover better in terms of health, and also makes the experience better for families. That fits well with the comprehensive aims of pediatric perioperative care. When we looked at different types of patients, we found that those with colostomy had a bigger drop in postoperative LOS (3.50 days) than those with small bowel stoma (2.00 days). It may be because the ERAS measures were followed more thoroughly. These measures included limited bowel preparation, early removal of catheters and drains, and starting low-residue feeding at the right time. This points to a dose-response pattern: Stronger adherence to ERAS measures corresponds to improved recovery[18]. These results also suggest that using several ERAS measures together works better than any single one on its own[19,20].

Successful ERAS application relies on tailored adjustments suited to children’s developmental characteristics and vulnerability. Preoperative education for caregivers helped set reasonable expectations and boost protocol compliance. This step is very important because babies cannot tell us clearly what they need[21]. We also used play-based methods, like showing medical toys to children. This helped calm their fears before the operation. These kinds of child-friendly changes are rarely used in adult ERAS plans and effectively lowered perioperative stress in our pediatric patients. We also changed the rules on fasting before surgery to better match children’s metabolic demands. Solid food and formula were stopped 6 hours before anesthesia. At the same time, we gave a 10% glucose drink by mouth 2 hours before the operation. This helped maintain normal blood glucose, eased the discomfort of hunger, and also helped calm parents’ anxieties[8]. In the ERAS group, we placed NGTs and urinary catheters after anesthesia had already started. That made the process less uncomfortable for the child. This is an important part of pediatric care, but it gets very little attention in ERAS plans made for adults.

Intraoperatively, we used two key steps to address the physical vulnerability of children. First, we gave fluids in a careful, limited way. This lowered the risk of pulmonary and intestinal edema, and also reduced cardiac burden. These problems are more likely to affect infants because their heart and lung systems are not fully grown[22]. Second, we kept the child’s body temperature above 36 °C during the whole perioperative period. This helped avoid problems linked to low body temperature, such as coagulopathy, infection at the surgical site, and arrhythmia. Children are more prone to these issues because they have a larger skin surface area compared to their body weight. These adjustments show that ERAS plans must be made to fit children’s anatomical and physiological features. We cannot simply take adult plans and use them as they are.

Effective pain control postoperatively is key to helping patients recover. But managing pain in children comes with its own special challenges. In children, the systems that control pain are not fully developed. Their body’s response to surgical stress can be three to five times stronger than in adults. If pain is not well controlled, it can delay early movement, harm lung function, and raise the risk of infection. Our ERAS plan used a mix of different methods to manage pain. These included putting 0.5% ropivacaine into the surgical site, keeping children distracted with cartoons and music, and giving a 0.3 mL/kg dose of 24% sucrose solution to boost the body's own pain-relieving opioids[23]. We also gave acetaminophen and ibuprofen on a regular schedule. This multimodal strategy delivered better pain relief. At every time point within the first 48 hours after surgery, FLACC scores were lower. It also reduced opioid use, helped children move around earlier and speed up GI recovery[24]. This combined approach works better than using just one type of pain medicine. Single-agent plans do not take into account how pain control works differently in a child’s body[25].

We used drains and tubes only when needed. This matches current evidence that putting in catheters and drains for every child brings little benefit in abdominal surgery[26]. An abdominal drain was placed only when the bowel join was with high tension or poor tissue perfusion. Also, we kept the use of NGTs and urinary catheters to a minimum, and removed them as early as possible. This conservative drainage approach did not raise rates of serious complications like urinary retention and anastomotic leakage. It also allowed earlier activity, faster GI recovery and higher parental satisfaction. The findings confirm it is safe to reduce routine catheter and drain use for pediatric enterostomy closure, departing from outdated traditional practice.

Early EN was another key ERAS component. Prolonged preoperative fasting hinders recovery, impairs wound healing and weakens immune function[27], while early enteral feeding eases metabolic stress and promotes rehabilitation[28]. Even so, many pediatric surgeons still follow the outdated practice of waiting for bowel sounds before resuming feeding[29]. Our study found starting oral feeding within 24 hours after surgery protected intestinal function, with no rise in abdominal distension or vomiting. This practice also shortened recovery time to first flatus and initial liquid intake, and improved metabolic indicators, including lower blood glucose and elevated serum prealbumin on POD2. Coupled with reduced IV fluid use, this nutritional protocol helped shorten LOS and cut medical expenses.

Postoperatively, the ERAS group had markedly lower CRP and NEUT levels (P < 0.05). Surgical injury induces NEUT accumulation at the wound site, aggravating local and systemic inflammation[30]. Meanwhile, liver-produced CRP regulates the immune reaction to tissue damage[31]. Both markers are reliable indicators reflecting the degree of surgical stress[32]. These results show that the protocol truly helps reduce inflammation after surgery in children. They also match up well with what we saw in the clinic.

This study is the first one to full assessment of ERAS pathways for closing enterostomies in children. It confirms that these pathways are safe and useful for this group of patients. We should also point out some limits that come with the study design. First, there may be a time-related bias. General improvements in routine care over the study period, along with other factors we did not measure-such as updates in nursing methods or social and economic influences-could still affect the results. Even after we adjusted for certain factors, we could not fully remove these effects. Second, this was a single-center study using past patients as controls. The sample size was small, so we could not use more complex statistical methods, like propensity score matching. Third, because the findings come from only one center, they may not apply to other hospitals. Other places may have different medical resources, different levels of surgical experience, or different standard perioperative care pathways.

CONCLUSION

This study gives early evidence that supports using a standard ERAS plan for closing enterostomies in children, as long as the clinical setting is similar. Future multicenter, randomized controlled trials with longer follow-up are needed to confirm these results. Those larger trials could help us build age-specific, evidence-based ERAS guidelines for children, and improve perioperative care for pediatric enterostomy closure.