Perioperative management based on the enhanced recovery after surgery concept in elderly patients undergoing laparoscopic common bile duct exploration plus laparoscopic cholecystectomy

Abstract

BACKGROUND

Choledocholithiasis is highly prevalent among the elderly, with laparoscopic common bile duct exploration (LCBDE) plus laparoscopic cholecystectomy (LC) serving as a key minimally invasive treatment. However, elderly patients often face increased surgical risks and prolonged recovery due to reduced physiological reserve and comorbidities. The enhanced recovery after surgery (ERAS) protocol has proven effective in optimizing perioperative outcomes across multiple surgical disciplines, yet its specific application in elderly patients undergoing LCBDE + LC remains insufficiently studied. This study therefore aims to evaluate the impact of ERAS-based perioperative management on recovery, complications, and overall outcomes in this vulnerable surgical population.

AIM

To explore the application value of perioperative management based on the ERAS concept in elderly patients undergoing LCBDE combined with LC.

METHODS

Elderly patients with choledocholithiasis who underwent LCBDE + LC in our hospital from April 2023 to April 2024 were selected. Using a random number table method, a statistician not involved in the study implementation generated a random number sequence using SPSS 27.0 software, which was placed in sealed, opaque envelopes. Upon enrollment, patients opened the envelopes in sequence and were assigned to either the ERAS group or the control group based on the enclosed number, with 40 cases in each group. The control group received conventional perioperative management, while the ERAS group received perioperative management based on the ERAS concept. Comparisons were made between the two groups regarding gastrointestinal function recovery indicators (time to first flatus, total intravenous fluid volume, time to first defecation, time to bowel sound recovery), inflammatory factor levels (high-sensitivity C-reactive protein, interleukin-6, tumor necrosis factor-α), pain status (Visual Analog Scale score, pain duration), complication rate, length of hospital stay, hospitalization costs, readmission rate, quality of life (Short Form-36 Health Survey), and satisfaction.

RESULTS

On postoperative day 3, high-sensitivity C-reactive protein (73.37 ± 8.73 mg/L), interleukin-6 (41.29 ± 4.74 pg/mL), tumor necrosis factor-α (0.75 ± 0.12 pg/mL), Visual Analog Scale score, and pain duration in the ERAS group were lower than those in the control group (P < 0.05). The ERAS group also showed shorter times to first flatus (38.56 ± 4.65 hours), bowel sound recovery (21.95 ± 3.22 hours), and first defecation (2.75 ± 0.63 days), lower total intravenous fluid volume (6.54 ± 0.57 L), lower overall complication rate (5.00%), lower readmission rate (2.50%), shorter hospital stay (9.25 ± 0.71 days), and lower hospitalization costs (2.51 ± 0.77 ten thousand CNY) compared to the control group. Furthermore, Short Form-36 Health Survey scores across all dimensions and satisfaction rate (95.00%) were higher in the ERAS group than in the control group (P < 0.05).

CONCLUSION

Perioperative management based on the ERAS concept can promote gastrointestinal recovery, reduce inflammation levels, improve pain status, lower complication rates, decrease hospitalization costs and readmission rates, and enhance quality of life and satisfaction in elderly patients with choledocholithiasis after LCBDE + LC.

Key Words: Enhanced recovery after surgery; Perioperative management; Elderly patients; Laparoscopic common bile duct exploration; Laparoscopic cholecystectomy

Core Tip: In elderly patients undergoing laparoscopic common bile duct exploration combined with cholecystectomy, perioperative management guided by the enhanced recovery after surgery concept significantly enhances recovery by accelerating gastrointestinal function, reducing inflammation and pain, lowering complication and readmission rates, shortening hospital stay, decreasing costs, and improving overall quality of life and satisfaction.

INTRODUCTION

Common bile duct stones are one of the common biliary diseases in general surgery. With the advancement of laparoscopic technology and endoscopic equipment, the treatment of biliary stones has achieved good therapeutic effects[1]. Laparoscopic common bile duct exploration (LCBDE) combined with laparoscopic cholecystectomy (LC) is one of the main minimally invasive treatment methods for common bile duct stones. Compared with other treatment methods for biliary stones, LCBDE has the advantages of preserving the function of Oddi’s sphincter, increasing the success rate of stone expulsion, and reducing the incidence of complications[2]. However, elderly patients generally have reduced tolerance for surgery, and often have multiple comorbidities, significantly increasing the risk of postoperative complications, thereby affecting the postoperative rehabilitation effect[3]. Therefore, optimizing the perioperative management of LCBDE + LC is particularly important for elderly patients. The concept of enhanced recovery after surgery (ERAS) refers to the adoption of a series of evidence-based optimization measures during the perioperative period to alleviate the surgical stress response of patients and promote their rapid recovery[4]. Lee et al[5] noted that traditional care for gastric cancer patients undergoing gastrectomy resulted in pain scores at 48 hours postoperatively and scores for time to oral intake-nausea-vomiting-examination-symptoms duration that were approximately 3 times and 1.5 times higher, respectively, compared to the ERAS group (P < 0.001). Madan et al[6] also reported in a study on patients undergoing stoma reversal surgery that compared to the standard care group, the ERAS group had significantly earlier times to resolution of ileus symptoms and first defecation (P < 0.001) and a significantly lower surgical site infection rate (P = 0.030). It can be seen that the perioperative management plan based on the ERAS concept has achieved significant therapeutic effects in the fields of gastrointestinal surgery and other surgeries. Therefore, this study designs a prospective randomized trial to compare the baseline data and postoperative recovery indicators of patients in the control group and the ERAS group, aiming to explore the application value of the ERAS-based perioperative management in LCBDE + LC for elderly patients.

MATERIALS AND METHODS

Study design

Patients aged over 60 years who underwent LCBDE + LC surgery in our hospital from April 2023 to April 2024 were selected. Using the random number table method, the statistical personnel who were not involved in the study implementation used SPSS 27.0 software to generate a random number sequence and load it into a sealed opaque envelope. When patients were enrolled, the envelopes were opened in sequence, and they were assigned to the ERAS group or the control group according to the internal numbered allocation, with 40 cases in each group. There was no statistically significant difference in the general data between the two groups (P > 0.05), as shown in Table 1. Inclusion criteria: (1) Confirmed by magnetic resonance cholangiopancreatography or ultrasound imaging[7]; (2) History of upper abdominal pain; (3) No abnormal coagulation function; (4) Signed the informed consent form; and (5) Age ≥ 60 years. Exclusion criteria: (1) Any contraindications for endoscopic procedures; (2) Immune system diseases or malignant tumors; (3) Acute severe pancreatitis, severe cholangitis or intestinal obstruction; (4) History of liver abscess or liver cirrhosis; (5) Repeated upper abdominal surgeries; and (6) Complicated with cholecystitis abscess, necrotizing suppurative cholecystitis or gallbladder perforation. This study is a single-center, small-sample-size exploratory study, aiming to preliminarily evaluate the application effect of the ERAS protocol in elderly patients undergoing LCBDE + LC. It is not a confirmatory clinical trial. According to the Institutional Ethics Committee and relevant registration guidelines, such studies are not required to be registered by law. The registration will be completed in subsequent studies.

Table 1 Comparison of general characteristics between the two groups, n (%)/mean ± SD.

Indicator	Gender		Age (years)	Number of CBD stones	CBD diameter (mm)	Chronic comorbidities	Previous abdominal surgery
	Male	Female
Control group (n = 40)	19 (47.50)	21 (52.50)	67.47 ± 6.28	2.41 ± 0.28	8.89 ± 1.78	18 (45.00)	4 (10.00)
ERAS group (n = 40)	21 (52.50)	19 (47.50)	66.47 ± 4.89	2.39 ± 0.37	9.15 ± 4.13	21 (52.50)	2 (5.00)
t/χ2	0.200		0.0001	0.2711	0.3651	0.4502	0.7212
P value	0.823		1.000	0.787	0.716	0.655	0.675

¹t-test.

²χ² test.

CBD: Common bile duct; ERAS: Enhanced recovery after surgery.

Sample size calculation[8]: Based on preliminary pilot results and relevant literature data[9], considering this study involves elderly patients who may have relatively longer hospital stays, the estimated postoperative hospital stay for the control group was about 11.2 ± 0.8 days. Assuming the ERAS group’s postoperative stay is shortened by more than 15% (mean 9.2 days) with similar standard deviations. Setting a two-sided test level α = 0.05 and power (1 - β) = 0.80. Using PASS 15.0 software (or the formula for comparing means between two independent samples), the calculated minimum sample size per group was 34 cases. Considering a 20% dropout rate, 40 cases per group were finally determined, totaling 80 cases.

Methods

LCBDE + LC surgical procedure: All patients underwent LCBDE + LC. After establishing the pneumoperitoneum using the standard four-hole method (with the pressure maintained at 12-14 mmHg), the physicians proceeded to dissect the gallbladder triangle and close (without disconnecting) the cystic duct, exposing the common bile duct. Once the location was confirmed, a disposable infusion set needle was used for puncture and drainage of bile to verify the structure. Subsequently, an electric coagulation hook was used to longitudinally incise the puncture point and suction out the bile. Then, an electronic cholangioscope was inserted through the incision, and the intrahepatic and extrahepatic bile ducts were comprehensively explored and the stone distribution was determined. Subsequently, a stone removal basket was used to remove the stones; if there was a lodged stone, it was first treated with laser lithotripsy, and then the fragments were removed in multiple sessions. After the stone removal was completed, a T-tube was routinely left in place, and LC was performed simultaneously. Then, a silicone drainage tube was routinely placed at the Wirsung’s foramen, allowing it and the T-tube to be led out of the body separately through the upper abdominal access hole. Finally, after confirming no leakage by pressurized water injection, the abdominal closure operation was completed.

Perioperative management: ERAS group: (1) Before the operation, a personalized health education manual was developed for the patients, systematically explaining the disease mechanism, treatment plan and surgical risks to alleviate preoperative anxiety; (2) 6 hours of fasting before the operation, 5% glucose solution 500 mL was orally administered 2 hours before the operation, and gastric tubes were not routinely inserted; (3) During the operation, drainage tubes were placed as needed, and if placed, they were removed within 24 hours after the operation; (4) During the operation, temperature protection measures were adopted to maintain the patient’s intraoperative body temperature at around 37 °C; (5) During the operation, thoracic nerve block was implemented to reduce the use of opioid drugs and maintain the appropriate temperature and humidity in the operating room. The liquid was heated to 37 °C, and the fluid volume was controlled at 500-1000 mL and the rate was adjusted according to blood pressure; (6) The urinary catheter was removed 24 hours after the operation; (7) Adopt a multimodal analgesic strategy mainly consisting of regional block and local anesthesia; and (8) Encourage patients to start bed rest and early ambulation on the day after surgery, resume drinking water 6 hours after surgery, start liquid food 12 hours later, and gradually resume normal diet 24 hours later.

Control group: (1) Only routine health education was provided before surgery; (2) Complete fasting and water restriction were imposed 12 hours before surgery; (3) Gastric tubes were routinely placed until post-exhaustion and then removed; (4) Routine placement of drainage tubes during surgery and removal when the drainage fluid disappeared; (5) No special temperature management was implemented; (6) Urinary catheters were removed 2-3 days after surgery; (7) Pain control mainly relied on intermittent use of opioid drugs; (8) Patients voluntarily decided the time for ambulation based on their own recovery conditions; and (9) Eating and drinking began after exhaust and defecation.

Observation indicators

Inflammatory level: A total of 3 mL of venous blood samples were collected from the patients before the operation and 3 days after the operation under fasting conditions. The samples were centrifuged at 3000 rpm/minute for 5 minutes and the upper clear liquid was collected. The levels of high-sensitivity C-reactive protein (hs-CRP), interleukin-6 (IL-6), and tumor necrosis factor-α (TNF-α) were determined using the enzyme-linked immunosorbent assay. The reagents were purchased from Wuhan Doctorde Biotechnology. All operations were carried out in accordance with the instructions of the reagents.

Pain status: The Visual Analog Scale (VAS)[10] was used to assess pain intensity preoperatively and on postoperative day 3. The VAS total score ranges from 0-10, with higher scores indicating greater pain. The intraclass correlation coefficient for VAS was 0.99 (95% confidence interval: 0.989-0.992). Postoperative pain duration was also recorded.

Quality of life: The 36-item Short Form Health Survey[11], covering eight aspects including mental health and physical role, was used to assess patients preoperatively and on postoperative day 3. Each aspect contains 2-10 items, scored 0-100, with higher scores indicating better quality of life. The Cronbach’s α coefficient for this scale was 0.791.

Satisfaction: The satisfaction was evaluated using a self-made questionnaire of our hospital. The score ranged from 0 to 100, with very satisfied > 90 points, relatively satisfied 80-90 points, generally satisfied 70-80 points, and dissatisfied < 70 points. The total satisfaction = very satisfied + relatively satisfied + generally satisfied. The Cronbach’s α coefficient of this questionnaire was 0.864.

Gastrointestinal function, hospital stay, etc. indicators: The time of anal exhaust after the operation, total fluid intake, defecation time, recovery time of bowel sounds, hospital stay, hospital expenses, 30-day readmission rate, and the occurrence of complications such as bile leakage, urinary retention, and abdominal distension were recorded for all patients.

Statistical analysis

Data were statistically analyzed using SPSS 27.0. Continuous variables were first tested for normality using the Shapiro-Wilk test. Normally distributed measurement data were expressed as mean ± SD. Intra-group comparisons used paired sample t-tests; inter-group comparisons used independent samples t-tests. Count data were expressed as n (%) and analyzed using χ² test or Fisher’s exact test. This study involved a total of 8 main outcome indicators. To control the cumulative risk of type I errors, the Bonferroni method was used for correction. The post-correction significance level was set as α’ = 0.00625 (0.05/8). A P value < 0.05 was considered statistically significant.

RESULTS

Comparison of gastrointestinal function recovery indicators between groups

The ERAS group showed significantly better outcomes than the control group in time to first flatus (38.56 ± 4.65 hours), time to bowel sound recovery (21.95 ± 3.22 hours), time to first defecation (2.75 ± 0.63 days), and total intravenous fluid volume (6.54 ± 0.57 L) (P < 0.05), as shown in Table 2.

Table 2 Comparison of gastrointestinal function recovery indicators between groups, mean ± SD.

Group	Time to first flatus (hours)	Time to bowel sound recovery (hours)	Time to first defecation (days)	Total IV fluid volume (L)
Control group (n = 40)	48.52 ± 6.64	34.89 ± 4.36	3.83 ± 0.64	8.87 ± 0.85
ERAS group (n = 40)	38.56 ± 4.65	21.95 ± 3.22	2.75 ± 0.63	6.54 ± 0.57
t	7.772	15.107	7.592	14.402
P value	0.000	0.000	0.000	0.000

ERAS: Enhanced recovery after surgery.

Comparison of inflammatory factor levels between groups

On postoperative day 3, the levels of hs-CRP (73.37 ± 8.73 mg/L), IL-6 (41.29 ± 4.74 pg/mL), and TNF-α (0.75 ± 0.12 pg/mL) in the ERAS group were lower than those in the control group (P < 0.05), as shown in Table 3.

Table 3 Comparison of inflammatory factor levels between groups, mean ± SD.

Group	hs-CRP (mg/L)		IL-6 (pg/mL)		TNF-α (pg/mL)
	Preop	Postop 3 days	Preop	Postop 3 days	Preop	Postop 3 days
Control group (n = 40)	132.90 ± 14.35	79.29 ± 9.56a	93.29 ± 8.55	47.68 ± 4.66a	2.45 ± 0.47	0.96 ± 0.14a
ERAS group (n = 40)	128.89 ± 13.94	73.37 ± 8.73a	94.29 ± 9.57	41.29 ± 4.74a	2.56 ± 0.78	0.75 ± 0.12a
t	1.268	2.897	0.493	6.074	0.824	7.341
P value	0.209	0.005	0.623	0.000	0.412	0.000

^aP < 0.05 compared with preoperative level in the same group.

hs-CRP: High-sensitivity C-reactive protein; IL-6: Interleukin-6; TNF-α: Tumor necrosis factor-α; ERAS: Enhanced recovery after surgery.

Comparison of pain status between groups

On postoperative day 3, the VAS score in the ERAS group (2.13 ± 0.46 score) was lower than that in the control group (P < 0.05). The postoperative pain duration in the ERAS group (14.73 ± 2.17 hours) was also shorter than that in the control group (P < 0.05), as shown in Table 4.

Table 4 Comparison of pain status between groups, mean ± SD.

Group	Preop VAS score (score)	Postop 3 days VAS score (score)	Postop pain duration (hours)
Control group (n = 40)	6.13 ± 1.11	4.23 ± 0.86a	20.13 ± 2.87
ERAS group (n = 40)	5.98 ± 1.14	2.13 ± 0.46a	14.73 ± 2.17
t	0.594	13.572	9.494
P value	0.554	0.000	0.000

^aP < 0.05 compared with preoperative level in the same group.

VAS: Visual Analog Scale; ERAS: Enhanced recovery after surgery.

Comparison of complication rates between groups

The total complication rate in the ERAS group (5.00%) was significantly lower than that in the control group (P < 0.05), as shown in Table 5.

Table 5 Comparison of complication rates between groups, n (%).

Group	Nausea/vomiting	Electrolyte imbalance	Bile leak	Deep venous thrombosis	Urinary retention	Abdominal distension	Total
Control group (n = 40)	3 (7.50)	1 (2.50)	2 (5.00)	1 (2.50)	1 (2.50)	3 (7.50)	11 (27.50)
ERAS group (n = 40)	1 (2.50)	1 (2.50)	0 (0.00)	0 (0.00)	0 (0.00)	0 (0.00)	2 (5.00)
χ2							7.440
P value							0.013

ERAS: Enhanced recovery after surgery.

Comparison of hospital stay, hospitalization costs, and readmission rate between groups

The ERAS group had a lower 30-day readmission rate (2.00%), shorter hospital stay (9.25 ± 0.71 days), and lower hospitalization costs (2.51 ± 0.77 ten thousand CNY) compared to the control group (P < 0.05), as shown in Table 6.

Table 6 Comparison of hospital stay, hospitalization costs, and readmission rate between groups, n (%)/mean ± SD.

Group	30-day readmission rate	Hospital stay (days)	Hospitalization costs (ten thousand CNY)
Control group (n = 40)	8 (20.00)	11.25 ± 0.84	3.27 ± 0.45
ERAS group (n = 40)	1 (2.50)	9.25 ± 0.71	2.51 ± 0.77
t/χ2	6.1352	11.5221	5.3491
P value	0.029	0.000	0.000

¹t-test.

²χ² test.

ERAS: Enhanced recovery after surgery.

Comparison of quality of life between groups

On postoperative day 3, scores in the ERAS group for mental health (82.95 ± 8.35), role-emotional (82.23 ± 7.34), social functioning (82.23 ± 8.75), vitality (84.23 ± 7.49), general health (82.23 ± 8.46), bodily pain (80.23 ± 8.55), physical functioning (82.23 ± 8.25), and role-physical (82.63 ± 8.45) were all higher than those in the control group (P < 0.05), as shown in Table 7.

Table 7 Comparison of quality of life between groups (mean ± SD, score).

Group	Control group (n = 40)	ERAS group (n = 40)	t	P value
Mental health
Preop	62.23 ± 6.45	62.33 ± 6.56	0.069	0.945
Postop 3 days	72.63 ± 8.05a	82.95 ± 8.34a	5.632	0.000
Role-emotional
Preop	61.45 ± 6.56	61.55 ± 6.85	0.067	0.947
Postop 3 days	72.22 ± 7.97a	82.23 ± 7.34a	5.839	0.000
Social functioning
Preop	63.53 ± 6.35	63.75 ± 6.34	0.159	0.874
Postop 3 days	72.22 ± 7.45a	82.23 ± 8.75a	5.503	0.000
Vitality
Preop	65.23 ± 6.63	64.88 ± 6.57	0.237	0.813
Postop 3 days	73.23 ± 7.25a	84.23 ± 7.49a	6.675	0.000
General health
Preop	62.65 ± 5.45	62.23 ± 6.76	0.310	0.758
Postop 3 days	72.45 ± 7.05a	82.23 ± 8.46a	5.616	0.000
Bodily pain
Preop	61.88 ± 6.06	62.65 ± 6.15	0.568	0.572
Postop 3 days	71.25 ± 7.93a	80.23 ± 8.55a	4.868	0.000
Physical functioning
Preop	60.55 ± 6.28	60.23 ± 6.95	0.219	0.827
Postop 3 days	72.83 ± 7.44a	82.23 ± 8.25a	5.351	0.000
Role-physical
Preop	61.23 ± 6.53	62.38 ± 6.05	0.817	0.417
Postop 3 days	71.23 ± 7.35a	82.63 ± 8.45a	6.440	0.000

^aP < 0.05 compared with preoperative level in the same group.

ERAS: Enhanced recovery after surgery.

Comparison of satisfaction between groups

The total satisfaction rate in the ERAS group (95.00%) was higher than that in the control group (P < 0.05), as shown in Table 8.

Table 8 Comparison of satisfaction between groups, n (%).

Group	Very satisfied	Satisfied	Generally satisfied	Dissatisfied	Total satisfaction
Control group (n = 40)	18 (45.00)	6 (15.00)	4 (10.00)	12 (30.00)	28 (70.00)
ERAS group (n = 40)	25 (62.50)	7 (17.50)	6 (15.00)	2 (5.00)	38 (95.00)
χ2					8.658
P value					0.006

ERAS: Enhanced recovery after surgery.

DISCUSSION

The ERAS concept refers to taking optimization measures during the perioperative period of patients to reduce the traumatic stress response caused by surgery, lower the occurrence of complications, and thereby promote the rapid recovery of all organs in the body[12]. Turaga[13] pointed out that the ERAS concept can effectively improve the prognosis of patients after colorectal surgery. This indicates that its application value in clinical practice is good. Relevant data show that the incidence of common bile duct stones in people over 70 years old can be as high as 30%[14]. Therefore, the disease burden of common bile duct stones in the elderly is gradually increasing. LCBDE + LC is a surgical method with many advantages for treating common bile duct stones and performs well in clinical practice[15]. However, elderly patients have weakened bodies and limited organ compensatory capacity, significantly increasing their perioperative risks. Although the ERAS concept has achieved remarkable results in multiple fields of general surgery, its application in LCBDE + LC for elderly patients still lacks systematic research. Therefore, this study aims to systematically explore the application value of the perioperative management plan based on the ERAS concept in LCBDE + LC for elderly patients, in order to provide reference for clinical practice.

The results of this study show that the levels of gastrointestinal function recovery indicators in the ERAS group patients were all lower than those in the control group. This indicates that perioperative management based on the ERAS concept can significantly promote gastrointestinal recovery in elderly choledocholithiasis patients after LCBDE + LC. The main reasons may be as follows: For elderly patients treated with LCBDE + LC therapy, the routine preoperative fasting and water deprivation time is 12 hours. Long-term fasting can easily increase the risk of hypoglycemia and postoperative stress response in elderly patients. In the ERAS group, patients orally take 500 mL of 5% glucose solution before surgery, which can effectively relieve their preoperative hunger state, thereby reducing the metabolic disorders such as insulin resistance in patients after surgery, and helping the body maintain a stable internal environment[16]. In this study, the ERAS group uses local anesthetics at the incision site and does not use opioid analgesics after surgery, which can avoid the binding of opioid drugs to the μ receptors in the gastrointestinal tract, strongly inhibiting the excitability of the intestinal plexus and the peristalsis of the intestinal smooth muscle, thereby achieving effective pain relief while fundamentally avoiding the direct inhibition of the intestinal interstitial nerve plexus and smooth muscle by opioid drugs[17]. The ERAS group resumes drinking water 6 hours after surgery and resumes eating 24-36 hours after surgery, enabling ERAS group patients to eat earlier, thereby promoting gastrointestinal peristalsis, accelerating gas and stool expulsion. Wangjian et al[18] showed that ERAS significantly reduced patients’ postoperative time to first defecation and first oral intake (P < 0.001), consistent with this study’s results, further confirming our findings.

The levels of hs-CRP, IL-6, TNF-α, VAS score and pain duration of patients in the ERAS group at 3 days after surgery were all lower than those in the control group. This confirmed that the perioperative management based on the ERAS concept could effectively reduce the inflammatory state and pain condition of elderly patients undergoing LCBDE + LC for common bile duct stones. Long-term fasting leads to depletion of liver glycogen, increased fat breakdown, and induces insulin resistance and hyperglycemic state, which further activates the nuclear factor-kappa B pathway and promotes the release of inflammatory factors such as IL-6 and TNF-α; patients in the ERAS group could maintain liver glycogen reserves through preoperative glucose supplementation, thereby alleviating the metabolic disorders caused by the surgery and reducing the expression and release of inflammatory factors[19,20]. At the same time, maintaining the patient’s body temperature at around 37 °C during the operation, controlling the fluid infusion volume and adjusting the speed according to blood pressure, could further reduce the cardiopulmonary burden of elderly patients with common bile duct stones, maintain the internal environment stability, and lower the levels of acute-phase response proteins such as hs-CRP[21]; the reduction of inflammatory mediators such as hs-CRP, IL-6, and TNF-α directly alleviated the stimulation of nerve endings and the production of pain-causing substances, and from the root, reduced pain and shortened the duration of pain[22].

Further analysis revealed that the total incidence of complications in the ERAS group was lower than that in the control group, indicating that the study protocol could reduce the risk of postoperative complications in elderly patients undergoing LCBDE + LC, and demonstrated good safety. The main reason for this might be that the ERAS group encouraged patients to start bed rest and early ambulation on the day after surgery, which helped promote venous return, reduce blood stasis, and prevent thrombosis[23]. Removing the catheter within a short period of time could reduce external infections and reduce the loss of electrolytes and body fluids, as well as minimize the stimulation of the external environment on the body[24]. The early drinking and eating after surgery in the ERAS group enabled patients to promptly replenish water and electrolytes, which was helpful in maintaining the stability of the internal environment; avoiding the routine use of gastric tubes reduced mechanical stimulation to the gastrointestinal tract and protected the normal peristalsis function of the gastrointestinal tract[4]. Li et al[25] suggested that improved pain control is associated with reduced risks of impaired wound healing, infectious complications, delirium occurrence, delayed mobilization recovery, and prolonged hospital stay. The significantly lower VAS scores in the ERAS group patients in this study further confirm that this protocol can effectively reduce complication risks in elderly patients.

In addition, the hospitalization time, hospitalization costs, and re-hospitalization rate of patients in the ERAS group were significantly lower than those in the control group, indicating that the perioperative management model based on the ERAS concept is a more efficient and economical management approach. Yu et al[26] pointed out that anxiety and fear experienced by elderly patients during the perioperative period may adversely affect physiological indicators like heart rate and blood pressure, as well as treatment efficacy and postoperative recovery. The ERAS group actively promoted ERAS-related knowledge to patients and their families before the surgery, provided detailed education and psychological counseling to patients, which alleviated patients’ anxiety and fear about the surgery, thereby improving patients’ cooperation and compliance, facilitating the smooth implementation of this research plan, and significantly promoting the recovery of patients[27]. The ERAS group avoided the use of analgesic pumps, intravenous non-steroidal drugs, and opioid drugs, directly reducing the costs of these medications for patients; by reducing the incidence of complications, avoiding additional expenses incurred from handling these complications, and lowering the risk of re-hospitalization due to complications[28]. The rapid recovery of the gastrointestinal tract, significant improvement of the inflammatory state, and reduction of pain in patients of the ERAS group further enhanced the quality of life and nursing satisfaction of patients. Bansal et al[29] indicated that postoperative accelerated recovery protocols can shorten hospital stays, reduce overall medical costs, and lower surgical complication rates, similar to this study’s findings, further confirming the reliability of this study’s protocol. Li et al[4] analyzed ERAS patients who underwent LCBDE and found that the ERAS protocol significantly shortened the postoperative hospital stay and reduced the complication rate. Zhang et al[30] pointed out that the ERAS protocol can reduce the stress response of patients after LC combined with LCBDE surgery, reduce complications, and accelerate recovery. Compared with the above studies, this study adopted a prospective randomized controlled design, effectively controlled confounding bias, specifically focused on elderly patients, and supplemented patient-reported outcome indicators such as quality of life (36-item Short Form Health Survey) and satisfaction. Together with previous studies, it supported the clinical value of promoting the ERAS concept in the LCBDE + LC surgical approach.

CONCLUSION

In summary, perioperative management based on the ERAS concept can promote gastrointestinal recovery, reduce inflammation levels, improve pain status, lower complication rates, decrease hospitalization costs and readmission rates, and enhance quality of life and nursing satisfaction in elderly patients with choledocholithiasis after LCBDE + LC. However, this study has several limitations: The sample size is relatively small, the long-term effect of the ERAS protocol has not been evaluated, the implementation status of various measures by patients has not been recorded, and the potential impact of protocol compliance on the therapeutic effect cannot be assessed; the effect size has not been reported, making the clinical significance of some statistically significant results less intuitive. Future studies should adopt a large sample, multi-center design, extend the follow-up period, include compliance assessment tools, and routinely report the effect size to further verify.