Application of enhanced recovery after surgery in perioperative care of infants and children with Hirschsprung disease

Table 1 Inclusion and exclusion criteria

Inclusion criteria

Exclusion criteria

(1) Age less than 6 years old; (2) Diagnosis of HD according to the guidelines of the American Pediatric Surgical Association Hirschsprung Disease Interest Group[21], based on full-thickness biopsy findings of the absence of mucosal and submucosal ganglion cells away from the dentate line; (3) Pathological type includes only common type; (4) Barium enema showing significant dilation of the rectosigmoid colon and the existence of a stricture segment, and intraoperative findings showing obvious thickening of the dilated colon and dark red or purple in color; (5) Anorectal manometry stimulated by balloon inflation showing absence of the anorectal inhibitory reflex; (6) Characteristic clinical manifestations, including intractable constipation, abdominal distension, and delayed fecal discharge; and (7) Treatment with the Soave procedure via the laparoscope

(1) Systemic comorbidities, such as congenital heart disease, nephrotic syndrome, glomerulonephritis, pneumonia, and severe liver insufficiency; (2) Serious infection or blood or immune system diseases; (3) Severe hypoproteinemia, anemia, or inadequate remission after treatment; and (4) Refusal to participate in the ERAS study by the parents

HD: Hirschsprung disease; ERAS: Enhanced recovery after surgery.

Table 2 Basic data of infants and children with Hirschsprung disease in the enhanced recovery after surgery and control groups

Item	ERAS (n = 20)	Control (n = 18)	χ2/t	P value
Age1, years	3.45 ± 1.60	3.05 ± 1.32	0.832	0.416
Sex, male/female	13/7	10/8	0.344	0.557
Weight1, kg	14.1 ± 2.6	15.9 ± 2.9	-1.939	0.060
Height1, m	1.06 ± 0.13	1.08 ± 0.12	-0.475	0.638
BMI1, kg/m2	12.88 ± 3.03	14.17 ± 4.44	-1.058	0.297
Colon dilation and spasm, n (%)	14 (70.0)	14 (77.8)	0.288	0.592
Rectoanal inhibitory reflex, n (%)	12 (60.0)	13 (72.2)	0.612	0.434
Ganglion cell loss	19 (95.0)	16 (88.9)	0.474	0.491

¹Independent-samples t-test was used for age, weight, height, and body mass index. χ²-test was used for the other variables. There were no statistically significant differences in these observation items between the enhanced recovery after surgery and control groups.

BMI: Body mass index; ERAS: Enhanced recovery after surgery.

Table 3 Compliance with treatment protocols in the enhanced recovery after surgery and control groups, n (%)

Protocol elements	Key, control group	Control group (n = 18)	Key, ERAS group	ERAS group (n = 20)
Preoperative education	Routine	18 (100.0)	20 (100.0)
Preoperative backflow bowel cleansing	10-14 days	17 (94.4)	7-10 days	19 (95.0)
Preoperative fasting	24 hours	18 (100.0)	8 hours	20 (100.0)
Preoperative fasting time for drinking	6 hours	16 (88.9)	2 hours	18 (90.0)
Colonic catheter after the last bowel cleansing	Pulled-up	17 (94.4)	Indwelled	17 (85.0)
Anesthesia	General anesthesia	16 (88.9)	Combined with sacral block anesthesia	20 (100.0)
Perioperative warming	Room temperature	15 (83.3)	Approximately 32 °C	19 (95.0)
Urethral, orogastric and anal canal drainage catheters	Routinely placed	18 (100.0)	Only anal canal drainage catheters to be placed	18 (90.0)
Infusion replenishment strategy	Empirical infusion replenishment strategy in accordance with requirements	16 (88.9)	Target-oriented volume-limiting replenishment strategy	20 (100.0)
Postoperative analgesia	Pumped opiate analgesics	14 (77.8)	Oral nonsteroidal analgesics	18 (90.0)
Postoperative nutrition	Fasting and intravenous infusion for 5-7 days followed by regular diet until intestinal function recovery	16 (88.9)	Intravenous infusion for 3 days with appropriate diet transition	20 (100.0)
Early activity management	Bedrest for at least 1 day	16 (88.9)	Suitable exercise on day 1	20 (100.0)

Count data in the enhanced recovery after surgery and control groups are expressed as number (percentage) of infants who complied with the respective treatment protocols. ERAS: Enhanced recovery after surgery.

Table 4 Differences in postoperative outcomes between the enhanced recovery after surgery and control groups

Outcome	ERAS (n = 20)	Control (n = 18)	t	P value	Power
Pain score at awakening	4.2 ± 1.3	5.2 ± 1.2	-2.516	0.017	0.671
Pain duration, hours	85.7 ± 7.5	67.0 ± 8.6	7.184	< 0.001	1.000
Fever duration, hours	40.7 ± 14.4	52.6 ± 18.7	-2.211	0.034	0.563
Bowel sound recurrence time, hours	33.6 ± 9.8	44.7 ± 16.9	-2.501	0.017	0.654
Regular diet time, hours	36.6 ± 9.6	49.4 ± 17.0	-2.884	0.007	0.775
Catheter indwelling time, hours	75.8 ± 13.8	93.4 ± 20.6	-3.104	0.004	0.842
Length of hospital stay, days	7.5 ± 0.9	8.3 ± 1.2	-2.400	0.022	0.609
Cost, yuan	14203 ± 2381	16847 ± 3558	-17.413	< 0.001	0.732
Satisfaction, %	96.1 ± 2.6	93.8 ± 3.4	2.338	0.025	0.616

All postoperative outcomes differed significantly between the two groups. In the enhanced recovery after surgery group, family satisfaction was higher, but other outcomes were lower. This indicates that the enhanced recovery after surgery protocol was helpful in improving perioperative recovery and postoperative outcomes in infants and children with Hirschsprung disease. ERAS: Enhanced recovery after surgery.