Journal of Pediatric Surgery 56 (2021) 115–120

Contents lists available at ScienceDirect

Journal of Pediatric Surgery

journal homepage: www.elsevier.com/locate/jpedsurg

An enhanced recovery after surgery pathway in pediatric colorectal

surgery improves patient outcomes☆
Laura N. Purcell a, Kathleen Marulanda a, Matthew Egberg b, Sabrina Mangat c, Christopher McCauley c,
Nicole Chaumont a, Timothy S. Sadiq a, Concetta Lupa d, Peggy McNaull d, Sean E. McLean a,
Andrea Hayes-Jordan a, Michael R. Phillips a,⁎
a
Department of Surgery, University of North Carolina at Chapel Hill, NC
b
Department of Pediatrics, University of North Carolina at Chapel Hill, NC
c
College of Medicine, University of North Carolina at Chapel Hill, NC
d
Department of Anesthesiology, University of North Carolina at Chapel Hill, NC

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Enhanced recovery after surgery (ERAS) pathways in adult colorectal surgery are known to reduce
Received 13 September 2020 complications, readmissions, and length of stay (LOS). However, there is a paucity of ERAS data for pediatric co-
Accepted 22 September 2020 lorectal surgery.
Methods: A 2014–2018 single-institution, retrospective cohort study was performed on pediatric colorectal sur-
Key words:
gery patients (2–18 years) pre- and post-ERAS pathway implementation. Bivariate analysis and linear regression
ERAS
were used to determine if ERAS pathway implementation reduced total morphine milligram equivalents per ki-
Pediatric surgery
Enhanced recovery
logram (MME/kg), LOS, and time to oral intake.
ERAS in colorectal surgery Results: 98 (70.5%) and 41 (29.5%) patients were managed with ERAS and non-ERAS pathways, respectively.
There was no statistical difference in age, sex, diagnosis, or use of laparoscopic technique between cohorts. The
ERAS cohort experienced a significant reduction in total MME/kg, Foley duration, time to oral intake, and LOS
with no increase in complications. The presence of an ERAS pathway reduced the total MME/kg (−0.071, 95%
CI −0.10, −0.043) when controlling for covariates.
Conclusion: The use of an ERAS pathway reduces opioid utilization, which is associated with a reduction in LOS
and expedites the initiation of oral intake, in colorectal pediatric surgery patients. Pediatric ERAS pathways should
be incorporated into the care of pediatric patients undergoing colorectal surgery.
Level of evidence: Level III evidence.
Type of study: Retrospective cohort study.
© 2020 Elsevier Inc. All rights reserved.

Enhanced recovery after surgery (ERAS) protocols have been imple- There are existing data regarding the effectiveness of an ERAS protocol
mented to standardize perioperative care to accelerate recovery by at- in adults, and emerging data for the use of ERAS pathways in small series
tenuating the operative stress response in adult surgical patients for of pediatric patients. However, many of the initial studies in the pediat-
specific surgical procedures, particularly colorectal surgery [1]. ERAS ric surgical population are “fast-track” pathways, as the implemented
pathways standardize the preoperative, intraoperative, and postopera- interventions do not meet the 17 core elements standard recommended
tive management of patients for specific surgical procedures. ERAS path- by ERAS USA and the ERAS Society [3]. A recent systematic review of pe-
ways focus on optimizing the patient preoperatively, avoiding fluid diatric gastrointestinal, urology, and thoracic surgery postoperative
shifts by eliminating bowel preparation and intravenous fluid overload, pathways, demonstrated studies averaged less than 5.6 interventions
antibiotic prophylaxis, minimizing opioids with multimodal pain con- per protocol [4].
trol, early enteral nutrition after surgery, and early mobilization [2]. Recently an expert panel used a modified Delphi process to identify 19
components of adult ERAS protocols suitable for use in a pediatric path-
way. The final pathway excluded the recommendation to avoid mechan-
☆ How this paper will improve care: We have shown that a pediatric enhanced recovery
after surgery (ERAS) pathway for open and laparoscopic colorectal surgery has reduced a ical bowel preparation and the use of insulin to control severe
patient’s total morphine milligram equivalents, which was associated with a reduced uri- hyperglycemia [5]. Initial implementation of this pathway has shown a
nary catheter duration and length of hospital stay. decrease in length of stay, lower perioperative opioid use, and faster
⁎ Corresponding author at: UNC School of Medicine, Assistant Professor of Surgery and time to general diet, without an associated increase in complications [5].
Pediatrics, Division of Pediatric Surgery, Physician's Office Building, 170 Manning Drive, CB
#7223, Chapel Hill, NC 27599-7223. Tel.: +1 919 966 4643; fax: +1 919 843 2497.
As there continues to be a lack of data in the pediatric surgery liter-
E-mail address: [email protected] (M.R. Phillips). ature and current published studies have small sample sizes, ERAS

https://doi.org/10.1016/j.jpedsurg.2020.09.028
0022-3468/© 2020 Elsevier Inc. All rights reserved.
L.N. Purcell, K. Marulanda, M. Egberg et al. Journal of Pediatric Surgery 56 (2021) 115–120

pathways for pediatric colorectal surgery require additional study [5]. based on these criteria and resulted in the narrowing of the confidence
Therefore, we evaluated the effect of the implementation of a compre- interval with minimal change in the coefficients.
hensive ERAS pathway in a pediatric surgical population at our institu- In the multivariate linear regression for evaluating the change in
tion. Specifically, we hypothesized that the implementation of an ERAS total MME/kg with ERAS implementation, age, sex, laparoscopic versus
pathway would decrease the length of stay, time to oral intake, and opi- open procedure, preoperative opioid use, and administration of epidural
oid utilization without increasing 30-day complication rates in our pedi- or block were included a priori. ASA physical status classification and
atric colorectal surgery population. procedure category were included in the multivariate linear regression
based on the significant p-value on bivariate analysis. On backward
1. Methods elimination, as previously described, sex, laparoscopic versus open, and
ASA physical status classification were removed to maintain precision
We performed a single-institution, retrospective cohort study from and reduce error.
2014 to 2019 on pediatric patients (≥2 and ≤ 18 years old) undergoing In the multivariate linear regression for evaluating the change in
colorectal surgery before and after implementation of an ERAS pathway, time to oral intake with ERAS, covariates included a priori were age,
covering two plan–do–study–act (PDSA) cycles with various pathway sex, procedure category, laparoscopic surgery, and preoperative and
elements to produce a single synthesized pathway. Patients who postoperative ERAS medications. ASA physical status classification and
underwent surgery at our tertiary hospital with dedicated children's total MME/kg were included based on previously described bivariate
hospital were identified by querying the electronic health records for analysis criteria. On backward elimination, sex and procedure categories
patients ≤ 18 years who underwent common colorectal procedures were removed based on the aforementioned criteria.
using Current Procedural Terminology (CPT) codes of interest (see Ap- This analysis was performed using StataCorp v14.2, College Station,
pendix A). Patients in both cohorts were operated on by eight surgeons, Texas. Confidence intervals are reported at 95%, and alpha was set at
who operated on a minimum of five patients in each cohort. 0.05 for this study. The University of North Carolina Institutional Review
The first ERAS pathway was implemented in September 2015 for Board approved this study and waived informed consent.
both open and laparoscopic, elective inflammatory bowel disease sur-
geries with plan–do–study–act cycles adding additional components 2. Results
throughout its lifespan. The second PDSA cycle increasing the utilization
of multimodal pain medication postoperatively (acetaminophen, Of the 139 patients that met inclusion criteria, 70.5% (n = 98) were
celecoxib, and pregabalin or gabapentin) was implemented in Novem- ERAS patients who underwent colorectal surgery with an ERAS path-
ber 2018. Ultimately, the final ERAS pathway (Appendix B) includes pre- way, and the remaining were classified as ERAS controls (n = 41,
operative patient and guardian education, preoperative carbohydrate 29.5%). There was no statistically significant difference between age,
loading, and early postoperative oral intake. Patients received a single sex, or body mass index between the ERAS patients and control cohorts.
15 mg/kg dose of acetaminophen in the preanesthesia care unit and The ERAS patient and control cohorts were primarily ASA physical status
on induction received the standard age-based induction anesthesia. Be- classification 2 and 3, respectively, p = 0.005. In both the ERAS patient
fore the start of the laparoscopic or open operation, a regional nerve and control cohort, the primary diagnoses were Crohn's disease and ul-
block or epidural catheter was performed, respectively. Standard intra- cerative colitis, p = 0.5, Table 1.
operative fluid management protocols were implemented, which em- There was no difference in preoperative steroid or opioid use be-
phasized goal-directed therapy and zero fluid balance. Finally, early tween the two cohorts. In the preanesthesia care unit, both the ERAS pa-
mobilization is encouraged postoperative day (POD) 0 for morning op- tients and controls were premedicated with acetaminophen (p = 0.6).
erations and POD 1 for afternoon operations, with a physical therapy Patients in the ERAS patient cohort were more likely to be premedicated
consult if ambulation requires more than minimal assistance on POD 1. in the preanesthesia unit with pregabalin or gabapentin (p < 0.001),
For analysis, patients undergoing operations before January 1, 2016, Celebrex (p < 0.001), and Entereg (p = 0.002). The ERAS patient cohort
were categorized as the preintervention ERAS controls, and the remain- primarily underwent ileocecectomy (n = 33, 33.7%) and total abdomi-
ing were categorized as postintervention ERAS patients. The a priori pri- nal colectomy with diverting ostomy (n = 19, 19.4%), while the ERAS
mary endpoints of our analysis were postoperative hospital length of control cohort primarily underwent ileostomy takedown (n = 9,
stay, in-hospital opioid use in morphine milligram equivalents per kilo- 22.0%) and ileocecectomy (n = 7, 17.1%). Between the cohorts, there
gram (MME/kg), and time to oral intake. Univariate analysis was per- was no difference between the number undergoing laparoscopic sur-
formed to assess missing data and the distribution of variables. There gery, receiving an epidural, or the procedure time. Patients in the ERAS
were less than 1% missing data. Bivariate analysis was conducted over patient cohort had lower total perioperative MME used than the ERAS
the preintervention and postintervention ERAS cohorts. The central ten- controls, 0.4 (SD 0.3) versus 0.7 (SD 0.4), p < 0.001, Table 1.
dency was described as means (standard deviations [SD]) and medians The ERAS patients and the control cohorts had no difference in post-
(interquartile range [IQR]) for normally and nonnormally distributed operative acetaminophen (p = 0.5) or Toradol (p = 1.0) use. The ERAS
covariates, respectively. To compare the distribution of exposure across patient cohort was more likely to use pregabalin or gabapentin
demographic variables, χ2 for categorical variables and Student's T-Test (p < 0.001), Celebrex (p < 0.001), and Entereg (p = 0.008) than the
or Kruskal–Wallis for normally and nonnormally distributed continuous control cohort. ERAS patients used less total MME/kg (p < 0.001) over
variables, respectively, were used. Total MME/kg per day was plotted their hospital stay, Fig. 1. ERAS patients had shorter postoperative time
against time. with Foley catheter (p < 0.001), time to oral intake (p < 0.001), and hos-
Multivariate linear regression was used to determine if ERAS path- pital length of stay (p = 0.002). There was no statistical difference in the
way implementation reduced postoperative length of stay, total MME/ number of returns to the emergency room, hospital readmissions, or un-
kg, and time to oral intake. A priori, age, sex, procedure category, planned returned to the operating room within 30 days between the
American Society of Anesthesiologist (ASA) physical status classifica- ERAS patients and control cohorts, Table 1.
tion, and laparoscopic versus open procedure were included in the re- On multivariate linear regression of factors influencing the patient's
gression. Variables significant (p < 0.05) on bivariate analysis were total MME/kg, the presence of the ERAS pathway (− 0.055, 95% CI
included in the multivariate linear regression model, including total − 0.093 – − 0.036, p < 0.001) and increasing age (− 0.0051, 95% CI
MME/kg. Covariates were removed from the model based on a back- −0.010 – −0.0014, p = 0.02) decreased total MME/kg used, Table 2.
ward elimination approach, based on p-value (<0.05), with the goals On multivariate linear regression showing factors assessing the
to maintain precision (narrowing confidence intervals) and reduce length of stay, increasing total MME/kg increased the patient's length
error (<10% change in coefficient). Sex was removed from the model of stay (1035.97, 95% CI 651.07–1420.87, p < 0.001). The presence of

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L.N. Purcell, K. Marulanda, M. Egberg et al. Journal of Pediatric Surgery 56 (2021) 115–120

Table 1
Patient demographics, operative, and postoperative characteristics — comparison of demographic data, and operative and postoperative characteristics in the overall cohort, and our con-
trol patients (pre-enhanced recovery after surgery (ERAS) implementation), and patients managed with a pediatric-specific ERAS pathway.

Overall ERAS Controls p-value

(n = 139) (n = 98, 70.5%) (n = 41, 29.5%)

Age: μ (SD) 14.8 (2.9) 14.7 (3.0) 14.9 (2.4) 0.7

Female sex: n (%) 76 (54.7) 50 (51.0) 26 (63.4) 0.2
Body mass index: median (IQR) 19.7 (17.3–22.3) 18.7 (16.7–21.4) 19.7 (17.7–22.3) 0.2
ASA physical status classification: n (%) 0.005
2 66 (47.5%) 54 (55.1) 12 (29.7)
3 73 (52.5) 44 (44.9) 29 (70.7)
Diagnosis: n (%) 0.5
Crohn's disease 66 (47.5) 47 (48.0) 19 (46.3)
Ulcerative colitis 60 (43.2) 39 (39.8) 21 (51.2)
Hirschsprung disease 5 (3.6) 5 (5.1) 0 (0.0)
Familial adenomatous polyposis 2 (1.4) 2 (2.0) 0 (0.0)
Other 6 (4.3) 5 (5.1) 1 (2.4)
Preoperative steroids: n (%) 34 (24.8) 27 (27.6) 7 (18.0) 0.2
Preoperative opioid use: n (%) 13 (9.4) 7 (7.1) 6 (14.6) 0.2
Preoperative ERAS medications
Acetaminophen: n (%) 93 (66.9) 67 (68.4) 26 (63.4) 0.6
Pregabalin or gabapentin: n (%) 57 (41.0) 53 (54.1) 4 (9.8) <0.001
Celebrex: n (%) 44 (31.7) 44 (44.9) 0 (0.0) <0.001
Entereg: n (%) 20 (14.4) 20 (20.4) 0 (0.0) 0.002
Procedure: n (%)
Small bowel resection 6 (4.3) 4 (4.1) 2 (4.9) 0.04
Completion coloproctectomy without ostomy 13 (9.4) 11 (11.2) 2 (4.9)
Completion coloproctectomy with diverting ostomy 17 (12.2) 10 (10.2) 7 (17.1)
Total abdominal colectomy with diverting ostomy 23 (16.6) 19 (19.4) 4 (9.8)
Ileocecectomy 40 (28.8) 33 (33.7) 7 (17.1)
Diverting ostomy 7 (5.0) 2 (2.0) 5 (12.2)
Ileostomy takedown 22 (15.8) 13 (13.3) 9 (22.0)
Partial colectomy with diverting ostomy 1 (0.7) 1 (1.0) 0 (0.0)
Partial colectomy without diversion 10 (7.2) 5 (5.1) 5 (12.2)
Laparoscopic surgery: n (%) 78 (56.1) 59 (60.2) 19 (46.3) 0.1
Procedure time (min): μ (SD) 193.6 (84.0) 187.0 (83.0) 209.4 (85.2) 0.2
Epidural: n (%) 31 (22.3) 18 (18.4) 13 (31.7) 0.09
Total perioperative MME: μ (SD) 0.5 (0.3) 0.4 ± 0.3 0.7 ± 0.4 <0.001
Postoperative medications
Acetaminophen: n (%) 137 (98.6) 97 (99.0) 40 (97.6) 0.5
Pregabalin or gabapentin: n (%) 65 (46.8) 59 (60.2) 6 (14.6) <0.001
Celebrex: n (%) 54 (38.9) 53 (54.1) 1 (2.4) <0.001
Entereg: n (%) 15 (10.8) 15 (15.3) 0 (0.0) 0.008
Toradol: n (%) 34 (24.5) 1 24 (24.5) 10 (24.4) 1.0
Floor total MME per day: median (IQR) 0.2 (0.1–0.4) 0.2 (0.1–1.8) 0.4 (0.2–0.7) <0.001
Total MME per kg: median (IQR) 0.03 (0.02–0.06) 0.02 (0.02–0.04) 0.06 (0.03–0.1) <0.001
Time with Foley (h): μ (SD) 39.5 (35.5) 33.0 (29.9) 54.9 (42.9) <0.001
Time to oral intake (h): μ (SD) 31.4 (30.9) 24.5 (22.8) 47.9 (40.6) <0.001
Length of stay (h): median (IQR) 118.9 (89.2–187.7) 99.3 (76.5–167.6) 139.3 (116.1–216.4) 0.002
Complications
Return to the emergency room in 30 days: n (%) 20 (14.4) 13 (13.3) 7 (17.1) 0.6
Readmission in 30 days: n (%) 27 (19.4) 18 (18.4) 9 (22.0) 0.6
Unplanned return to operating room in 30 days: n (%) 0.5
None 126 (91.3) 88 (89.8) 38 (95.0)
Unplanned 10 (7.3) 8 (8.2) 2 (5.0)
Planned 2 (1.5) 2 (2.0) 0 (0.0)

Abbreviations: μ: mean, SD: standard deviation, IQR: interquartile range, ASA: American Society of Anesthesiologists, ERAS: enhanced recovery after surgery, MME: morphine milligram
equivalents, kg: kilogram.

an ERAS pathway, increasing age, increasing ASA Physical Status Classi- reduction in time with Foley and time to oral intake by nearly a day in
fication, and procedure performed did not change the length of stay the ERAS postintervention cohort. Also, there was a significant decrease
when controlling for pertinent factors, Table 3. in total MME/kg over a patient's hospitalization with the initiation of an
Using multivariate linear regression to determine factors influencing ERAS pathway. Multivariable regression showed the implementation of
time to oral intake, the presence of an ERAS pathway (−15.10, 95% CI an ERAS pathway reduced the total MME/kg used in the perioperative
− 26.21 – − 3.98, p = 0.008) and increasing age (− 3.06, 95% CI period and decreased the time to oral intake when controlling for perti-
− 4.75 – − 1.36, p = 0.001) decreased time to oral intake. Increasing nent covariates. Finally, we showed a reduction of MME/kg was associ-
total MME/kg increased the time to oral intake (102.99, 95% CI ated with a decrease in hospital length of stay. Importantly, there was no
32.44–173.53, p = 0.005), Table 4. difference in complications between the two cohorts.
Only a few studies have examined the effect of the implementation
3. Discussion of ERAS pathways in pediatric surgical patients. A recent systematic re-
view found five studies examining the implementation of a “fast-track”
This is the largest study to date on ERAS pathways for pediatric pa- pathway, all with six or fewer ERAS pathway components. Even with
tients undergoing colorectal surgery. We have shown there was a de- the relatively small number of components, the pediatric fast-track pa-
crease in the postoperative hospital length of stay by 40 h and tients were shown to have a shorter length of stay and decreased opioid

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L.N. Purcell, K. Marulanda, M. Egberg et al. Journal of Pediatric Surgery 56 (2021) 115–120

Median Total Morphine Equivalents Used Per Day

1.5000 0.5883
1.2999

Median Total Morphine Equivalens Used

1.0000

(mg/kg/day)
0.5000 CL

0.0000
0.3737 0.1884

0.5000

0.5526 0.2114
1.0000

Fig. 1. Run chart — total morphine milligram equivalents per kilogram per day (MME/kg/day) before and after enhanced recovery after surgery (ERAS) pathway implementation
(September 2016). The blue line represents median morphine equivalents used controlling for weight and time. The red lines represent upper and lower confidence intervals.

use, with no associated increase in perioperative complications in our study with Short et al. owing to the inconsistency in the reporting
[4,6,7–10]. In addition, each included study had its challenges. Specifi- of opioid use and units of measurement (MME and MME/kg). Our study
cally, in two studies, controls were taken from national billing databases, builds on the work of Short et al., by broadening the generalizability, as
which introduced significant unaccounted for provider and practice var- it includes a significant cohort of open operations [11].
iability [6,7,9]. In a third study, there was no control group in which to Individual components of the ERAS pathway have been shown to be
compare the ERAS cohort [8]. Finally, the population was limited to in- effective in children. Specifically, studies have demonstrated that multi-
clude only laparoscopic procedures, which limited its generalizability modal analgesia, early mobilization and oral intake, nausea control, and
[10]. avoiding unnecessary urinary catheters were safe in pediatric patients.
Short et al. introduced a pediatric colorectal ERAS pathway in 2015 Also, excluding mechanical bowel preparation has been associated
[6]. The authors show that patients undergoing major laparoscopic colo- with improved outcomes [12–16]. Previously, it has been demonstrated
rectal operations in the ERAS postintervention arm had a decrease in that ERAS pathways were effective in reducing LOS, opioid utilization,
length of stay by one-day, received a lower volume of intraoperatively and time to oral intake in pediatric IBD patients. The current study ex-
intravenous fluids, and had an earlier start to a regular diet compared pands on those findings and demonstrates that the effect was consistent
to the preintervention arm. In addition, there was a reduction in opera- across other indications and patients. The current study also demon-
tive MME/kg and postoperative MME. While this represents the most strates our findings across a much larger cohort (nearly double). Inter-
comprehensive pediatric ERAS study to date, it is limited by its sample estingly during the PDSA to expand the use of multimodal pain
size (n = 79) and focus on only laparoscopic surgery rate in the pre- medications, we did not see a significant effect on our run chart as we
and postintervention cohorts [11]. anticipated. However, we continued the practice based on similar com-
While each of the previously mentioned studies has limitations, find- plication rates and likely unrecognized benefits. Our study contributes
ings in these studies correlate with what we have found in our study. to the growing body of work demonstrating that individual components
Unfortunately, we cannot compare the magnitude in MME reduction combined into a comprehensive ERAS pathway can improve patient

Table 2
Multivariate linear regression showing the change in the total morphine equivalents per kilogram with implementation of an enhanced recovery after surgery (ERAS) pathway and con-
trolling for age, preoperatively opioid use, neuraxial and regional anesthesia, and procedural category.

Coefficient 95% Confidence interval p-value

ERAS −0.055 −0.093 – −0.036 <0.001

Age −0.0051 −0.010 – −0.0014 0.02
Preoperative opioid use 0.031 −0.017 – 0.065 0.1
Epidural 0.0031 −0.023 – 0.044 0.8
Block −0.030 −0.051 – 0.017 0.2
Procedure category
Small bowel resection Ref - -
Completion coloproctectomy without ostomy −0.077 −0.14 – −0.016 0.02
Completion coloproctectomy with diverting ostomy −0.086 −0.15 – −0.027 0.006
Total abdominal colectomy with diverting ostomy −0.063 −0.12 – −0.0037 0.04
Ileocectomy −0.066 −0.13 – −0.012 0.02
Diverting ostomy 0.029 −0.044 – 0.010 0.4
Ileostomy takedown −0.086 −0.15 – −0.029 0.005
Partial colectomy with diverting ostomy −0.095 −0.23 – 0.048 0.2
Partial colectomy without diversion −0.083 −0.15 – −0.016 0.01

Abbreviation: ERAS: enhanced recovery after surgery.

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L.N. Purcell, K. Marulanda, M. Egberg et al. Journal of Pediatric Surgery 56 (2021) 115–120

Table 3
Multivariate linear regression showing the change in length of stay (LOS) with implementation of an enhanced recovery after surgery (ERAS) pathway and controlling for age, American
Society of Anesthesiologist physical status classification, mode of surgery (open vs. laparoscopic), opioid utilization, and procedure category.

Coefficient 95% Confidence interval p-value

ERAS 34.62 −26.03 – 95.27 0.3

Age 6.05 −3.20 – 15.31 0.2
ASA
2 Ref – –
3 50.31 −1.64 – 102.25 0.06
Laparoscopic surgery −41.15 −98.80 – 16.51 0.2
Total MME per kg 1035.97 651.07–1420.87 <0.001
Procedure category
Small bowel resection Ref – –
Completion coloproctectomy without ostomy 93.59 −50.65 – 237.84 0.2
Completion coloproctectomy with diverting ostomy 8.43 −128.05 – 144.91 0.9
Total abdominal colectomy with diverting ostomy −38.14 −168.81 – 92.53 0.6
Ileocectomy 3.48 −123.12 – 130.08 1.0
Diverting ostomy 9.84 −147.62 – 167.20 0.9
Ileostomy takedown 21.27 −116.45 – 159.00 0.8
Partial colectomy with diverting ostomy 49.11 −256.99 – 355.20 0.8
Partial colectomy without diversion 49.61 −98.54 – 197.76 0.5

Abbreviations: ERAS: enhanced recovery after surgery, ASA: American Society of Anesthesiologists, MME: morphine milligram equivalents, kg: kilogram.

Table 4
Multivariate linear regression showing the change in time to oral intake after implementation of an enhanced recovery after surgery (ERAS) pathway and controlling for age, mode of sur-
gery (open vs. laparoscopic), American Society of Anesthesiologist physical status classification, opioid utilization, and procedure category.

Coefficient 95% Confidence interval p-value

ERAS −15.10 −26.21 – −3.98 0.008

Age −3.06 −4.75 – −1.36 0.001
Laparoscopic surgery −6.01 −16.57 – 4.56 0.3
ASA
2 Ref – –
3 5.52 −6.18 – 12.80 0.3
Total MME per kg 102.99 32.44–173.53 0.005
Procedure category
Small bowel resection Ref – –
Completion coloproctectomy without ostomy −23.06 −49.50 – 3.38 0.09
Completion coloproctectomy with diverting ostomy −19.05 −44.06 – 5.97 0.1
Total abdominal colectomy with diverting ostomy −18.02 −41.97 – 5.93 0.1
Ileocectomy −9.13 −32.34 – 14.07 0.4
Diverting ostomy −23.59 −52.44 – 5.27 0.1
Ileostomy takedown −7.12 −32.36 – 18.12 0.6
Partial colectomy with diverting ostomy 6.99 −49.11 – 63.09 0.8
Partial colectomy without diversion −1.89 −29.04 – 25.26 0.8

Abbreviations: ERAS: enhanced recovery after surgery, ASA: American Society of Anesthesiologists, MME: morphine milligram equivalents, kg: kilogram.

outcomes without increasing complication rates [11]. Declarations of competing interest

This study was limited owing to its retrospective nature. All of the
components in the ERAS protocol could not be tracked on retrospective None.
review. Specifically, preoperative carbohydrate loading, time to first Supplementary data to this article can be found online at https://doi.
postoperative mobilization, time to return of bowel function, and post- org/10.1016/j.jpedsurg.2020.09.028.
operative nausea and emesis were not consistently recorded and identi-
fied on chart review. In addition, this study includes a heterogeneous
mix of patient diagnoses, including patients with severe ulcerative coli-
tis and elective prophylactic procedures, such as total abdominal References
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