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EDITED BY
Hiroo Uchida,
Nagoya University Graduate School of
Medicine, Japan
REVIEWED BY
Gabriele Lisi,
University of Studies G. d’Annunzio Chieti and
Pescara, Italy
Luca Pio,
St. Jude Children’s Research Hospital,
United States
*CORRESPONDENCE
Xiao-yun Wang
81096465@qq.com
Yue-qi Jia
zjg3134@sina.com
†
These authors have contributed equally to this
work and share first authorship
RECEIVED 19 July 2023
ACCEPTED 25 September 2023
PUBLISHED 20 October 2023
CITATION
Zhang J-g, Li H-w, Wu X-m, Yu H-b, Liu Y-h,
Qi L, Bai Y, Yang L, Zhang H-l, Wang X-y and
Jia Y-q (2023) The impact of enhanced
recovery after surgery on inflammatory
indicators and prognosis related to complex
appendicitis in children.
Front. Pediatr. 11:1261191.
doi: 10.3389/fped.2023.1261191
COPYRIGHT
© 2023 Zhang, Li, Wu, Yu, Liu, Qi, Bai, Yang,
Zhang, Wang and Jia. This is an open-access
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comply with these terms.
The impact of enhanced recovery
after surgery on inflammatory
indicators and prognosis related
to complex appendicitis in children
Jian-guo Zhang1†, Hao-wei Li2†, Xiang-ming Wu2, Hai-bin Yu1,
Yan-hui Liu1, Lin Qi1, Yu Bai1, Lin Yang1, Hai-long Zhang1,
Xiao-yun Wang1*and Yue-qi Jia1*
1
Pediatric Surgery, Inner Mongolia Maternal and Child Health Care Hospital, Hohhot, China,
2
Pediatric
Surgery, The Fourth Hospital of Baotou, Baotou, China
Objective: To explore the application effect of enhanced recovery after surgery
(ERAS) perioperative plan in the treatment of complex appendicitis in children,
and further enrich the implementation plan of ERAS in the field of pediatric
surgery.
Method: This study selected 122 children who underwent laparoscopic complex
appendectomy at Inner Mongolia Maternal and Child Health Hospital and
Baotou Fourth Hospital from August 2018 to July 2022, and randomly divided
them into a traditional surgery group (TS) and an enhanced recovery surgery
group (ERAS). The changes of white blood cell (WBC), hypersensitive C-reactive
protein (CRP), pro Calcitonin (PCT) and interleukin 6 (IL-6) before and after
surgery were compared. The degree of pain, recovery time of intestinal function,
length of hospital stay, hospital costs, postoperative complications and parental
satisfaction were compared between the two groups.
Result: The WBC and CRP levels in the ERAS group at 6 h after surgery, as well as
the IL-6 levels on the 3rd day after surgery, were lower than those in the TS group.
Meanwhile, the analgesic effect of ERAS group at 3 h and 6 h after surgery was
better than that of TS group. And the ERAS group had a shorter postoperative
first exhaust time, fewer overall hospital stays, and lower hospitalization costs. In
addition, the ERAS group had high parental satisfaction during hospitalization.
There was no statistically significant difference in postoperative complications
between the two groups of children.
Conclusion: ERAS can promote postoperative recovery of children, reduce
surgical stress, save family medical expenses, alleviate the pain of children, and
improve parental satisfaction. It is a safe and effective method for treating
complex appendicitis in children.
KEYWORDS
ERAS, laparoscopic surgery, inflammatory indicators, complex appendicitis, children
Introduction
The concept of enhanced recovery after surgery (ERAS) was proposed by Dr. Henrik
Kehlet in 1990 to improve the patient’s perioperative plan (1). The purpose is to promote
postoperative patient recovery through various perioperative interventions, thereby
reducing complications and overall medical costs. Through continuous research and
improvement in recent years, these plans have played a positive role in almost all aspects,
TYPE Original Research
PUBLISHED 20 October 2023
|
DOI 10.3389/fped.2023.1261191
Frontiers in Pediatrics 01 frontiersin.org
from simple daily surgeries to complex surgeries, becoming
effective tools for surgeons to accelerate patient recovery and
improve prognosis.
The children’s appendix wall is thin, the ileocecal region is rich
in lymphoid tissue, the greater omentum is poorly developed, and
the peritoneal cavity area is relatively large, so it is prone to
suppuration and perforation, thus developing into complex
appendicitis (CAA). At the same time, peritonitis, sepsis,
intestinal obstruction, abscess formation, and fertility problems
are combined (2), which leads to longer hospital stays and
additional costs. Abdominal inflammation in children is difficult
to control and limited, with severe systemic poisoning symptoms,
a high incidence of complications, and a significantly higher
mortality rate than in adults. Scientific perioperative preparation
can help the smooth progress of the surgery and accelerate the
recovery of the patient. Therefore, the concept of enhanced
recovery after surgery has certain research significance in the
treatment of complex appendicitis in children and improving
their prognosis.
Materials and methods
General information
This study selected 122 children who underwent laparoscopic
complex appendectomy at Inner Mongolia Maternal and Child
Health Hospital and Baotou Fourth Hospital from August 2018
to July 2022. The cases were randomly divided into the
traditional surgery group (TS) and the enhanced recovery after
surgery (ERAS) group according to the random number table.
Briefly, all cases are numbered first, then three digits are taken as
corresponding numbers according to the random number table,
and finally, the random number is sorted from smallest to
largest, so as to achieve complete random grouping. 62 children
who underwent perioperative intervention according to the
accelerated rehabilitation surgical standards were used as the
experimental group (ERAS group), while 60 children who
underwent traditional perioperative intervention were used as the
control group (TS group). The preoperative general information
(including gender, age, appendix case classification—purulent
and perforated) of all patients was collected. This study was
approved by the Ethics Committee of the Maternal and Child
Health Hospital of Inner Mongolia Autonomous Region
(Approval No. [2020] Lun Han Shen No. [074–2]) and obtained
informed consent from patients’guardians.
Diagnostic and exclusion criteria for
inclusion in this study
Inclusion criteria: (1) Having signs of appendicitis (symptoms
such as fever, abdominal pain, vomiting, etc.); (2) Preoperative
blood and imaging examinations support the diagnosis of
appendicitis; (3) The pathological type of appendicitis is based
on surgical and pathological diagnosis (purulent, gangrenous,
perforated); (4) The surgical procedure is laparoscopic
appendectomy.
Exclusion criteria: (1) Patients over 15 years old; (2) Previous
history of abdominal surgery; (3) Having related symptoms for
more than 2 weeks or a history of chronic appendicitis; (4)
Merge with other diseases or have anatomical abnormalities; (5)
Patients who are unable to tolerate minimally invasive surgery or
who fail to undergo minimally invasive surgery and switch to
open surgery.
Surgical methods and perioperative
management
Surgical methods
Both groups of children underwent laparoscopic surgery. After
completing routine preoperative preparation, an incision was made
along the upper edge of the child’s navel, and a CO
2
pneumoperitoneum (pressure 8–12 mmHg) was established using
a pneumoperitoneum needle. A 5 mm or 10 mm Trocar was
implanted according to the child’s age and development, and the
abdominal cavity was routinely explored using laparoscopy.
Under laparoscopic direct vision surgery, a trocar was used to
puncture the operating hole along the midline of the clavicle,
approximately 2 cm below the right costal margin, and one-third
of the “reverse Mack’s point”on the line connecting the left
lower abdominal navel and the anterior superior iliac spine. After
exploring the situation in the abdominal cavity again, adjusted
the operating table, changed the child’s head to a high and low
lying position on the left side (leaning 15–30° to the left),
carefully separated the adherent appendix and surrounding
tissues, separate and ligate the mesentery of the appendix,
dissociate it to the root of the appendix about 0.5 cm away from
the ileocecal part and clamp it with an absorbable clamp, cut off
the appendix, and treat the appendix stump. Use a suction
device and clean gauze to clean the pus in the abdominal cavity.
After removing the appendix, recheck the residual end of the
appendix and the condition of the abdominal cavity. If necessary,
rinse the abdominal cavity, and send the appendix specimen to
the pathology department.
Comparison of perioperative management
methods between two groups of pediatric
patients
The preoperative, intraoperative, and postoperative
management plans of the ERAS group are different from those
of the TS group. Through the study of the ERAS consensus and
guidelines (3) and the retrieval of relevant research literature, this
study developed an ERAS protocol suitable for this study, and
compared it with the TS group protocol (Table 1).
The specific scheme of preoperative anesthesia induction,
intraoperative analgesia and fluid management were as follows:
(1) Induced anesthesia: a. Sufentanil, 0.2–0.4 μg/kg; b. Propofol,
2.5–4 mg/kg (1 month-3 years old), about 2.5 mg/kg (>8 years
old); c. Vecuronium bromide,0.1–0.2 mg/kg and 0.02 mg/kg
(intermittent administration was maintained during the
Zhang et al. 10.3389/fped.2023.1261191
Frontiers in Pediatrics 02 frontiersin.org
operation); d. Remifentanil, 0.5–1μg/kg/min and 0.05–2μg/kg/min
(intraoperative anesthesia maintenance); e. Dexmedetomidine,
0.2–0.7 μg/kg/h. (2) Intraoperative analgesia (including regional/
local analgesia) ropivacaine (0.75%; 10 ml) was injected into
incisions one by one before subcutaneous suture with absorbable
line. The ropivacaine was diluted 1:1 with saline and injected into
incisions according to the incision size. (3) Fluid management:
Children with complex appendicitis are usually complicated by
dehydration, electrolyte disturbance, hypoglycemia and other
conditions after admission. Perioperative fluid rehydration should
be calculated according to the specific situation of each child, and
the urine volume of the child should be monitored and
dynamically adjusted. During the operation, the fluid volume was
calculated mainly according to the physiological requirements of
the child, the amount of fasting water lost before the operation,
the amount of loss during the operation, the amount of third
space loss, and the amount of blood loss. The balance of isotonic
electrolyte solution was the main method, and the adjustment of
electrolyte and blood glucose level was referred to before the
operation.
Postoperative treatment
Both groups of children were treated with antibiotics of the same
grade after surgery. The temperature of the children was observed to
drop to normal for 2 days, and the inflammatory indicators were
tested to normal before discontinuing antibiotics. After discharge,
the patients were followed up for 3 months. The main follow-up
methods are outpatient follow-up, ultrasound examination of the
appendix stump and intra-abdominal conditions.
Observation indicators
Record the first postoperative exhaust time, hospitalization
days, hospitalization expenses, postoperative complications, and
parental satisfaction of the two groups of children.
The pain degree (VAS scoring method) at 3 h, 6 h and 12 h
after surgery was recorded (4). The pain level was evaluated
using the VAS scoring method, with no wound pain (0–2
points), mild pain (3–5 points), significant but tolerable pain
(6–8 points), and unbearable pain (8–10 points). At the first
evaluation, the doctor and the parents of the child jointly
describe and explain to the child.
The changes of white blood cell (WBC), hypersensitive
C-reactive protein (CRP), interleukin 6 (IL-6), pro Calcitonin
(PCT) and other related inflammatory indicators before, 6 h after
surgery, and 3 days after surgery were recorded.
Discharge standard
The patient has no fever or normal blood count within 2 days,
no discomfort after a normal or semi-liquid diet, no other
complications, and the incision has recovered well.
TABLE 1 Differences in perioperative measures between TS group and ERAS group.
TS group ERAS group
Propaganda and
education
Regular admission education Popularize disease related knowledge, introduce ERAS concept, introduce
specific procedures and precautions for admission, examination, surgery, and
discharge
Preoperative ①Strictly fasting for 12 h before surgery and drinking water for 6 h
before surgery, or strictly fasting and drinking water at the time of self-
diagnosis.
②Perform intestinal preparation such as enema, and place a
nasogastric tube if necessary.
③Routine preoperative visits are usually based on parents providing
information to check the condition of the child.
④After entering the operating room, anesthesia will be administered.
①Fasting for 6 h before surgery, and drinking water for 2 h before surgery.
Prior to this, give the child 12.5% glucose water 5 ml/kg for consumption (up to
100 ml).
②Try to minimize or avoid preoperative intestinal preparation, and do not leave
a nasogastric tube.
③Anesthesiologists patiently visit, introduce themselves, inquire about the
patient’s name, age, etc., and have good interaction with the patient.
④Induce anesthesia before entering the operating room.
Intraoperative ①No special heating device, ordinary sterile sheet.
②Anesthesia has no special emphasis and is mainly evaluated by the
anesthesiologist during surgery.
③Retain drainage tube and catheter according to the situation.
④Regular use of absorbable suture for subcutaneous suture.
①During surgery, devices such as insulation blankets and hot air fans should be
used to maintain the child’s body temperature at least 36 °C and prevent
excessive body temperature.
②The chief surgeon communicates fully with the anesthesiologist, adjusts the
anesthetic medication in a timely manner, and fully shortens the postoperative
recovery time.
③Do not place any drainage and do not place a catheter.
④Inject ropivacaine (0.75%; 10 ml) into each incision before subcutaneous
suturing with absorbable suture, and dilute and inject 1–2 ml according to the
size of the incision.
Postoperative ①Provide painkillers as needed (regardless of type).
②There are no special requirements for postoperative fluid
replacement, and the required amount of fluid should be replenished.
③Start moving out of bed on the first day after surgery.
④After exhausting, one can drink water and consume a small amount
of liquid food.
①Analgesic effects of acetaminophen suppositories, avoiding the use of
morphine like drugs.
②Strictly follow the principle of fluid replacement, try to reduce the amount of
intravenous crystal fluid supplementation for children, and group fluid
replacement according to the status of the children.
③Bed activity can begin 6 h after surgery, and on the first day after surgery, get
out of bed and develop an activity plan.
④After the child wakes up 6 h under anesthesia, a small amount of water can
begin to flow, gradually increasing after no discomfort.
Zhang et al. 10.3389/fped.2023.1261191
Frontiers in Pediatrics 03 frontiersin.org
Satisfaction survey
When the child is discharged, the satisfaction level of the
parents was understood and recorded. The evaluation content
includes: (1) understanding of the child’s disease; (2) Satisfaction
with admission notification and communication; (3)
Understanding of treatment plans; (4) The comfort level and
crying situation of the patient during hospitalization; (5) The
feelings and anxiety of family members during bedtime; (6)
Overall satisfaction with the ward environment; (7) Satisfaction
with the recovery level of the child; (8) Satisfaction with the
attitude of medical staff; (9) Satisfaction with health education
and discharge guidance; (10) Willing to recommend
undergraduate programs to relatives and friends in need. The
ERAS group was scored anonymously by the patient’s family
members, with satisfaction (7–9 points), relatively satisfied (4–6
points), and dissatisfied (1–3 points).
Statistical methods
All statistical data were imported into SPSS 20.0 software for
analyzing differences. The count data were represented by n(%)
and a chi-square test was used to analyze the difference. The
measurement data were represented by mean ± standard
deviation (SD) and analyzed by T-test (conforming to normal
distribution) and nonparametric tests (not conforming to normal
distribution), respectively. P< 0.05 indicates a statistically
significant difference.
Results
Baseline information
In total, 122 cases were included and divided into ERAS (n=62)
and TS group (n= 60). All of which successfully completed
laparoscopic appendectomy without any conversion to open
surgery. Baseline characteristics of patients in the two groups were
listed in Table 2. The results showed that there were no significant
differences in gender, age and pathological classification between
the two groups (P>0.05),whichcouldbefollowedbycomparison.
The effect of ERAS perioperative regimen
on postoperative inflammatory-related
indicators in patients after surgery
To determine the effect of the ERAS perioperative regimen on
postoperative inflammatory status in patients with appendicitis, we
measured WBC, CRP, PCT, and IL-6 levels in patients with
appendicitis before surgery, 6 h after surgery, and on the third
day after surgery. The results showed that there were no
significant differences in the levels of WBC, CRP, PCT and IL-6
between the TS and ERAS groups before operation (P> 0.05).
Compared with the TS group, the patients in the ERAS group
had lower WBC (P= 0.036) and CRP (P= 0.027) levels at 6 h
after surgery, and lower IL-6 levels (P= 0.031) on the 3rd day
after surgery, with a faster recovery rate (Table 3).
The impact of ERAS perioperative regimen
on the pain of patients with appendicitis
after surgery
Subsequently, we assessed postoperative pain in patients with
appendicitis using the VAS scale (Table 4). Compared with the
TS group, pain scores of appendicitis patients in the ERAS group
were significantly lower at 3 h (3.807 ± 1.226 vs. 4.417 ± 1.279,
P= 0.008) and 6 h (3.097 ± 1.327 vs. 3.6333 ± 1.365, P= 0.030)
after surgery. The pain index of appendicitis patients in the
ERAS group at 12 h after surgery was lower than that in the
TS group, but there was no significant difference (P> 0.05).
These results showed that the analgesic effect of the ERAS group
at 3 h and 6 h after surgery was better than that of the
traditional surgical group.
The effect of ERAS perioperative regimen
on postoperative intestinal exhaust, length
of hospital stay, and hospitalization costs in
patients after surgery
In order to further clarify whether there were differences in
hospital stay and cost between the two groups of patients with
appendicitis, we counted the first postoperative exhaust time of
the patient and evaluated the hospitalization days and expenses
according to the discharge standards. The results showed that the
mean first exhaust time (17.581 ± 4.668 vs. 20.883 ± 8.501,
P= 0.009) and length of hospital stay (9.597 ± 3.375 vs. 10.967 ±
3.760, P= 0.036) in the ERAS group were significantly shorter
than those in the TS group. The corresponding hospitalization
cost (11,722.602 ± 2,588.964 vs. 12,896.126 ± 3,426.475, P= 0.034)
was also significantly reduced (Table 4). The patients in the
ERAS group had a shorter postoperative first exhaust time, fewer
overall hospital stays, and lower hospitalization costs, effectively
accelerating the postoperative recovery level of patients,
increasing patient comfort, and reducing economic pressure and
parental burden.
TABLE 2 Comparison of baseline characteristics in patients between ERAS
group and TS group.
Characteristic ERAS
(n= 62)
TS (n= 60) t/χ
2
P
Value
Gender, n(%) 0.265 0.607
Male 40 (52.63%) 36 (47.37%)
Female 22 (47.83%) 24 (52.17%)
Age, Mon th 88.645 ± 36.948 86.683 ± 38.885 0.286 0.776
Pathological
classification, n(%)
0.032 0.859
Suppurative 32 (51.61%) 30 (50%)
Perforation 30 (48.39%) 30 (50%)
Data were expressed as mean ± standard deviation or n(%).
Zhang et al. 10.3389/fped.2023.1261191
Frontiers in Pediatrics 04 frontiersin.org
The effects of ERAS perioperative regimen
on postoperative complications in patients
We recorded the occurrence of postoperative complications in
two groups of appendicitis patients. There were 4 postoperative
complications in the ERAS group, including 1 case of incision
bleeding caused by children’s postoperative activities;1 case of
incision infection; 2 cases of abdominal pain after a small amount
of liquid diet, and a small amount of gas-liquid level found on
abdominal plain film, indicating incomplete intestinal obstruction.
In the TS group, 3 postoperative complications occurred, with 1
case experiencing abdominal pain 5 days after surgery, and a small
amount of fluid accumulation in the abdominal cavity was assisted
in the examination; One case had abdominal pain 7 days after
surgery, with ultrasound indicating abdominal abscess and elevated
infection indicators. One case developed abdominal pain after a
small amount of liquid diet, and a small amount of gas-liquid level
was found on abdominal plain film, indicating incomplete
intestinal obstruction. There was no significant difference in
postoperative complications between the two groups of children
(6.45% vs.5%,P= 0.730) (Table 4).
The effects of ERAS perioperative regimen
on parental satisfaction
The ERAS group was scored anonymously by the patient’s
family members, with satisfaction (7–9 points), relatively satisfied
(4–6 points), and dissatisfied (1–3 points). The satisfaction level
of parents in the ERAS group was higher than that in the TS
group (P= 0.038) (Table 4).
Discussion
The ERAS concept refers to enhancing patient recovery and
reducing the incidence of complications by optimizing
perioperative plans (5). At present, there is an average of 23.8
protocols applied to adult surgery (6), and good results have
been achieved. However, the development of standard
perioperative protocols for enhanced recovery surgery in
pediatric surgery is still relatively slow. Currently, research has
confirmed that the ERAS concept can be safely applied to
children undergoing routine surgery (7–10), but we still need a
TABLE 3 Comparison of inflammatory indexes between the two groups.
Inflammatory indexes ERAS (n= 62) TS (n= 60) tPValue
WBC (×10
9
/L) pre-operation 14.624 ± 4.8489 15.730 ± 5.6281 −1.164 0.247
6 h after surgery 11.304 ± 4.100 13.131 ± 5.348 −2.121 0.036
3rd day after surgery 7.936 ± 2.845 8.836 ± 4.862 −1.253 0.213
CRP (mg/L) pre-operation 52.564 ± 50.929 61.847 ± 69.650 −0.842 0.401
6 h after surgery 50.356 ± 42.650 71.823 ± 61.790 −2.239 0.027
3rd day after surgery 15.977 ± 26.329 17.222 ± 26.302 −0.261 0.794
PCT (ng/ml) pre-operation 6.369 ± 9.429 4.313 ± 10.596 1.133 0.259
6 h after surgery 7.767 ± 8.620 6.431 ± 9.956 0.794 0.429
3rd day after surgery 0.739 ± 0.971 0.816 ± 1.618 −0.319 0.750
IL-6 (ng/L) pre-operation 121.882 ± 275.814 104.357 ± 223.727 0.385 0.701
6 h after surgery 40.448 ± 69.362 52.902 ± 78.147 −0.932 0.353
3rd day after surgery 6.051 ± 6.147 9.717 ± 11.623 −2.188 0.031
Values were expressed as mean ±standard deviation. WBC, white blood cell; CRP, C-reactive protein; PCT, pro Calcitonin; IL-6, interleukin 6.
TABLE 4 Comparison of postoperative analgesia, postoperative intestinal exhaust time, postoperative hospital stay, overall hospitalization expenses, the
incidence of postoperative complications and satisfaction of parents between the two groups.
ERAS (n= 62) TS (n= 60) t/χ²/zPValue
Postoperative analgesia
3 h after surgery 3.807 ± 1.226 4.417 ± 1.279 −2.690 0.008
6 h after surgery 3.097 ± 1.327 3.6333 ± 1.365 −2.201 0.030
12 h after surgery 3.807 ± 0.902 3.933 ± 0.899 −0.778 0.438
Intestinal exhaust time (hours) 17.581 ± 4.668 20.883 ± 8.501 −2.671 0.009
Postoperative hospitalization stay (days) 9.597 ± 3.375 10.967 ± 3.760 −2.119 0.036
Hospitalization expenses (Yuan) 11,722.602 ± 2,588.964 12,896.126 ± 3,426.475 −2.139 0.034
Postoperative complications, n(%) 0.119 0.730
Incidence 4 (6.45%) 3 (5.00%)
Non-incidence 58 (93.55%) 57 (95.00%)
Satisfaction, n(%) −2.071 0.038
Satisfaction 48 (77.42%) 36 (60.00%)
Relatively satisfaction 13 (20.97%) 22 (36.67%)
Dissatisfy 1 (1.61%) 2 (3.33%)
Data were expressed as mean ± standard deviation or n(%).
Zhang et al. 10.3389/fped.2023.1261191
Frontiers in Pediatrics 05 frontiersin.org
lot of research to explore and enrich truly applicable accelerated
protocols for pediatric surgery.
The physical signs of appendicitis in children are numerous
and not obvious. Inflammation in the abdominal cavity is prone
to spreading, leading to complications such as perforation,
peritonitis, and peripheral abscesses. In severe cases, sepsis may
occur and endanger life (11). The research results compared the
changes in four inflammatory indicators between the two groups
of children before surgery, 6 h after surgery, and 3 days after
surgery. There were differences in WBC at 6 h after surgery, CRP
at 6 h after surgery, and IL-6 indicators on 3 days after surgery.
Summary of the reasons: (1) Within 6 h after surgery, the WBC
and CRP levels in the ERAS group decreased rapidly, indicating
that preoperative and intraoperative ERAS measures could help
the child recover after removing the lesion. There is not much
difference in IL-6 between the two groups, which may be due to
the use of laparoscopic minimally invasive technology in both
groups, which effectively controls postoperative stress levels, or
the set time points for blood sampling are too few to accurately
detect the changes in postoperative inflammatory indicators. The
ERAS protocol plays an important role in helping patients
recover and alleviate postoperative stress (9). Anna W (12) found
that during surgical stress response, the mRNA levels of
inflammatory pathway genes (such as IL6, TNF, and nuclear
factors) change. CRP is an acute phase protein synthesized by
liver cells, discovered by Tillett and Francis in 1930 (13). CRP
reflects the impact of trauma on the body and is related to the
severity of tissue damage. After surgery, CRP concentration
usually increases rapidly within 4–12 h and reaches its peak
within 24–72 h, lasting up to 2 weeks. The increase of
proinflammatory cytokine IL-6 after surgery is related to insulin
resistance (14), and its sensitivity is higher than CRP. Jawa RS
(2011) pointed out that the increase of IL-6 after surgery is
related to the degree of tissue damage (15), including the surgical
approach, laparoscopy and open surgery, the complexity of
surgery, cholecystectomy, and colectomy. (2) On the third day
after surgery, the IL-6 levels in the ERAS group were
significantly lower than those in the TS group, indicating that
ERAS related regimens have certain effects in reducing stress and
accelerating recovery in children. Preoperative oral administration
of carbohydrates improves insulin resistance and reduces hunger,
which may be beneficial for the patient’sinflammatory response,
immune function, and postoperative recovery, without increasing
the risk of anesthesia and aspiration during the surgery (16). In
addition, preoperative induction anesthesia and medication
before anesthesia can calm the child, reduce anxiety, optimize
intraoperative hemodynamic stability, and reduce postoperative
side effects. The chief surgeon communicates fully with the
anesthesiologist, which helps the anesthesiologist determine the
dosing time, reduce anesthesia dosage, and accelerate
postoperative recovery. Simultaneously, the application of
intraoperative insulation devices can reduce the side effects of
anesthesia, such as hypothermia, decreasing the impact on
coagulation pathways and surgical stress (17). A series of
perioperative strategies have played a promoting role in helping
children recover postoperative inflammatory indicators.
Accelerate postoperative intestinal recovery, shorten hospital
stays, and reduce hospital expenses. Three indicators in the
ERAS group are superior to those in the TS group, which are
important indicators for accelerating the recovery of pediatric
patients and a comprehensive reflection of the ERAS
perioperative plan. We analyzed them based on the following
aspects: (1) Preoperative: Shorten fasting time. Because children’s
stomach capacity is smaller than that of adults, traditional
preoperative fasting with water can make children hungry and
increase anxiety. Drinking 12.5% glucose water 2 h before
surgery, and abstaining from water 2 h before surgery, can
reduce this anxiety and help reduce blood pressure fluctuations
and reduce intravenous fluid replacement in children.
Preoperative mechanical bowel preparation can also increase the
loss of intestinal fluid, so we should avoid unnecessary bowel
preparation; No catheter before an operation and no drainage
tube during the operation can reduce the discomfort and pain of
children, which is conducive to getting out of bed early (18).
In addition, indwelling abdominal drainage tubes may also
increase complications such as incision infection and small
intestinal obstruction (19). (2) Intraoperative: Control fluid
velocity and intake, develop personalized fluid replacement plans.
Low blood volume can lead to insufficient organ perfusion,
while high blood volume can increase the incidence of
postoperative intestinal obstruction (20). Postoperative: Early
bedridden activities can distract children’s attention, reduce pain,
shorten fasting time, reduce fluid replacement, and promote
gastrointestinal recovery.
Postoperative analgesia is a crucial measure for children, as
non-opioid drugs and local analgesia can effectively reduce
gastrointestinal suppression and reduce stress reactions (7). This
study achieved good analgesic effects by combining ropivacaine
incision analgesia with acetaminophen suppository anal
tamponade. Under the premise of effective analgesia, avoiding
analgesic drugs that inhibit gastrointestinal peristalsis can
accelerate the recovery speed of children. The analgesic effect of
the ERAS group at 3 h and 6 h after surgery is significantly
better than that of the TS group, which is closely related to
ropivacaine incision analgesia and stabilizing the patient’s
emotions. Local anesthesia can effectively reduce postoperative
incision pain in children, alleviate their resistance to emotions,
and reduce the use of early postoperative painkillers. We did not
find any differences in complications between the two groups of
children. Both groups of children suffered from partial
completeness intestinal obstruction and abdominal pain after
surgery. The analysis of the main causes found that we need to
take into account the intra-abdominal conditions of children
during surgery while shortening the fasting time according to
ERAS. For children with perforated appendicitis and high
accumulation of pus between the intestines, fasting with water
and a liquid diet should be appropriately extended. The
stimulation of pus and inflammatory reactions can slow down
the recovery of intestinal peristalsis, and early eating may cause
symptoms such as abdominal pain and vomiting. The results of
this study may be due to the fact that ERAS accelerates the
recovery of children without affecting complications, and may
Zhang et al. 10.3389/fped.2023.1261191
Frontiers in Pediatrics 06 frontiersin.org
also be related to the small sample size of this study. More clinical
evidence is needed to determine the impact of ERAS on the
incidence of complications and readmission rates. This study
found that the satisfaction of parents in the ERAS group was
higher than that in the TS group, mainly because ERAS
education can fully reduce the emotional impact of parents’
anxiety on children, and accelerate the progress of preoperative
(chest x-ray, electrocardiogram, etc.) examinations, allowing
parents to fully participate in treatment. In addition, the ERAS
program greatly solves the problems of preoperative and
postoperative hunger and crying, postoperative pain, long
infusion time, high dosage, and the impact of crying among
patients in the same ward. It increases the interaction and
communication between patients and medical staff, reflects more
humanistic care, helps promote harmonious progress of doctor-
patient relationships, and establishes a mutual trust medical
environment.
In summary, the application effect of the ERAS concept in
complex appendicitis in children is better than that of traditional
perioperative preparation. It can promote postoperative recovery,
shorten hospitalization time, and improve comfort and parental
satisfaction of children. It has a positive role in reducing patients’
economic burden and promoting the good development of
doctor-patient relationships. The smooth progress of the
accelerated rehabilitation plan requires the joint cooperation of
clinical doctors, nursing staff, anesthesiologists, and relevant
clinical departments. At the same time, after fully understanding
the disease situation and treatment plan, the family members of
the patient can actively cooperate with the doctor to participate
in clinical treatment, reduce their anxiety, increase
communication and trust between doctors and patients, help the
patient overcome fear, and better cooperate with treatment.
Conclusion
In conclusion, ERAS has obvious advantages in patients with
appendicitis after surgery over traditional surgery in reducing
inflammation-related indicators levels, promoting postoperative
recovery, analgesia, shortening the first exhaust time, shortening
the length of hospital stay, saving hospitalization costs and
improving parental satisfaction, and does not increase the
incidence of postoperative complications. This study demonstrates
that ERAS appears to be a safe and feasible postoperative recovery
option for patients with complex appendicitis.
Data availability statement
The raw data supporting the conclusions of this article will be
made available by the authors, without undue reservation.
Ethics statement
The studies involving humans were approved by this study was
approved by the Ethics Committee of the Maternal and Child
Health Hospital of Inner Mongolia Autonomous Region
(Approval No. [2020] Lun Han Shen No. [074-2]) and obtained
informed consent from patients’guardians. The studies were
conducted in accordance with the local legislation and
institutional requirements. Written informed consent for
participation in this study was provided by the participants’legal
guardians/next of kin.
Author contributions
JZ: Conceptualization, Writing –original draft. HL:
Conceptualization, Writing –original draft. XW: Data curation,
Formal Analysis, Writing –original draft. HY: Data curation, Formal
Analysis, Writing –original draft. YL: Data curation, Formal Analysis,
Writing –original draft. LQ: Data curation, Formal Analysis, Writing
–original draft. YB: Data curation, Formal Analysis, Writing –
original draft. LY: Data curation, Formal Analysis, Writing –original
draft. HZ: Data curation, Formal Analysis, Writing –original draft.
XW: Supervision, Writing –review & editing. YJ: Supervision,
Writing –review & editing.
Funding
The author(s) declare financial support was received for the
research, authorship, and/or publication of this article.
This work was financially supported by Inner Mongolia Science
and Technology Department Technology Research Project
(No.2021GG0397).
Conflict of interest
The authors declare that the research was conducted in the
absence of any commercial or financial relationships that could
be construed as a potential conflict of interest.
Publisher’s note
All claims expressed in this article are solely those of the
authors and do not necessarily represent those of their affiliated
organizations, or those of the publisher, the editors and the
reviewers. Any product that may be evaluated in this article, or
claim that may be made by its manufacturer, is not guaranteed
or endorsed by the publisher.
Zhang et al. 10.3389/fped.2023.1261191
Frontiers in Pediatrics 07 frontiersin.org
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