Comparison Between Conventional and Enhanced Recovery After Surgery (ERAS) Protocol in Cases of Emergency Laparotomy

Enhanced Recovery After Surgery (ERAS) or Early Recovery Programs (ERP) represents a paradigm shift in perioperative care, aiming to mitigate surgical stress and accelerate patient recovery. While well-established in elective colorectal surgeries, its efficacy in emergency settings, particularly for acute abdomen requiring emergency laparotomy, remains less explored. This study investigates the effect of a tailored ERAS care protocol on patients undergoing emergency laparotomy.

A prospective randomized controlled study was conducted in the Department of General Surgery, Indira Gandhi Institute of Medical Sciences, Patna, India, from April 2023 to April 2025 (CTRI No: CTRI/2023/05/052783).Seventy-eight patients aged 18-65 years, presenting with acute abdomen and scheduled for emergency laparotomy (ASA I-II), were randomized 1:1 into either the ERAS group or conventional (CONV) group (n=39 each) using computer-generated block randomization and serially numbered opaque sealed envelopes (SNOSE). The study was blinded to patients, envelope opening personnel and investigators. The primary endpoint variable was the duration of hospital stay (DHS). Secondary endpoints included postoperative morbidities/ complications (according to Clavien-Dindo classification), time to first flatus, postoperative pain scores/analgesia requirement and reexploration readmission rate.

The mean DHS was significantly shorter in the ERAS group (3.17 ± 0.79 days) than the CONV one (7.87 ± 3.22 days) (p<0.001). Early removal of nasogastric tubes (64.10% on Day 0 vs 58.97% on Day ≥3, p<0.001) and urinary catheters (97.44% on Day 1 vs 69.23% on Day ≥3, p<0.001) was significantly higher in the ERAS group. Also, ERAS patients were mobilized earlier (100% on Day 1 vs 48.72% on Day 2, p<0.001) and showed faster recovery of bowel function (early flatus passage 100% vs 74.36% in ≤ three days, p<0.001). Oral diet initiation was significantly earlier in the ERAS group (66.67% on Day 1 vs 87.18% on Day ≥3, p<0.001). Overall postoperative complications were lower in the ERAS group (10.26% vs 33.33%) for immediate complications, and specifically, ERAS showed lower incidences of postoperative ileus (2.56% vs 15.36%), postoperative nausea vomiting (PONV) (5.12% vs 10.24%), lung complications (0% vs 8.18%), superficial surgical site infection (SSI) (5.13% vs 12.82%), deep SSI (0% vs 5.12%) and anastomotic leak (0% vs 2.56%) and readmission-requiring complications (5.13% vs 7.69%). Also, ERAS patients reported lower postoperative pain scores and required less opioid analgesia than subjects in the CONV group.

Application of a tailored ERAS care protocol approach in patients undergoing emergency laparotomy significantly reduces the DHS, lowers intraoperative blood loss, facilitates earlier removal of tubings, promotes early mobilization and bowel function recovery, accelerates oral diet initiation and significantly decreases postoperative complications including Postoperative ileus, PONV, lung complications and surgical site infections. These findings support the adoption of ERAS principles even in challenging emergency surgical settings.