So many measures in ERAS protocol: Which matters most?

Enhanced recovery after surgery (ERAS), which includes multiple measures, has gradually become the standard perioperative management in pediatric surgery. However, it is still unclear which of the many measures has a greater impact on the outcomes. We retrospectively analyzed the medical records of children with congenital choledochal cyst who underwent surgical treatment in a specialized children's hospital from January 2019 to December 2022. Data including baseline factors, implementation of ERAS interventions, postoperative complications and postoperative length of hospital stay (PLOS) were collected. Univariate and multivariate analysis were performed to identify the association between PLOS and baseline factors or specific ERAS measure. The implementation rate of ERAS measures ranged from 5.02% to 100% in 219 cases who underwent 3 to 14 ERAS measures. Univariate analysis showed that body mass index-for-age z-scores (BAZ) and liver function indicators, as well as postoperative complications, were the significant baseline factors for PLOS, while the measures with greater impact on PLOS were early postoperative feeding and early removal of tubes. Multivariate analysis with different models revealed that postoperative complications, early postoperative feeding, and early catheter removal influenced the PLOS the most. A prolonged PLOS was associated with poor preoperative nutritional status, elevated liver function indexes, and postoperative complications. Early postoperative feeding and tubeless seem more likely to be with a reduced PLOS compared to other measures, which need to be paired more attention when implementing the ERAS protocol.