Available online 28 March 2024, 151400

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Enhanced recovery protocols (ERP) have been widely adopted in adult populations, with over 30 years of experience demonstrating the effectiveness of these protocols in patients undergoing gastrointestinal (GI) surgery. In the last decade, ERPs have been applied to pediatric populations across multiple subspecialties. The objective of this manuscript is to explore the evolution of how ERPs have been implemented and adapted specifically for pediatric populations undergoing GI surgery, predominantly for inflammatory bowel disease. The reported findings reflect a thorough exploration of the literature, including initial surveys of practice/readiness assessments, consensus recommendations of expert panels, and data from a rapidly growing number of single center studies. These efforts have culminated in a national prospective, multicenter trial evaluating clinical and implementation outcomes for enhanced recovery in children undergoing GI surgery. In short, this historical and clinical review reflects on the evolution of ERPs in pediatric surgery and expounds upon the next steps needed to apply ERPs to future pediatric populations.

Section snippetsEvaluation of ERPs in Pediatric Surgery

While ERPs were being widely adopted in adult populations, the translation of ERPs from adult to pediatric surgical populations lagged. In 2016, Shinnick et al. reviewed the existing literature on ERPs in pediatric surgery, which, at the time, was limited to one retrospective and four prospective cohort studies.13 These studies incorporated 6 or fewer of the 20 recommended interventions in the adult ERAS® Society guidelines including the use of preoperative counseling with expectation setting,

Development of a National Prospective Clinical Trial

In 2020, Raval et al. launched, to date, the largest prospective study of a pediatric-specific ERP, entitled the ENhanced Recovery In CHildren Undergoing Surgery (ENRICH-US) intervention.30 This stepped-wedge, cluster-randomized clinical trial is currently ongoing at 18 sites across the country. The study employs a hybrid design to concurrently explore ERP effectiveness and implementation. Each site was randomly assigned to 1 of 3 clusters (cluster-randomized) with 6 hospitals per cluster (

Preliminary Results and Experience from ENRICH-US

Publications on the preliminary results and experience from the first three years of the ENRICH-US trial have already provided novel contributions to ERP and randomized controlled trial development. Reiter et al. examined the alignment between pediatric patient and caregiver perspectives using ENRICH-US patient-reported outcome (PRO) data.31 As part of the trial, patients and caregivers complete preoperative and postoperative surveys regarding surgery preparedness, perioperative expectations,

Current State and Future Directions

As of 2023, publications on enhanced recovery in children totaled over 3,000 results. While most of the literature consists of single-center studies with small sample sizes, the cumulative evidence for pediatric ERPs is growing and promising. More recently, updated meta-analyses on pediatric ERPs have been published reflecting this rapid growth in the literature. Longanathan et al. included 16 studies representing 1,723 patients.36 The authors found studies implemented, on average, 15 ERP

Conclusion

This review demonstrates how ERPs in pediatric surgery have evolved from fringe practice to a contemporary standard of care at many institutions. Nonetheless, high-quality data supporting ERP bundles are needed. Further, studies demonstrating which specific elements of an ERP are most important could guide deployment of resources. Obstacles to widespread implementation of ERPs remain a practical challenge, and identifying strategies to optimize adoption and dissemination should continue to be

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