YJPSU-59406; No of Pages 5

Journal of Pediatric Surgery xxx (xxxx) xxx

Contents lists available at ScienceDirect

Journal of Pediatric Surgery

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

ERAS Protocol for Pediatric Laparoscopic Cholecystectomy Promotes Safe

and Early Discharge☆,☆☆,☆☆☆
Andrew Yeh a, Gabriella Butler b, Stephen Strotmeyer b, Kelly Austin b, Mihaela Visoiu c,
Franklyn Cladis c, Marcus Malek b,⁎
a
Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA
b
Division of Pediatric General and Thoracic Surgery, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
c
Department of Anesthesiology, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA

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

Article history: Purpose: Elective laparoscopic cholecystectomy (LC) pediatric patients in our institution have historically been
Received 15 September 2019 admitted for an overnight hospital stay (OHS). The purpose of this study was to implement an ERAS protocol
Accepted 29 September 2019 for elective LC in pediatric patients to promote same-day discharge (SDD) while maintaining excellent outcomes.
Available online xxxx Methods: An ERAS protocol for elective LC was implemented encompassing pre-, peri-, and postoperative man-
agement. A retrospective review of prospectively collected data from patients before (BI) and after implementa-
Key words:
tion (AI) of the protocol was performed.
ERAS
Laparoscopic cholecystectomy
Results: A total of 250 patients (BI 105, AI 145) were included in the study. The AI group had significantly higher
rate of SDD compared to BI (77.2% vs. 1.9%, p b b 0.01) and significantly decreased opioid use (morphine equiv-
alents mg/kg AI 0.36 vs. BI 0.46, p b b 0.001). There were also no significant differences in the rate of total 30-day
emergency department visits (BI 11.4% vs. AI 9.7%, p = 0.52) or surgery-related 30-day emergency department
visits (BI 7.6% vs. AI 8.3%, p = 0.53). Factors that predisposed patients to an OHS after LC included higher ASA,
later surgery start times, and longer operative times.
Conclusions: The ERAS protocol significantly increased the rate of SDD after elective LC in pediatric patients with-
out an associated increase in emergency department visits or readmissions.
Level of evidence: III.
© 2019 Published by Elsevier Inc.

The laparoscopic approach to cholecystectomy was first performed
in adults in the 1980s and has now clearly supplanted the open proce-
dure as the standard approach to cholecystectomy. The laparoscopic ap-
proach offers several advantages over the open technique, including
decreased length of stay, smaller incisions, and reduced postoperative
pain [1]. The dramatic reduction in postoperative pain has allowed elec-
tive laparoscopic cholecystectomy (LC) to become a largely outpatient
procedure in adults. Several adult studies comparing same-day dis-
charge (SDD) versus an overnight hospital stay (OHS) after LC show
☆ Financial Support: None.
☆☆ Conflicts of Interest: None.
☆☆☆ How this paper will improve care: Implementation of an ERAS protocol for perioper-
ative management of laparoscopic cholecystectomy promotes reduced perioperative opi-
oid usage and an increased rate of same-day discharge while maintaining excellent
outcomes. Input from surgery, anesthesia, and nursing were critical for the success of this
protocol.
⁎ Corresponding author at: Division of Pediatric General and Thoracic Surgery, UPMC
Children's Hospital of Pittsburgh, 4401 Penn Avenue, 7th floor Faculty Pavilion, Pittsburgh,
PA 15244. Tel.: +1 4126 928 735; fax.:+1 412 6928 299.
E-mail address: marcus.malek@chp.edu (M. Malek).
no differences in mortality, adverse events, or readmission rates [2].
Furthermore, no differences in the degree of postoperative symptoms
(pain, nausea, anxiety) have been shown when comparing SDD or
OHS patients [2].
In the pediatric population, there are limited data evaluating the role
of SDD after LC. A study by Mendez et al. retrospectively reviewed 35
pediatric patients that underwent either SDD or OHS after an LC and
found that SDD was safe and effective when comparing these small
groups [3]. Dalton et al. and Gould et al. have also demonstrated safe
SDD in larger patient series, and interestingly found the ability to do
so was correlated with an early start time for surgery [4,5].
Enhanced Recovery After Surgery (ERAS) protocols have become
more prevalent over the past decade, and have helped improve postop-
erative management strategies. ERAS protocols have demonstrated that
a multidisciplinary approach to perioperative care of surgical patients,
with early diet advancement and ambulation, limitation of narcotics,
and aggressive prevention of postoperative nausea and vomiting
(PONV) can accelerate recovery, and lead to earlier discharge from the
hospital, while maintaining patient safety. These protocols were initially
developed for colorectal surgery patients, but have since extended to

https://doi.org/10.1016/j.jpedsurg.2019.09.053
0022-3468/© 2019 Published by Elsevier Inc.

Please cite this article as: A. Yeh, G. Butler, S. Strotmeyer, et al., ERAS Protocol for Pediatric Laparoscopic Cholecystectomy Promotes Safe and Early
Discharge, Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2019.09.053
2 A. Yeh et al. / Journal of Pediatric Surgery xxx (xxxx) xxx
adult patients undergoing hepatobiliary, cardiac, and urologic proce-
dures. In pediatric surgery, ERAS implementation has certainly lagged
behind, but some groups are starting to present data on their early expe-
rience [6].
Understanding there was an opportunity to streamline the care of
pediatric patients following LC, we used what we have learned from
ERAS to design and implement a multidisciplinary protocol for elective
pediatric LC. We performed a retrospective review of prospectively col-
lected data of pediatric patients undergoing LC before and after imple-
mentation of the ERAS protocol over a 4-year period. We hypothesize
that standardization of perioperative care with aggressive pain and
PONV management would lead to increased rates of SDD while main-
taining excellent outcomes.
1. Material and methods
1.1. Patient population
Patients undergoing an elective LC between January 2014 and 2018
were included in the study. This time period included patients prior to
implementation of the ERAS protocol when the standard of care was
for an OHS. This study was approved by the Institutional Review Board.
1.2. Pre-ERAS patient management
Prior to implementation of the ERAS protocol, patients generally had
an OHS at the discretion of the surgeon. Diet advancement and PONV
management were at the discretion of the surgeon and/or
anesthesiologist.
1.3. ERAS protocol
The design of the ERAS protocol was a collaborative effort with sur-
geons, anesthesiologists, nursing staff, and quality officers. The protocol
is summarized in Fig. 1 and contains preoperative, perioperative, and
postoperative components.
The preoperative clinic component was initiated in patients once
they were scheduled to undergo an elective LC. Patients and their fam-
ilies were counseled on the ERAS protocol and the aim for a SDD. They
Fig. 1. Overview of ERAS protocol.
Please cite this article as: A. Yeh, G. Butler, S. Strotmeyer, et al., ERAS Protocol for Pediatric Laparoscopic Cholecystectomy Promotes Safe and Early
Discharge, Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2019.09.053
were counseled on early postoperative mobilization, diet advancement,
and PONV management. Patients were then scheduled with an early op-
erating room start time.
The perioperative component was initiated in the preoperative
holding area. Patients deemed to be at high risk for PONV based on an
Apfel score of 4 were administered a transdermal 1.5 mg extended re-
lease scopolamine patch [7]. Pain management included the use of
scheduled acetaminophen and ketorolac IV (at the surgeon's discretion)
and fentanyl IV as needed. Emphasis was made on limiting the use of
narcotics and intravenous fluids. PONV was managed with scheduled
dexamethasone IV at the start of the case and scheduled ondansetron
IV at the conclusion of surgery.
The postoperative component was initiated in the postanesthesia
care unit (PACU) and involved pain management (hydromorphone IV,
oxycodone PO, acetaminophen IV, and ketorolac IV), early mobilization,
and early diet advancement. Postoperative nausea was managed with
ondansetron IV as needed. Nurses and the anesthesia team in the
PACU were given discretion on when the patient was adequately alert
to begin ambulation and diet advancement. If the patient was ambulat-
ing, tolerating a diet, and their pain was under control, they were
discharged from the PACU with prescriptions for a short course of oxy-
codone (5 mg tablets), acetaminophen, ibuprofen, and senna.
Following discharge, postoperative monitoring for emergency de-
partment and readmissions was completed.
1.4. Data collection
Prospective collection of patient demographic and clinical data from
the electronic medical record was performed on a monthly basis for all
patients undergoing an elective LC.
1.5. Statistics
Univariate and multivariate logistic regression was performed to as-
certain the effects of age, gender, ethnicity, BMI, ASA, indication for pro-
cedure, surgery start time, and operative time on the likelihood of SDD
after implementation of the ERAS protocol.
 A. Yeh et al. / Journal of Pediatric Surgery xxx (xxxx) xxx 3

Table 1
Patient demographics and surgical indications before and after ERAS implementation.

Before Implementation (BI; n = 105) Full Implementation (AI; n = 145) p-value

Age 13.5 (0 to 20) 14.6 (3 to 31) 0.08

Female 78 118
Gender 0.58
Male 27 27
White 94 132
Black 8 10
Ethnicity Asian 0 0 0.43
Pacific Islander 1 0
Not specified 2 3
Body Mass Index 24.2 (13.9 to 46.0) 26.6 (13.3 to 57.6) bb0.01
Abdominal pain 21 15
Biliary dyskinesia 37 38
Cholelithiasis / biliary colic 8 13
Indication for Surgery 0.17
Chronic acalculous cholecystitis 8 30
Chronic calculous cholecystitis 27 42
Other 4 7

Age and body mass index are shown as means with the range in brackets.

2. Results patients). The rate of 30-day readmissions were also not significantly
different between groups (BI 5.7% vs. AI 2.1%, p = 0.37).
2.1. Patient population
2.3. SDD vs OHS after ERAS implementation
A total of 250 pediatric patients undergoing an elective LC between
2014 and 2018 were included in the study. There were 105 patients in
We sought to determine what patient and/or clinical factors after
the group before implementation of the protocol (BI) and 145 patients
implementation of the ERAS protocol may predict an OHS. On univariate
in the group after full implementation of the protocol (AI). Patient char-
analysis, we found that patients in the AI group that were more likely to
acteristics are shown in Table 1. Age, gender, ethnicity, and ASA were
be admitted overnight had a higher ASA class (p b b 0.001), were more
not different between BI and AI. BMI was slightly greater in the AI
likely to have a later surgery start time (SDD 10:12 AM vs OHS
group compared to BI (24.2 vs 26.2, p = 0.0004). Indications for surgery
11:53 AM, p = 0.006) and had longer operative times (SDD 1.11 h vs.
between the BI and AI groups were not statistically different. However,
OHS 1.46 h, p = 0.004) compared to patients that underwent SDD. Mul-
there was a trend toward a greater proportion of acalculous chronic
tivariate logistic regression confirmed these findings with a lower ASA
cholecystitis and lesser proportion of biliary dyskinesia and abdominal
(p = 0.01), earlier surgery start time (p = 0.002), and shorter operative
pain not otherwise specified in the AI group compared to BI.
time (p = 0.005) associated with SDD.

2.2. BI vs AI 3. Discussion

The AI group had a significantly greater rate of SDD (77.2%) com-
pared to the BI group (1.9%) (Table 2). In regards to length of stay
(LOS) in hours, AI had an average LOS of 13.6 h compared to BI with
27.5 h (p b b 0.001). When comparing surgery start time, patients in
the AI group had an earlier average surgery start time of 10:37 AM com-
pared to BI with an average surgery start time of 12:22 PM (p b b0.001).
Operative time, type of surgery (laparoscopic vs. robotic), and estimated
blood loss were not significantly different between groups. Opioid use
was significantly reduced on the day of surgery in the AI group com-
pared to BI (morphine equivalents/kg AI 0.36 vs. BI 0.46, p b b0.001,
Fig. 2). There were also no significant differences in the rate of total
30-day emergency department visits (BI 11.4% vs. AI 9.7%, p = 0.52)
or surgery-related 30-day emergency department visits (BI 7.6% vs. AI
8.3%, p = 0.53). Most common reasons for surgery-related visits to
the emergency department included nausea/vomiting (BI 5 of 8
patients, AI 6 of 12 patients) and pain (BI 3 of 8 patients, AI 2 of 12
The goal of this study was to implement an ERAS protocol that stan-
dardized the postoperative care of pediatric LC patients and actively
promoted SDD. After implementation of our protocol, we saw a signifi-
cant increase in the rate of SDD from 1.9% to 77.2%. The simple act of
creating a standardized protocol and the associated awareness of the
protocol, likely played a major role in the dramatic increase in SDD
and decrease in opioid administration on the day of surgery. Preopera-
tive patient and family education regarding ERAS and SDD, as well as
changes in analgesic strategy and aggressive management of PONV,
was likely also important contributing factors.
In adults, several studies have demonstrated that SDD after LC is safe,
well tolerated by patients, and does not result in increased rates of failed
discharges [2]. There are published studies that show patients undergo
SDD after elective LC but do not evaluate its effect on failed discharges
[8,9]. Dalton et al. and Gould et al. compared SDD to OHS and found
no increased rates of complications [4,5]. Our study is the largest cohort

Table 2
Surgical parameters and outcomes of patients before and after ERAS implementation.

Before Implementation (BI; n = 105) Full Implementation (AI; n = 145) p-value

Surgery Start Time 12:22 PM (7:40 AM–7:03 PM) 10:37 AM (7:45 AM–6:19 PM) bb0.01
Operative Time (h) 1.17 (0.43–2.97) 1.22 (0.33–2.90) 0.78
Length of Stay (h) 27.5 (10.5–48.6) 13.6 (0.4–52.9) bb0.01
Same Day Discharge 2 (1.9%) 112 (77.2%) bb0.01
Total Visits 12 (11.4%) 14 (9.7%) 0.52
ED Return Visits
Surgery-Related Visits 8 (7.6%) 12 (8.3%) 1
30 day Readmissions 6 (5.7%) 3 (2.1%) 0.17

Values display either means or total number of patients. Brackets denote either ranges or percentage of patients.

Please cite this article as: A. Yeh, G. Butler, S. Strotmeyer, et al., ERAS Protocol for Pediatric Laparoscopic Cholecystectomy Promotes Safe and Early
Discharge, Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2019.09.053
4 A. Yeh et al. / Journal of Pediatric Surgery xxx (xxxx) xxx
Fig. 2. Opioid administration on the day of surgery. Morphine equivalents normalized to
patient weight (mg/kg) on the day of surgery before and after implementation of the
protocol. There was a significant decrease in AI compared to BI (0.36 vs. BI 0.46,
p b b0.001). Error bars denote standard deviation
to our knowledge showing that SDD did not result in an increase in
these balancing measures.
This is also the first study to our knowledge to publish results from
implementation of an ERAS protocol for pediatric LC in a large cohort
of patients. Only a handful of studies have evaluated the role of ERAS
in pediatric surgery in general. Surgical procedures that have been stud-
ied include appendectomies, hypospadias repairs, nephrectomies,
pyloromyotomies, fundoplications, ileocecectomies, and bowel surger-
ies requiring anastomoses [10–14]. Most of these studies did demon-
strate a reduction in hospital length of stay when the ERAS protocol
was implemented. Jawaheer et al. implemented an ERAS protocol for
LC that is similar to what we present here. Although they were able to
show an increase in SDD, the study was limited to evaluation of only
13 patients in the ERAS arm and 25 patients total [6].
This study has also demonstrated that, after implementation of the
ERAS protocol, factors associated with an OHS included a higher ASA
class, longer operative times, and later surgery start times, similar to
what was found in the studies by Dalton et al. and Gould et al. [4,5].
These factors make intuitive sense in that more medically complex pa-
tients (higher ASA class) or difficult cases (longer operative times)
result in overnight observation. Additionally, later surgery start times
most likely resulted in an increased rate of OHS because of insufficient
time remaining in the day to recover adequately in the PACU and thus
led to an OHS.
One weakness of this study is that it is a retrospective review com-
paring patients before and after ERAS implementation. Whether the ob-
served increase in SDD is because of protocol awareness, the changes in
perioperative management initiated by the protocol, or a combination
of these factors cannot be elucidated by the current study, but we do
clearly show that creation of the protocol led to a dramatic increase in
SDD, without an increase in balancing measures. Future work will deter-
mine the cost benefit of this ERAS protocol and whether it can be
adopted for other elective surgical procedures.
4. Conclusions
The implementation of an ERAS protocol for pediatric patients
undergoing an elective LC dramatically increased the rate of SDD
Please cite this article as: A. Yeh, G. Butler, S. Strotmeyer, et al., ERAS Protocol for Pediatric Laparoscopic Cholecystectomy Promotes Safe and Early
Discharge, Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2019.09.053
without increasing the rate of postoperative emergency department
visits or readmissions. Patients that required an OHS after imple-
mentation of the ERAS protocol were more likely to be sicker (higher
ASA class), have more complicated operations (longer operative
time), or had cases that started later in the day making SDD less
likely.
Appendix A. Discussion: ERAS Protocol for Pediatric Laparoscopic
Cholecystectomy Promotes Safe and Early Discharge
Presenter: Andrew Yeh.
Male Did you want to show anything from the toolkit?
Andrew Yeh I have it uploaded online.
Male While we take a question, we could switch to the online
website. That would be great.
Q. Kurt Heiss, Atlanta Nice presentation. Can you tell us a little bit about
important steps you made in implementation of this in your
team in your institution? Every time you start a new semi-
enhanced recovery type thing, it requires some adjustments.
What were the inflection points as you worked with your
team to make this happen?
Andrew Yeh I think the most important thing as with all these QI pro-
jects I'm sure, is gathering all the stakeholders, getting every-
body on the same page, and working toward the same goal.
This includes not only just the anesthesia staff, which is obvi-
ously very important, but also the nursing staff and the EMR
people that helped us make a very easy to use power plan
that residents that rotate in and out of the service can use
quite easily and follow the protocol.
Q. Female Cincinnati. Quick question. The patients that you had, were
they actually discharged from the PACU, or did they actually
get admitted to the floor? Because for us in our institution,
there's a significant cost difference for patients who are actu-
ally admitted to the floor as a 22 h admit. And you don't utilize
that same cost savings if you have to admit them to the floor.
Andrew They were discharged from the PACU.
Q. Male Nice protocol. Thank you. It says you're admitting the average
start time was 10:30 in the morning. But then your average
length of stay was 13 h. So, are you discharging them at 11
o'clock or midnight?
Andrew Yeh Usually no. I think that's a result of the statistical analysis.
And I think they usually go home early evening around six
o'clock at the latest.
Q. Male Andrew, I had two questions while you pull up the toolkit
there. One is, did you guys stagger the Tylenol and Toradol
that you used intraoperatively such that in the postoperative
setting, in the PACU, they weren't waiting a full six hours be-
fore they could get additional doses of those medications.
That's something we're struggling with when we're doing a
similar same day discharge for appendicitis protocol. And
that's one of the things that we've been very thoughtful
about. Did you have to do anything along those lines?
Andrew Yeh We didn't, but it think that would be a great addition to
the QI project, and probably it would reduce opioid use
even further if we could actually stagger out the doses of
Tylenol and Toradol.
Q. Male And then the second question was for your sickle cell pa-
tients. Were any of these patients sickle cell patients with
prior opioid exposure and higher pain requirements? Were
you able to successfully get those patients home the same
day?
Andrew Yeh That's a great question. I think there were a couple of
sickle cell patients in the implementation group, but I would
have to go back and look at that. But they were included in
the study.
 A. Yeh et al. / Journal of Pediatric Surgery xxx (xxxx) xxx
Q. Male Enjoyed the presentation. I just wanted to know, when you
send these people home do you give them any narcotics? Or
is the decreased use because they don't need them?
Andrew Yeh They are given a very short course of narcotics, but they're
also given a script of Ibuprofen and Tylenol and instructed to
use those before. But yes, they are given a small short course.
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