A modified enhanced recovery after surgery (ERAS) protocol shortened the postoperative hospital stay without increasing complications among children undergoing open appendectomy for complicated acute appendicitis in a Mexican public hospital, according to a randomized clinical trial. Researchers said the findings support the feasibility of implementing ERAS protocols in resource-limited healthcare settings.

Published in Pediatric Surgery International, the trial found that children managed with a modified ERAS protocol had significantly shorter postoperative hospital stays than those receiving conventional care, without an increase in 30-day postoperative complications. The researchers concluded that the protocol is a feasible and effective strategy for resource-limited healthcare systems.

Speaking with Medscape’s Spanish edition, Gabriela Ambriz González, MD, pediatric surgeon and chief of the Department of Pediatric Surgery, High Specialty Medical Unit, Pediatric Hospital of the Medical Center of the West, Mexican Social Security Institute, Guadalajara, Mexico, and a coauthor of the study, said, “It is an easy-to-implement protocol that benefits patients, healthcare professionals, and healthcare systems alike.” 

Ambriz González noted that many public hospitals in Mexico continue to face shortages of staff and financial resources. She added that prolonged hospitalization after surgery increases the risk for surgical and nonsurgical complications, while reducing bed availability for other patients.

“The earlier patients are discharged, the lower their risk for complications. Earlier discharge also frees hospital beds for patients who might otherwise remain on waiting lists because of limited capacity,” she said.

Trial Findings

The researchers conducted a randomized clinical trial during the second half of 2022 at the same tertiary care hospital. This study enrolled 40 children aged < 17 years with complicated acute appendicitis who underwent open appendectomy. Participants had a mean age of 8 years, 70% were boys, the mean duration of symptoms before presentation was 47 h, and 85% had a perforated appendix.

Twenty participants received a modified 3-day ERAS protocol that included intravenous (IV) ceftriaxone (50-100 mg/kg/d) and metronidazole (30 mg/kg/d), or amikacin and metronidazole for children with beta-lactam allergy. Ondansetron (0.15 mg/kg every 8 hours) was administered during the immediate postoperative period to prevent nausea and vomiting. Oral intake began 6 hours after surgery with a liquid diet.

After completing 3 days of IV antibiotics and meeting the discharge criteria, including adequate oral diet intake, effective pain control, and remaining afebrile for ≥ 24 hours, children continued oral metronidazole and amoxicillin or clindamycin for those with beta-lactam allergy for an additional 7 days.

The remaining 20 patients received conventional postoperative care consisting of a 5-day hospital stay, a triple IV antibiotic regimen (100 mg/kg ampicillin every 8 hours, 15 mg/kg/d amikacin, and 30 mg/kg/d metronidazole), and the initiation of oral feeding with a liquid diet only after the restoration of bowel function. At discharge, these children received the same oral antibiotic regimen as the ERAS group.

Children treated with the ERAS protocol had a significantly shorter postoperative hospital stay than those receiving conventional care (mean, 3.15 vs 5.20 days; P = .001). The 30-day postoperative complication rate was identical in both groups (40%) and consisted primarily of minor events, including seromas, surgical site infections, and wound dehiscence involving less than 25% of the incision site.

Expert Perspective

Mario Andrés González Chávez, MD, general surgeon at Hospital Español de México in Mexico City, who was not involved in the study, said the findings are particularly relevant for Mexico and Latin America because they reflect routine clinical practice.

“Unlike many ERAS studies conducted in centers where laparoscopic surgery predominates, this trial was performed in a Mexican public hospital and evaluated open appendectomy, which remains common throughout the region,” he said.

Although González Chávez praised the study design, he cautioned that the single-center trial included only 20 patients per group, limiting its ability to detect less common but clinically important outcomes such as intra-abdominal abscesses, reoperations, and hospital readmissions.

“Its greatest contribution is demonstrating that ERAS principles, including early nutrition, early mobilization, and standardized perioperative care, can accelerate recovery without compromising safety,” he said. “These benefits were achieved using simple, low-cost measures, demonstrating that optimizing clinical processes can be just as important as introducing new technology.”

Overcoming Resistance

González emphasized that the findings alone are not sufficient to warrant a change in clinical practice. However, they provide a strong rationale for surgical departments to review traditional postoperative protocols and consider implementing ERAS programs tailored to local resources.

Resistance to change remains a major barrier. Despite growing evidence supporting ERAS, many surgeons continue to favor traditional postoperative practices, including delayed oral feeding, routine use of nasogastric tubes, and surgical drains after pediatric appendectomy.

“The greatest challenge was changing long-held beliefs. Many surgeons see little reason to change practices that appear to work without considering complications such as antibiotic resistance and phlebitis,” Ambriz González said.

She emphasized that successful implementation requires coordinated participation by pediatric surgeons, anesthesiologists, nursing staff, patients, and families.

González agreed, noting that successful ERAS programs depend more on multidisciplinary coordination than on additional staffing.

“For decades, surgeons were trained to use prolonged fasting, delayed oral feeding, routine catheter placement, and longer hospital stays,” he said. “Changing practices that have long been considered safe requires changing deeply ingrained habits.”

According to González Chávez, education, standardized protocols, and measurable outcomes are the most effective ways to encourage adoption.

“When surgical teams see that ERAS shortens hospital stay without increasing complications, acceptance tends to grow,” he said.

Implications for Health Systems

Ambriz González noted that the ERAS protocol has already become standardized at her public hospital, although a small number of clinicians remain reluctant to adopt it. She attributed its successful implementation in part to the hospital’s role as a training center, where surgical residents were introduced to the protocol early in their careers.

She expects adoption to become more widespread over time but noted that ERAS is currently more common in Mexico’s private healthcare sector, where patients are more likely to have access to its benefits.

“In private practice, most surgeons already manage appendectomy patients using ERAS principles. In the public sector, we still need stronger teamwork and greater involvement of patients and their families throughout the recovery process,” she said.

González also noted that the ERAS implementation at his hospital has progressed gradually, with early mobilization, multimodal analgesia, and early oral feeding proving the easiest components to incorporate into routine care.

He believes that health policymakers should consider ERAS a safe, effective, and efficient strategy.

“The available evidence, including this Mexican study, shows that ERAS can shorten hospital stay without increasing complications. In resource-limited healthcare systems, this translates into greater bed availability, more efficient use of resources, and faster recovery for patients,” he said.

Ambriz González agreed that health authorities should actively promote ERAS protocols.

“Implementing these protocols benefits patients while helping preserve scarce healthcare resources in Latin American hospitals facing shortages of medical supplies and personnel,” she said. “Children recover best at home. Earlier discharge allows them to return to their normal lives sooner while minimizing disruption for their families.”

Ambriz González and González Chávez reported having no relevant conflicts of interest.

This story was translated from Medscape’s Spanish edition.