Development of an Enhanced Recovery Program in Pediatric, Adolescent, and Young Adult Surgical Oncology Patients

Abstract

Enhanced recovery after surgery (ERAS) protocols are standardized perioperative treatment plans aimed at improving recovery time in patients following surgery using a multidisciplinary team approach. These protocols have been shown to optimize pain control, improve mobility, and decrease postoperative ileus and other surgical complications, thereby leading to a reduction in length of stay and readmission rates. To date, no ERAS-based protocols have been developed specifically for pediatric patients undergoing oncologic surgery. Our objective is to describe the development of a novel protocol for pediatric, adolescent, and young adult surgical oncology patients. Our protocol includes the following components: preoperative counseling, optimization of nutrition status, minimization of opioids, meticulous titration of fluids, and early mobilization. We describe the planning and implementation challenges and the successes of our protocol. The effectiveness of our program in improving perioperative outcomes in this surgical population could lead to the adaptation of such protocols for similar populations at other centers and would lend support to the use of ERAS in the pediatric population overall.

Optimizing the Postoperative Management of Children Undergoing Resection of High-Risk Abdominal Neuroblastoma

“…Neuraxial anesthesia is recommended as a component of multimodal analgesia regimens to minimize opioid use after surgery. 10 In patients receiving neuraxial anesthesia, we observed a decrease in opioid use immediately after surgery (POD zero), but it did not lead to a sustained decrease on subsequent days or in total opioid use. This may be due to the early removal of epidural catheters which may lead to equivalent opioid utilization between the two groups after epidural catheter removal.…”

“…This study also provides the rationale for further studies examining the utility of ERP elements in the postoperative management of HR-NB-where expedited recovery is paramount. 9,10,16 In summary, this study explores the use of ERP elements in pediatric patients undergoing open abdominal resection of HR-NB and highlights the benefits of avoiding routine NGT use, while the utility of neuraxial anesthesia is less clear. As the translation of ERAS/ERPs to pediatric surgery has shown promise, protocols are being explored in pediatric surgical oncology to improve postoperative outcomes and optimize patient recovery for adjuvant therapy.…”

“…8 Thus, while a large proportion of pediatric patients with abdominal HR-NB undergo an extensive open abdominal operation requiring expedited convalescence, wide variation in postoperative clinical management exists and little is known regarding the implementation of ERP elements in this distinct population. 9,10 This study aimed to evaluate the utility of two components of a standard adult ERP (avoidance of routine NGT and use of neuraxial anesthesia) and their effect on postoperative outcomes in pediatric patients undergoing open abdominal resection of HR-NB. We hypothesized that avoidance of routine postoperative nasogastric tube (NGT) use would permit earlier initiation of enteral intake, while the use of neuraxial anesthesia would increase utilization of indwelling urinary catheters, with no effect on total opioid utilization.…”

“…8 Thus, while a large proportion of pediatric patients with abdominal HR-NB undergo an extensive open abdominal operation requiring expedited convalescence, wide variation in postoperative clinical management exists and little is known regarding the implementation of ERP elements in this distinct population. 9,10…”

Pain and Analgesia in Children with Cancer after Hemipelvectomy: A Retrospective Analysis

“…Further investigation at MDACC within this scope will focus on our prospective Enhanced Recovery Program [ 44 ], which aims to standardize perioperative treatment plans for pediatric surgical patients in order to optimize opioid sparing pain control, improve mobility, reduce length of stay, and improve other surgical outcomes. We also plan to compare pain control and opioid exposure, in patients following our ERP guideline, to patients in our historical cohort.…”