Intestinal Obstruction Surgical Recovery To Exploit ERAS Enhancements
Overview
Acute intestinal obstruction is a medical emergency where a blockage in the intestine leads to symptoms such as severe abdominal pain, nausea, and obstipation. If left untreated, it can become life-threatening. When surgery is required, using an enhanced recovery after surgery (ERAS) pathway has shown benefits in speeding up recovery, shortening hospital stays, and improving surgical outcomes. This review aimed to gather and analyze current evidence on the use of ERAS components, particularly after surgery, in patients with acute intestinal obstruction.
The review followed a systematic process, searching databases like PubMed-Medline and Embase. Of the 1860 studies initially identified, 16 were included. These were all quantitative studies, with 11 using 10 or more ERAS interventions. The most commonly used intervention was multimodal pain relief, while blood glucose management and screening tools were the least common.
The review found that more than half of the studies used 10 or more ERAS interventions. However, it also highlighted the need for further research on the full implementation of ERAS guidelines in emergency surgery for acute intestinal obstruction.
Introduction
Acute intestinal obstruction refers to a critical blockage in the intestines that leads to a spectrum of severe clinical manifestations, including acute abdominal pain, nausea, vomiting, and an inability to pass stool or gas (obstipation). This condition is a medical emergency, as untreated obstruction can lead to life-threatening complications such as intestinal perforation, which may cause the release of intestinal contents into the abdominal cavity. This, in turn, can lead to peritonitis—a severe infection of the abdominal lining—septic shock, and death if immediate surgical intervention is not performed. The most frequent causes of intestinal obstruction include intra-abdominal adhesions, tumors, and hernias, with less common causes being volvulus (twisting of the intestine), diverticulitis, and gallstones. In particular, mechanical obstructions significantly elevate intra-abdominal pressure, potentially resulting in bowel perforation and the need for emergency surgical management.
The urgency of surgical intervention is critical in these patients, as delays are strongly associated with increased mortality rates. Rapid evaluation and timely surgery are essential in reducing the risk of fatal outcomes. Literature consistently shows that acute intestinal obstruction accounts for approximately 20% of all emergency surgeries, placing it among the leading causes of death in emergency surgical cases. This highlights the critical importance of efficient perioperative management, particularly because emergency surgery patients often present with more complex physiological issues compared to those undergoing elective surgery. These patients frequently exhibit derangements in vital systems, increasing their vulnerability to complications both during and after surgery. Such complications may include wound infections, pneumonia, and anastomotic leaks, which prolong hospital stays and significantly increase morbidity and mortality. Notably, the mortality rate for patients undergoing emergency abdominal surgery is around 15%, rising to 25% in elderly patients.
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To address these challenges, Enhanced Recovery After Surgery (ERAS) programs have emerged as an effective perioperative care pathway. ERAS is a multimodal approach designed to enhance patient recovery following major surgeries. It integrates evidence-based interventions across preoperative, perioperative, and postoperative phases of care, aimed at reducing the physiological stress response to surgery. By grouping these interventions into structured care bundles, ERAS programs have been shown to reduce postoperative complications, accelerate recovery, and shorten hospital stays. Originally developed for elective colorectal surgeries, ERAS protocols have consistently demonstrated improved patient outcomes, including reduced surgical stress, fewer postoperative complications, and shorter lengths of hospitalization.
Recent studies suggest that these benefits are not limited to elective surgeries. Emerging evidence supports the use of ERAS protocols in emergency surgical cases, including those involving acute intestinal obstruction. Emergency surgeries, especially for intestinal blockages, pose a unique set of challenges due to the urgency and the heightened risk of complications. While early ERAS protocols for emergency surgeries were adapted from elective colorectal guidelines, more recent research has led to the development of specific ERAS guidelines for emergency abdominal surgeries, including those for intestinal obstruction. Published between 2021 and 2023, these new guidelines aim to standardize evidence-based interventions in emergency settings, incorporating them into a multidisciplinary care model.
These guidelines outline 35 key ERAS interventions, which are divided into three phases: preoperative (items 1–12), perioperative (items 13–26), and postoperative (items 27–35). The interventions cover a wide range of practices, including multimodal analgesia for pain control, early mobilization to reduce postoperative complications, and nutritional support to aid recovery. This structured approach ensures that patients undergoing emergency surgery for acute intestinal obstruction receive comprehensive, coordinated care designed to optimize recovery outcomes.
This scoping review was conducted to identify and synthesize the current body of evidence regarding the implementation of ERAS protocols, with a specific focus on postoperative components in patients undergoing surgery for acute intestinal obstruction. By summarizing the available research, this review aims to provide a clearer understanding of how ERAS protocols are applied in emergency surgical cases and to highlight areas where further research is needed. In particular, the review underscores the importance of future studies focusing on the effectiveness of ERAS guidelines in emergency laparotomies, as this could lead to further improvements in patient outcomes and reduced healthcare costs.
Methods
This scoping review was conducted following the PRISMA-ScR checklist and the Arksey & O’Malley framework, utilizing the PEO (population/exposure/outcome) methodology to guide the search strategy. The search was designed to focus on patients undergoing emergency laparotomy or laparoscopy for intestinal obstruction (population), the use of ERAS interventions (exposure), and the number of guideline interventions applied along with their implementation method (outcome). The search was carried out systematically across PubMed and Embase databases on February 2, 2024, using a combination of medical subject headings (MESH/Emtree) and relevant free text terms related to ERAS guidelines, surgical procedures (laparoscopy or laparotomy), and postoperative complications. The search terms were connected using Boolean operators to maximize the inclusion of pertinent studies.
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Inclusion criteria for this review required studies to have been published before February 2, 2024, and to have involved patients undergoing emergency laparotomy or laparoscopy due to acute intestinal obstruction. These studies had to focus on the application of ERAS interventions either preoperatively, perioperatively, or postoperatively. The study sample was limited to adult populations, and multicenter studies were preferred to avoid duplication of subpopulation data. Manual checks were performed to ensure that no relevant articles were overlooked.
Exclusion criteria included studies where intestinal obstruction was resolved nonsurgically, as well as those investigating only elective surgeries. Pediatric and geriatric-specific studies were excluded to maintain a focus on the adult population undergoing emergency surgical intervention. Meta-analyses, case reports, study protocols, editorials, reviews, and conference abstracts without accompanying full articles were also excluded. Non-English language studies were excluded to avoid potential biases related to language translation.
To manage the review process, studies were imported into the Covidence software, where they underwent a two-stage review. Any disagreements between reviewers were resolved through consensus discussions. ERAS interventions were categorized into pre-, peri-, and postoperative phases, with attention paid to risk scoring, medication management, screening tools, and strategies for reducing postoperative complications such as ileus. Each intervention was evaluated for its evidence level and recommendation grade based on the ERAS guidelines.
Results
The search process yielded 1860 articles, with 174 duplicates removed. A total of 1686 articles were screened by title and abstract, resulting in 65 selected for full-text review. Primary reasons for exclusion included inappropriate study design (n = 32), meta-analyses (n = 8), abstracts without full articles (n = 5), and irrelevant studies. The final review included 16 studies with a mean sample size of 1783 participants, ranging from 30 to 15,856. The studies comprised five randomized controlled trials, 10 cohort studies, and one case-control study. Six of the cohort studies were retrospective, while five were prospective. Most studies aimed to assess the efficacy and benefits of Enhanced Recovery After Surgery (ERAS) components. Eleven studies demonstrated significantly reduced hospital length of stay (LOS), fewer complications, and/or decreased mortality, while one study reported a prolonged LOS and another showed no benefit in mortality, hospital stay, or readmission rates.
The 16 studies were compared to examine their aims, outcomes, types of interventions, and the number of ERAS components applied. More than half (56%) implemented 10 or more ERAS interventions, with an average of 13 interventions in these studies, while the overall average across all studies was 10 interventions. Multimodal systemic analgesia was the most frequently used intervention, followed by infection prevention, goal-directed hemodynamic therapy (GDHT), and intravenous fluid and electrolyte management. Postoperative interventions like urinary catheter removal, nasogastric tube use, nutrition, ileus prevention, and early mobilization were applied in 6 to 10 studies.
The least common interventions were neuromuscular block monitoring, blood glucose management, and postoperative delirium screening, which were not used in any of the reviewed studies.
Regarding outcomes, three studies reported significant reductions in mortality rates, with risk-adjusted mortality decreasing from 5.3% to 4.5% in one study and unadjusted 30-day mortality decreasing from 21.8% to 15.5% in another. Seven studies observed significant reductions in morbidity, including decreased surgical site infections (SSI) and overall complications. One study found a reduction in SSI from 58% to 20.7%, while another noted a reduction in major complications. Seven studies reported significant decreases in LOS, with an average reduction of at least two days, leading to an average hospital stay of about 8 days across studies.
Conclusion
This scoping review highlights that while there is substantial evidence supporting the effectiveness of ERAS interventions and care bundles, only 56% of the reviewed studies implemented more than 10 interventions. It is anticipated that the introduction of the new ERAS guidelines will encourage broader adoption of these interventions. Future research should focus on evaluating the implementation of various ERAS protocols in patients undergoing emergency abdominal surgery.
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