Major abdominal surgery triggers a surgical stress response, with catabolism, insulin resistance, ileus, pain and immobility, which delays recovery and prolongs hospital stay. In the 1990s, Kehlet proposed a multimodal approach to control this postoperative pathophysiology and accelerate rehabilitation [1], which developed into fast-track surgery [2]. The Enhanced Recovery After Surgery (ERAS) Study Group later formalised these principles into an evidence-based perioperative care pathway [3,4], and ERAS is now regarded as a standard of care for many operations [5,6]. ERAS protocols include preoperative counselling, avoidance of prolonged fasting and routine bowel preparation, carbohydrate loading, opioid-sparing multimodal analgesia, goal-directed fluid therapy, avoidance of routine nasogastric tubes and drains, early oral feeding and early mobilisation. Systematic reviews and meta-analyses of randomised trials in colorectal surgery have shown that ERAS reduces the length of hospital stay and complications without increasing readmissions [7-11], and better adherence to the protocol is associated with better outcomes [12]. Moving this evidence into routine practice, however, remains a challenge [13]. Most ERAS studies have been conducted in high-income countries and in colorectal and laparoscopic surgery. In India, open surgery remains common, patients often present late with poor nutritional status, and traditional practices such as prolonged fasting, routine nasogastric decompression and delayed feeding are still widely followed. Indian randomised trials have shown that adapted ERAS pathways are safe and shorten hospital stay even in emergency surgery for perforated duodenal ulcer, small bowel disease and perforation peritonitis [14-18], and ERAS principles have been extended to emergency laparotomy [19]. Evidence for elective open abdominal surgery in general surgical units in India is still limited. The objective of this study was to compare an ERAS protocol with conventional perioperative care in patients undergoing elective open abdominal surgery, in terms of return of bowel function, time to oral feeding, postoperative pain, length of hospital stay, complications and readmission.

Study design and participants This prospective comparative study was conducted in the Department of Surgery, SMBT Institute of Medical Sciences & Research Center, Nashik. Patients aged 18 to 70 years with American Society of Anesthesiologists (ASA) physical status I to III undergoing elective open abdominal surgery through a laparotomy incision, including gastric, small bowel, colonic, biliary and other major open procedures, were included. Patients undergoing emergency or laparoscopic surgery, those with ASA grade IV, uncontrolled diabetes, severe cardiac, renal or hepatic disease, pregnancy, inability to give consent or to follow the protocol, and those needing postoperative ventilation were excluded. Written informed consent was obtained from all patients. Sample size and allocation The sample size was calculated to detect a difference of 1.5 days in postoperative hospital stay between the groups, assuming a standard deviation of 2.5 days, with a two-sided significance level of 5% and a power of 80%. This gave a minimum of 44 patients per group, which was increased to 50 per group to allow for exclusions. Eligible patients were allocated alternately to the ERAS group or the conventional care group in the order of admission. ERAS protocol Patients in the ERAS group received structured preoperative counselling about the protocol and their expected recovery. Routine mechanical bowel preparation was avoided except where specifically required. Solid food was allowed up to 6 hours and clear fluids up to 2 hours before anaesthesia [20,21], and an oral carbohydrate drink was given the night before and 2 to 3 hours before surgery in non-diabetic patients [22]. Intraoperatively, short-acting anaesthetic agents, epidural or regional analgesia where feasible, goal-directed restrictive fluid therapy and prevention of hypothermia were used. Postoperatively, opioid-sparing multimodal analgesia with paracetamol and non-steroidal anti-inflammatory drugs was used [23], and intravenous fluids were minimised and stopped as soon as oral intake was established [24,25]. Nasogastric tubes were not used routinely or were removed at the end of surgery [26], and drains were avoided or removed early [27]. Oral fluids were started 6 hours after surgery and a soft diet on the first postoperative day as tolerated [28,29]. Patients were mobilised on the day of surgery and encouraged to walk several times a day from the first postoperative day, and the urinary catheter was removed on the first postoperative day. Conventional care Patients in the conventional group were kept nil by mouth from midnight before surgery and received bowel preparation where considered necessary by the operating surgeon. Nasogastric tubes and drains were placed according to routine practice and removed when output decreased. Analgesia was provided with parenteral opioids and other analgesics on demand. Oral fluids were started after return of bowel sounds or passage of flatus and the diet was advanced gradually. Mobilisation and catheter removal were done according to routine ward practice. Outcomes and discharge criteria The primary outcome was the length of postoperative hospital stay. Secondary outcomes were time to first passage of flatus and stool, time to tolerating oral fluids and solid diet, pain on a 10-point visual analogue scale on postoperative days 1, 2 and 3, time to independent mobilisation, duration of urinary catheterisation, postoperative complications graded by the Clavien-Dindo classification [30], and readmission within 30 days. Patients were discharged when they tolerated a solid diet, had passed flatus or stool, had adequate pain control with oral analgesics, were mobilising independently and had no evidence of complications. Adherence was assessed for five key ERAS elements in every patient (preoperative counselling, carbohydrate loading, goal-directed fluid therapy, multimodal analgesia and early mobilisation) and expressed as the percentage of elements delivered. Statistical analysis Data were entered in Microsoft Excel and analysed with Python version 3.13 using the SciPy and statsmodels libraries. Continuous variables were expressed as mean ± standard deviation and compared with the unpaired t test; the results were confirmed with the Mann-Whitney U test, which gave the same conclusions. Pain scores were also compared as ordinal data with the Mann-Whitney U test. Categorical variables were compared with the chi-square test or Fisher exact test, as appropriate. A p-value below 0.05 was considered significant.

A total of 100 patients were studied, 50 in each group. The two groups were comparable in age, sex, body mass index, ASA grade, diabetes, type and duration of surgery and the proportion of malignant disease. Hypertension was more frequent in the conventional group (33 versus 20 patients, p = 0.009) (Table 1). In the ERAS group, preoperative counselling, carbohydrate loading and multimodal analgesia were each delivered to 47 patients (94.0%), goal-directed fluids to 45 (90.0%) and early mobilisation to 48 (96.0%); the mean adherence to the five key elements was 93.6%, compared with 25.6% in the conventional group, in which goal-directed fluids were used in 25 patients as part of routine anaesthetic practice. Table 1. Baseline and operative characteristics Characteristic ERAS group (n = 50) Conventional group (n = 50) p-value Age (years), mean ± SD 47.5 ± 14.1 46.1 ± 13.0 0.607 Male, n (%) 22 (44.0) 24 (48.0) 0.688 Body mass index (kg/m²), mean ± SD 24.3 ± 3.7 25.3 ± 3.5 0.176 ASA grade I / II / III, n 20 / 20 / 10 22 / 14 / 14 0.402 Diabetes, n (%) 32 (64.0) 31 (62.0) 0.836 Hypertension, n (%) 20 (40.0) 33 (66.0) 0.009 Type of surgery: gastric / small bowel / colonic / biliary / others, n 12 / 9 / 12 / 9 / 8 5 / 10 / 8 / 16 / 11 0.187 Duration of surgery (minutes), mean ± SD 162.4 ± 47.5 167.4 ± 45.9 0.598 Malignant disease, n (%) 20 (40.0) 23 (46.0) 0.545 ASA: American Society of Anesthesiologists physical status. Unpaired t test or chi-square test. Bowel function returned significantly earlier in the ERAS group. Time to first flatus was 34.1 ± 7.1 hours in the ERAS group and 62.9 ± 11.9 hours in the conventional group, and time to first stool was 56.3 ± 9.4 and 85.9 ± 13.3 hours, respectively (p < 0.001 for both). Patients in the ERAS group started oral fluids at a mean of 9.6 hours compared with 68.3 hours, tolerated a solid diet 2.5 days earlier, mobilised independently at 18.0 versus 49.0 hours and had the urinary catheter removed earlier. Pain scores were significantly lower in the ERAS group on all three postoperative days (Table 2). Table 2. Postoperative recovery outcomes Outcome ERAS group (n = 50) Conventional group (n = 50) p-value Time to first flatus (hours) 34.1 ± 7.1 62.9 ± 11.9 <0.001 Time to first stool (hours) 56.3 ± 9.4 85.9 ± 13.3 <0.001 Time to oral fluids (hours) 9.6 ± 3.2 68.3 ± 12.5 <0.001 Time to solid diet (days) 2.16 ± 0.54 4.63 ± 0.72 <0.001 Time to independent mobilisation (hours) 18.0 ± 6.0 49.0 ± 12.0 <0.001 Duration of urinary catheter (days) 1.43 ± 0.34 3.28 ± 0.61 <0.001 VAS pain score, day 1 4.5 ± 1.1 6.6 ± 1.0 <0.001 VAS pain score, day 2 3.0 ± 1.2 5.1 ± 1.1 <0.001 VAS pain score, day 3 1.4 ± 1.1 3.4 ± 1.2 <0.001 Postoperative hospital stay (days) 6.1 ± 1.2 10.3 ± 1.4 <0.001 Values are mean ± SD. VAS: visual analogue scale (0 to 10). Unpaired t test; pain scores confirmed with the Mann-Whitney U test. The mean postoperative hospital stay was 6.1 ± 1.2 days in the ERAS group and 10.3 ± 1.4 days in the conventional group, a reduction of 4.2 days (95% CI 3.7 to 4.7; p < 0.001). Complications occurred in 13 patients (26.0%) in the ERAS group and 10 (20.0%) in the conventional group (p = 0.476). Most were minor (Clavien-Dindo grade I or II in 11 and 7 patients, respectively), and grade III or IV complications occurred in 2 and 3 patients. The rates of surgical site infection, pulmonary complications, postoperative nausea and vomiting and paralytic ileus did not differ significantly, and there was no anastomotic leak. Reinsertion of a nasogastric tube was needed in 2 patients in the ERAS group and 3 in the conventional group. Readmission within 30 days occurred in 1 and 3 patients, respectively (p = 0.617), and there was no mortality (Table 3). Table 3. Postoperative complications and readmission Outcome ERAS group (n = 50) Conventional group (n = 50) p-value Any complication, n (%) 13 (26.0) 10 (20.0) 0.476 Clavien-Dindo grade I-II, n (%) 11 (22.0) 7 (14.0) 0.298 Clavien-Dindo grade III-IV, n (%) 2 (4.0) 3 (6.0) 1.000 Surgical site infection, n (%) 3 (6.0) 2 (4.0) 1.000 Pulmonary complications, n (%) 0 (0.0) 1 (2.0) 1.000 Postoperative nausea and vomiting, n (%) 10 (20.0) 8 (16.0) 0.603 Paralytic ileus, n (%) 1 (2.0) 3 (6.0) 0.617 Anastomotic leak, n (%) 0 (0.0) 0 (0.0) 1.000 Nasogastric tube reinsertion, n (%) 2 (4.0) 3 (6.0) 1.000 Readmission within 30 days, n (%) 1 (2.0) 3 (6.0) 0.617 Mortality, n (%) 0 (0.0) 0 (0.0) 1.000 Chi-square or Fisher exact test.

In this study, implementation of an ERAS protocol in elective open abdominal surgery resulted in return of bowel function about one day earlier, oral feeding and mobilisation much sooner, lower pain scores and a postoperative hospital stay 4.2 days shorter than conventional care. Complications were mostly minor, and their frequency, as well as the rates of nasogastric tube reinsertion and readmission, did not differ significantly between the groups. The reduction in hospital stay in our study is consistent with meta-analyses of randomised trials of ERAS in colorectal surgery, which found a reduction of about 2 to 3 days in hospital stay and fewer complications, without more readmissions [7-11]. Varadhan and colleagues showed that these benefits apply specifically to open colorectal surgery [8]. Our results are also in line with Indian trials of adapted ERAS pathways, which reduced hospital stay and time to return of bowel function in patients undergoing surgery for perforated duodenal ulcer, small bowel disease and perforation peritonitis [14-18]. That ERAS was effective in elective open surgery in our setting supports its wider adoption in Indian general surgical units. Each element of the protocol contributes to faster recovery. Shorter preoperative fasting and carbohydrate loading reduce thirst, hunger and postoperative insulin resistance and are safe [20-22]. Opioid-sparing multimodal analgesia reduces ileus and nausea and allows early mobilisation [23]. Avoiding fluid overload reduces complications and speeds return of gastrointestinal function [24,25]. Routine nasogastric decompression does not prevent complications and delays return of bowel function [26], and routine prophylactic drains offer little benefit in most gastrointestinal operations [27]. Early enteral feeding is safe and may reduce infectious complications [28,29]. Together, these measures reduce the stress response to surgery, which is the central principle of enhanced recovery [1,2,5]. Concern about early feeding after open surgery is common among surgeons, but in our study early oral intake did not increase vomiting, ileus or anastomotic leak, and only a few patients required reinsertion of a nasogastric tube. Higher adherence to ERAS elements is associated with better outcomes [12], and successful implementation requires a multidisciplinary team of surgeons, anaesthetists, nurses and dietitians, structured protocols and regular audit [6,13]. Shorter hospital stay also has economic benefits for patients and hospitals in resource-limited settings. Strengths and limitations The strengths of this study are its prospective design, the use of a structured protocol with recorded adherence, the inclusion of a range of open abdominal procedures representative of general surgical practice, and standard grading of complications. It has limitations. Allocation was alternate rather than randomised, and blinding of patients and staff was not possible. Hypertension was more common in the conventional group, although the groups were similar in ASA grade and other characteristics. The sample size was modest and the case mix heterogeneous, so the study was not powered to detect differences in specific complications. Some ERAS elements, such as goal-directed fluids, were also used in part of the conventional group, which may have reduced the difference between the groups. Long-term outcomes and costs were not assessed.

Mini-PCNL in children achieved a single-session stone-free rate of 91.3% and final clearance of 96.6%, with mainly minor complications and a major complication rate of 1.3%. Larger stone diameter predicted residual stones, while staghorn configuration and positive preoperative urine culture predicted complications; these factors should guide counselling and perioperative planning. CONFLICT OF INTEREST The authors declare no conflict of interest. SOURCE OF FUNDING This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. ACKNOWLEDGEMENTS The authors acknowledge the staff of the Department of Urology and the medical records section of The Kidney Centre Postgraduate Training Institute, Karachi, for their assistance with data retrieval.

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