Modified Enhanced Recovery Program in Emergency Surgery (MERES)

A modified ERAS (mERAS) protocol was investigated. The study is a prospective, randomized nonblinded. All patients underwent LA. Modified ERAS protocol included patient informing, limitation of drainage use; intraperitoneal anesthesia with long-acting anesthetics; low-pressure pneumoperitoneum; early mobilization and oral nutrition. Pain level was assessed in rest using visual analogue scale (VAS). The primary endpoint was postoperative length of stay (pLOS).

• Laparoscopic appendectomy (Procedure): Preoperative care in both arms. Crystalloid isotonic solutions and antibiotic prophylaxis 30 min prior to surgery. Surgery. General anesthesia with strict control of fluid therapy and hemodynamic changes during surgery. Appendectomy with the use of monopolar coagulation by experienced surgeons following appendix stump ligation by two Roeder knots. Postoperative care. Antibiotics for 3-5 days for patients with complicated appendicitis (Gomez ≥ 3A). The postoperative pain level evaluation in rest by VAS in 0 h (immediately after awakening), 2, 6, 12 and 24 h postop. The postoperative analgesic modality "on demand": Ketorolac 30 mg for patients with VAS pain level ≥ 5 cm. Antiemetics in dyspepsia. No iv infusions postoperatively. Intestinal peristalsis evaluation by auscultation every 2 h after surgery.

Primary outcomes

• Postoperative length of stay (pLOS) [30 days]: Time interval measured from the end of the surgery until the moment of discharge from the hospital, measured in days

Secondary outcomes

• Complication rate [30 days]: Number of patients who develop postoperative complications (surgical site infections, intraabdominal organ-specific infection, postoperative ileus) in relation to the total number of patients, measured in percentage
• Readmission rate [30 days]: Number of patients with readmission to the hospital after discharge in relation to the total number of patients, measured as a percentage
• Postoperative pain [24 hours]: Level of postoperative pain syndrome measured with a visual analog scale in centimeters
• Shoulder pain incidence [24 hours]: Quantity of patients who developed shoulder pain after surgery in relation to the total number of patients, measured as a percentage
• Shoulder pain level [24 hours]: Level of shoulder pain syndrome measured with visual analog scale in centimeters

Sex: All, ages: 18 Years to any

Inclusion Criteria:

* Patients with any stage of acute appendicitis except 3B according to Gomes classification;
* Class I-II surgical patients according to the classification of The American Society of Anesthesiologists (ASA).

Exclusion Criteria:

* Patient refusal to participate in the study or to sign the informed consent form;
* Language barrier;
* Transfer to the intensive care unit (ICU) after surgery;
* ASA class ≥ III;
* Conversion to open procedure;
* Appendicular mass found during laparoscopy;
* Gomes 3B appendicitis requiring immersion of the appendicular stump;
* Pregnancy.

• Results publication: Sazhin AV, Nechay TV, Titkova SM, Petukhov VA, Tyagunov AE, Stradymov EA, Ermakov IV, Mishakina NY. [Appendectomy technique: paradigm shift or a well-forgotten old one? The role of mesoappendectomy in prevention of infectious intra-abdominal complications (announcement of RCT)]. Khirurgiia (Mosk). 2020;(10):49-59. doi: 10.17116/hirurgia202010149. Russian. PMID 33047586
• Results publication: Nechay T, Sazhin A, Titkova S, Tyagunov A, Anurov M, Melnikov-Makarchuk K, Tyagunov A. Evaluation of enhanced recovery after surgery program components implemented in laparoscopic appendectomy: prospective randomized clinical study. Sci Rep. 2020 Jul 1;10(1):10749. doi: 10.1038/s41598-020-67591-5. PMID 32612104

• Alexander V Sazhin, Prof., Study chair, Pirogov Russian National Research Medical University