Mehul Raval, MD, discusses an enhanced recovery protocol for pediatric GI surgery

Children undergoing elective gastrointestinal (GI) surgery may experience better postoperative outcomes when enhanced recovery protocols are implemented consistently, according to findings from the multicenter ENRICH-US trial published in JAMA Surgery. Although implementation of the protocol across participating hospitals did not significantly reduce hospital length of stay overall, investigators found that patients who received a greater proportion of protocol elements had shorter hospitalizations, fewer complications, and faster recovery.^1,2

What are enhanced recovery protocols for pediatric gastrointestinal surgery?

The prospective stepped-wedge cluster-randomized trial enrolled 597 patients aged 10 to 18 years undergoing elective GI surgery at 18 pediatric surgical centers across the United States between 2019 and 2024. Most participants (72.5%) underwent surgery for inflammatory bowel disease. Hospitals transitioned from usual care to a consensus-based 21-element enhanced recovery protocol supported by structured implementation strategies, allowing investigators to evaluate both clinical outcomes and how effectively the protocol was adopted.

"The Enrich Us study is a very exciting study that we've been conducting here at Lurie Children's and at Northwestern University alongside 18 clinical sites across the United States to study the implementation of an enhanced recovery protocol for children undergoing surgery, specifically gastrointestinal surgery," said lead author Mehul Raval, MD, professor of surgery and pediatrics at Northwestern University Feinberg School of Medicine.

Raval noted that the project was designed to examine not only patient outcomes but also whether hospitals successfully incorporated the protocol into routine care.

"The study lasted about five years and identified a number of components to enhance children's recovery after surgery that resulted in improved clinical outcomes, as well as we assessed implementation outcomes, was which was very important."

Did the enhanced recovery protocol shorten hospital stays?

The primary study outcome—postoperative length of stay—did not differ significantly across the baseline, implementation, and sustainability phases. However, investigators reported significant improvements in several secondary outcomes, including shorter time to a regular diet and lower inpatient opioid use. Patient adherence to protocol elements also increased substantially as hospitals implemented the program.

Why did implementation fidelity matter more than protocol adoption alone?

The most notable findings emerged when investigators evaluated implementation fidelity. Patients who received at least 13 enhanced recovery protocol elements experienced a median hospital stay that was 1.14 days shorter than those receiving fewer elements and had significantly lower odds of postoperative complications. Faster return to a regular diet was also associated with higher protocol adherence.

"There was a, a interesting caveat to the study where as children had more of the elements of the enhanced recovery protocol implemented we actually were even able to demonstrate a decrease in overall length of stay," Raval said.

He emphasized that implementation fidelity may explain why some quality improvement initiatives appear less effective than expected.

"It really boils down to understanding when we are making these changes... that we are first of all implementing to the degree that we want, so you can call that fidelity or adherence."

"Oftentimes if we make an intervention and we think we're making changes, but on the front lines we're actually not making changes... it was simply because we didn't implement it as well as we thought we did."

Which enhanced recovery strategies may improve postoperative recovery?

Several protocol components focus on optimizing recovery before, during, and after surgery. Raval highlighted preoperative education, allowing children to drink clear carbohydrate-containing fluids closer to anesthesia, reducing unnecessary intravenous fluids, encouraging early ambulation, and minimizing opioid exposure.

"It's really hard to put your finger on exactly one or two of the components that were the most mission critical," he said. "Rather, if you put it all together in a bundle, there are levers that we can pull at every step... and then ultimately it's the accumulation of all of them, the synergistic effect that really results in the best possible outcomes."

What factors helped hospitals successfully implement the protocol?

The investigators also identified organizational factors that supported successful implementation. Hospitals with stronger multidisciplinary engagement and greater integration of protocol elements into electronic health record order sets demonstrated higher implementation fidelity. The study found moderate correlations between protocol adherence and both institutional culture supporting enhanced recovery and integration into electronic health record workflows.

What is next for enhanced recovery protocols in pediatric surgery?

Looking ahead, Raval said the team is expanding enhanced recovery protocols beyond pediatric GI surgery.

"What I'm most excited about is really expanding the horizons of the populations that could potentially benefit from enhanced recovery protocol," he said, noting ongoing efforts to develop enhanced recovery pathways for neonatal surgical patients, orthopedic surgery, neurosurgery, chest wall reconstruction, appendicitis, and other pediatric surgical conditions.

The authors concluded that future research should evaluate enhanced recovery protocols in younger children and broader pediatric surgical populations while continuing to measure implementation fidelity alongside clinical outcomes.

References

1. Northwestern Now. Pediatric surgery program cuts opioid use by 56%. Northwestern University. May 13, 2206. Accessed June 25, 2026. https://news.northwestern.edu/stories/2026/05/pediatric-surgery-program-cuts-opioid-use-by-56?fj=1

2. Raval MV, Tian Y, Schäfer W, et al. Implementation and effectiveness of an enhanced recovery protocol for children undergoing surgery: the ENRICH-US stepped-wedge cluster-randomized trial. JAMA Surg. Published online May 13, 2026. doi:10.1001/jamasurg.2026.1382