ERAS in Choledochal Cyst & Biliary Atresia

Enhanced Recovery After Surgery (ERAS) pathways are evidence-based, multidisciplinary perioperative care protocols designed to reduce surgical stress, maintain physiological function, accelerate recovery, improve patient outcomes, and reduce healthcare costs. Early enteral nutrition is a key component of ERAS programs and has been associated with improved gastrointestinal recovery, reduced postoperative morbidity, and shorter hospital stay across multiple surgical specialties.

The role of early oral feeding following pediatric hepatobiliary surgery remains insufficiently studied, particularly in low- and middle-income countries. Biliary atresia and choledochal cysts are among the most common pediatric hepatobiliary disorders requiring major reconstructive surgery. Postoperative feeding practices vary considerably, and many centers continue to delay oral intake until bowel sounds return or passage of stool occurs. However, delayed feeding may prolong recovery, increase dependence on intravenous fluids, and extend hospitalization.

This prospective randomized controlled trial will be conducted at the Department of Paediatric Surgery, University of Child Health Sciences and The Children's Hospital Lahore. The study aims to compare early oral feeding with conventional postoperative feeding in children undergoing surgery for biliary atresia and choledochal cyst.

A total of 46 eligible patients will be enrolled and randomized equally into two groups. Children aged up to 14 years undergoing elective surgery for Type I or Type IV choledochal cyst and infants up to 3 months of age undergoing surgery for biliary atresia will be considered for inclusion. Patients with preoperative malnutrition, hypoalbuminemia, emergency procedures, external cyst drainage, or those not undergoing portoenterostomy after operative cholangiography will be excluded.

All enrolled participants will receive standardized perioperative care. In the intervention group, oral clear liquids will be initiated within 24 hours after surgery and advanced progressively to semisolid and full feeds according to tolerance. In the control group, oral feeding will commence after more than 48 hours postoperatively, following clinical evidence of return of bowel function, including passage of stool or flatus.

Patients will be monitored for postoperative complications including anastomotic leakage, surgical site infection, vomiting, abdominal distension, need for nasogastric tube reinsertion, and requirement for reoperation. Discharge criteria will be standardized for both groups and include stable vital signs, adequate oral intake, satisfactory bowel function, and surgeon approval.

The primary outcomes will be postoperative hospital stay, anastomotic leakage, and surgical site infection. Secondary outcomes will include time to initiation of feeds, time to full feeding, gastrointestinal tolerance, nasogastric tube reinsertion, postoperative complications, and need for repeat surgical intervention.

Data will be analyzed using SPSS version 26. Continuous variables will be reported as mean, median, and standard deviation, while categorical variables will be presented as frequencies and percentages. Comparisons between groups will be performed using independent sample t-tests or Chi-square tests as appropriate, with statistical significance defined as a p-value ≤0.05.

This study seeks to generate local evidence regarding the safety and effectiveness of early postoperative feeding following pediatric hepatobiliary surgery. The findings may support implementation of ERAS principles in pediatric surgical practice and contribute to improved recovery, reduced hospitalization, and more efficient utilization of healthcare resources.

Inclusion criteria

• All children diagnosed with choledochal cyst type I and IV on MRCP or CT scan, undergoing elective Roux-En-Y hepaticojejunostomy
• All children with provisional diagnosis of biliary atresia undergoing Roux-En-Y portoenterostomy

Exclusion criteria

• Patients with suspected biliary atresia not undergoing portoenterostomy after Per-op cholangiogram either due to ruling out of disease or advanced disease deemed candidates for liver transplant
• patients with history of Emergency surgery or external drainage of choledochal cyst
• Hemodynamically unstable patients after surgery
• Previous history of GI surgery