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Key interventions and outcomes in perioperative care pathways in emergency laparotomy: a systematic review

World Journal of Emergency Surgery volume 20, Article number: 20 (2025) Cite this article

Abstract

Introduction

Emergency laparotomy (EmLap) is a complex clinical arena, delivering time-sensitive, definitive care to a high-risk patient cohort, with significant rates of post-operative morbidity and mortality. Embedding perioperative care pathways within this complex setting has the potential to improve post-operative outcomes, however, requires an in-depth understanding of their design, delivery and outcome assessment. Delivering and implementing complex interventions such as perioperative pathways require transparent reporting with detailed and indepth description of all components during the assessment and evaluation phase. The aim of this systematic review was to identify the current design and reporting of perioperative pathways in the EmLap setting.

Methods

The OVID SP versions of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials were searched between January 1950 and December 2023. All randomised and non-randomised cohort studies reporting outcomes on perioperative care pathways in adult patients (> 18 years old) undergoing major emergency abdominal surgery were included. A narrative description of all perioperative pathways included was reported to identify design and description of the pathway including the delivery and timing of component interventions. All pathways were evaluated against the Template for Intervention Description and Replication (TIDieR) checklist.

Results

Eleven RCTs and 19 non-randomised studies were identified, with most studies considered to be at moderate risk of bias. Twenty-six unique pathways were identified and described, delivering a total of 400 component interventions across 44,055 patients. Component interventions were classified into 24 domains across the perioperative pathway. Twenty studies (66.6%) did not report the TIDieR framework items, with thirteen studies reporting less than 50% of all items. Two hundred and fifty individual outcomes were reported across pathways, with the most commonly reported outcomes related to morbidity, mortality and length of stay.

Conclusion

Current perioperative pathways in EmLap setting are underpinned by variable component interventions, with a lack of in-depth intervention reporting and evaluation. Future studies should incorporate the TIDieR checklist when reporting on perioperative pathways in the EmLap setting.

Clinical trial number

Not applicable.

Background

Major emergency abdominal surgery is a complex clinical arena serving a heterogenous patient population, with variable physiological status. This high-risk cohort requires time-sensitive, definitive care to potentially mitigate the impact of their physiological and pathological status on post-operative outcomes. The burden of emergency surgery is significant, with reported rates of post-operative morbidity and mortality of 14–47% and 10–20% respectively [1, 2]. There have been considerable efforts made in recent times to try and improve these outcomes through the introduction of structured and standardised care pathways to attenuate the physiological stress of emergency laparotomy and improve post-operative clinical outcomes. Initiatives such as the ELPQuiC (Emergency Laparotomy Quality Improvement Care Bundle) have demonstrated the feasibility of implementing dedicated EmLap pathways into the early peri-operative period in the emergency setting to improve post-operative mortality [3,4,5]. Modified Enhanced Recovery after Surgery (ERAS) protocols in the emergency setting have demonstrated improvements in broader clinical outcomes, including reduced length of stay, post-operative complications and improved gastrointestinal functions [6, 7].

These perioperative pathways often comprise several components, which interact to exert their overall effects. As demonstrated by the EPOCH trial, it is the combination of high-fidelity component interventions and overall compliance to the perioperative pathway, that drives overall improvement [8]. Understanding the design and delivery of perioperative pathways in the EmLap setting is essential to evaluate their clinical and cost-effectiveness, and to facilitate broader adoption and implementation. Surgical and perioperative interventions are often poorly reported with a lack of detailed and in-depth intervention reporting [9,10,11,12]. There is growing recognition of the importance of intervention reporting. The Template for Intervention Description and Replication (TIDieR) checklist and guide was developed in 2014 to provide a structure for assessing the completeness of intervention descriptions [13]. The overarching purpose of the TIDieR checklist is to describe interventions in sufficient detail to allow their replication. The use of the TIDieR checklist has led to enhanced and in-depth reporting of complex interventions, which has led to improved implementation across clinical practice and trials [14,15,16]. Detailed reporting of the types of interventions delivered across EmLap perioperative pathways, as well as, key aspects of each component, including mode of delivery, frequency, intensity and overall duration, is essential to ensure effective and time sensitive treatment is delivered. Comprehensive reporting of all aspects of perioperative pathways is important in clinical studies to ensure appropriate assessment of clinical effectiveness and onward implementation into clinical practice. Incorrect implementation leads to the initiation of ineffective or lesser treatment. This has implications for the patient, potentially impacting on their clinical outcomes, and on wider healthcare resources.

The aim of this systematic review was to identify the current design and make-up of perioperative pathways in the EmLap setting, including identifying component interventions, their associated reported clinical and patient-reported outcomes and to understand their design and reporting in line with the TIDieR checklist.

Methods

This systematic review was conducted according to a pre-specified protocol based on guidance from the Centre for Reviews and Dissemination [17] and the Cochrane Handbook [18] and is reported in line with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement [19]. Our protocol was registered with the international, prospective register of systematic reviews, PROSPERO (CRD42021277211).

Eligibility criteria

All randomised and non-randomised cohort studies reporting outcomes on perioperative care pathways (PCP) in adult patients (≥ 18 years old) undergoing major emergency abdominal surgery were included. Perioperative care pathways were defined as multimodal perioperative care bundles, perioperative protocols, dedicated clinical pathways or ERAS protocols comprising of a number of components. Studies were excluded if they reported on perioperative care protocols/pathways in the trauma or elective setting or did not include clinical outcomes.

Search strategy

The OVID SP versions of MEDLINE (1950 to 31st December 2023), EMBASE (1980 to 31st December 2023) and the Cochrane Central Register of Controlled Trials were searched using the following search terms ‘emergency surgery’, ‘laparotomy’ ‘enhanced recovery’, ‘fast track’, ‘multimodal’, ‘care bundles’, ‘perioperative protocols’, ‘care pathways’ separated by the Boolean operator ‘AND’. Reference lists of included articles were hand-searched to identify any additional studies. All citations were collated within EndNote X7.8®, USA and duplicates were removed. All relevant titles and abstracts were screened by two reviewers (DH and BG). The full text versions of potentially eligible abstracts were retrieved in full. Only studies that fulfilled all eligibility criteria were included. Any conflicts were resolved through discussion.

Study quality

Methodological quality assessment of included studies was undertaken using the ‘Risk of Bias In Non-Randomised Studies of Intervention’ (ROBINS-I) assessment tool [20] for non-randomised studies and the Cochrane risk of bias tool for randomised controlled trials (RCTs) [21].

Data analysis

A narrative description of all perioperative pathways was reported to identify design of the pathway including the delivery and timing of component interventions. To assess the completeness of intervention reporting and its replicability each PCP was assessed against the TIDieR checklist. To assess the consistency of outcome reporting the frequency of each definition and any inconsistencies in definitions across individual studies were reported. Descriptive data were expressed using basic statistics including proportions and averages. All data were entered into Microsoft Excel (Microsoft, Redmond, Washington USA) for analysis.

Results

A total of thirty studies outlining 26 unique pathways in EmLap were included in this review [3, 5, 8, 22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48]. A total of 10 randomised controlled trials (RCTs), 1 pilot RCT, 4 prospective cohort studies, 1 propensity matched cohort study, 5 retrospective cohort studies, 8 before and after studies and 1 case-control study were included (Table 1; Fig. 1). Outcomes were reported in 44,055 patients undergoing major emergency abdominal surgery. Care pathways were defined in different ways with 16 studies reporting on emergency ERAS protocols, 7 studies reporting on care bundles, 3 studies reporting on the implementation of a perioperative protocol, 2 studies reporting on protocolised care pathways and 1 study defined its care pathway as intermediate care and 1 study defined it PCP as a quality improvement programme. The earliest reported perioperative pathway was in 2011, with a total of 3 studies predating the introduction of the TIDieR checklist, and 27 studies published following its introduction.

Table 1 Studies included
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Fig. 1
figure 1

Search Strategy

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Study Bias

The majority of RCTs were low overall risk of bias: with 6 RCTs identified to be low risk, 4 RCTs were considered to have some concerns and 1 RCT was considered to be high risk (Fig. 2a). The majority of 19 non-randomised studies were moderately biased: with 16 identified moderate risk and 3 considered to be seriously biased (Fig. 2b). Key areas for concern include confounding variables, participant selection, measurement of outcomes and selection of reported results.

Fig. 2
figure 2

(a) Risk of Bias Summary for RCTs. (b) Risk of Bias Summary for non-randomised studies

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Peri-operative pathway design

Twenty-six unique pathways were identified, with a total of 400 component interventions delivered across all studies. These component interventions were classified into 24 domains (Fig. 3) across three distinct time points; pre-, intra- and post-operatively. There was significant overlap with delivery of domain interventions across perioperative timepoints. Six domains; multimodal analgesia, goal-directed fluid therapy, antibiotics, monitoring, thromboembolism prophylaxis and post-operative nausea and vomiting (PONV), were delivered across all three timepoints. Urgent radiology was identified as the only domain intervention delivered exclusively in the pre-operative phase. Risk stratification, timely intervention, prescriptive anaesthetic strategy and prescriptive surgical strategy were domain interventions delivered during the pre- and intra-operative phases of PCPs. There were no exclusive intra-operative domain interventions identified. Five domains were exclusively delivered during post-operative phase; early nutrition, chest physiotherapy, early mobilisation, early removal of drains and discharge/follow up criteria. Three domain interventions were delivered in the pre- and post-operative phases: medical optimisation, review and escalation policies and stress ulceration prophylaxis. Maintaining normothermia was the only domain that was delivered in the intra- and post-operative phases.

Fig. 3
figure 3

Component Interventions

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Twenty-one studies reported on EmLap care pathways with a pre-operative phase, consisting of a median of 6 individual components (Table 2). A total of 108 pre-operative component interventions were mapped to 14 broad pre-operative intervention domains. There was significant variation in the coverage of domains delivered in the pre-operative phase, with the sepsis screening/antibiotic prophylaxis domain being the most commonly employed; 14 (66.7%) studies reported component interventions within this domain.

Table 2 Pre-operative intervention domains
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Twenty-two studies reported PCPs with an intra-operative phase, consisting of a median of 3 individual components. One hundred and ten intra-operative component interventions were mapped to 12 intra-operative intervention domains (Table 3). Commonly covered domains across PCPs intra-operatively were prescriptive surgical strategy (n = 13, 59.1%), prescriptive anaesthetic strategy (n = 10, 45.5%), normothermia (n = 12, 54.5%), goal directed fluid therapy (n = 10, 45.5%) and analgesia (n = 14, 63.6%).

Table 3 Intra-operative intervention domains
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Twenty-five studies reported PCPs with a post-operative phase, consisting of a median of 8 components (Table 4). A total of 191 individual component interventions were identified and mapped to 18 post-operative intervention domains. The most commonly employed domain interventions across PCPs were early nutrition, early mobilisation, early removal of drains and analgesia.

Table 4 Post-operative intervention domains
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PCPs tidier checklist

The intervention characteristics of PCPs according to the TIDieR framework are outlined in Table 5. The majority of studies (n = 20, 66.6%) did not report the TIDieR framework items, with thirteen studies reporting less than 50% of all items. Three studies reported 90% of the items within the TIDiER framework; reporting on all components of the PCPs intervention, apart from the item on modifications. There was no in-depth detail provided across all PCPs regarding the component intervention delivered, with no data provided on component interventions in specific patient or clinical groups. The PCP designed for use by Burcharth et al. was designed specifically in keeping with the TIDiER framework [42]. The commonest TIDiER item reported across all studies was Item 2: why to describe the rationale, theory, or goal of the elements essential to the intervention. Poorly reported domains included Item 5: Who provided the interventions (n = 8, 30.8%), Item 7: Where (n = 7, 26.9%), and Item 9: Tailoring (n = 5, 19.2%). There was a failure to report Item 10: Modifications across all studies.

Table 5 TiDiER checklist
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PCPs reported outcomes

Seventeen studies reported on a primary outcome; with 6 studies reporting on post-operative mortality, 3 studies on length of stay (LoS), 3 studies reported on outcomes related to complications, 2 studies reported of composite post-operative outcomes, 1 study reported on compliance, 1 study reported on cost and 1 study reported on gastrointestinal function.

A total of 250 individual outcomes were extracted from 30 studies and mapped to 13 overarching categories: mortality, length of stay (LoS), readmission, reoperation, complications, gastrointestinal function, invasive tube removal, analgesic requirements, mobility, cost-effectiveness, compliance rates, post-operative treatment, recovery and function and quality of life (QoL) (Table 6). Clinical outcomes such as morbidity, mortality and LoS were most commonly reported. Outcomes relating to analgesic requirement, compliance, mobility, recovery, function and QoL were poorly reported across all studies.

Table 6 Outcome Reporting Across All Studies
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Post-operative mortality was the most frequently reported outcome measure across all studies, with 24 (80%) studies reporting this outcome. However, there was significant heterogeneity in the definitions and timing in reporting this outcome measure, with 8 different definitions identified. The most commonly used definition was overall 30-day mortality, with other definitions including in-hospital and risk-adjusted mortality, as well as reporting mortality outcomes at 90 days, 180 days and 1 year post-operatively. Post-operative morbidity was reported by 23 (76.7%) studies in 27 different ways at variable timepoints ranging from 3 to 180 days post-operatively. Seven studies reported specific complications including pulmonary complications, acute kidney injury, ileus, surgical site infection, post-operative bleeding, trocar site hernia, urinary tract infections, septic shock, anastomotic leak, peritonitis and abscess. Two grading systems were identified to grade the severity of complications; the Clavien-Dindo classification and the Post-operative Morbidity Score, across 7 studies. Outcomes for the gastrointestinal function domain were reported across 12 (40%) studies using 8 different definitions. No standardised definition of gastrointestinal function was identified. Patient-reported outcomes such as recovery and function and QoL were poorly reported, with 6 identified outcome measures across 2 (6.6%) studies.

Discussion

We highlight the heterogenous nature of current perioperative pathway design in the EmLap setting, with multiple component interventions delivered in a variable manner. Our review identified 400 individual components mapping to 24 domains, with variable quality intervention and outcome reporting as measured by the TIDiER checklist. The overall lack of intervention description and reporting for EmLap perioperative pathways limits understanding their effectiveness, implementation and generalisability. EmLap perioperative pathways consist of several interacting components, with little understanding of the underlying interaction due to the variable quality evidence base underpinning each component intervention [49, 50]. This leads to significant heterogeneity in the type of interventions employed, with this systematic review identifying 26 unique perioperative pathways. Although the interventions delivered within these pathways mapped to 24 broad overarching domains, the overall delivery and reporting of individual interventions within these domains was heterogenous and inconsistent across different pathways.

The TIDieR framework provides a standardised and robust manner to report complex interventions to enable broader adoption and implementation. However, adherence to this framework is variable in EmLap perioperative pathways. There is a significant focus on key aspects of the TIDieR framework including reporting on rationale for implementation and evaluation with reporting of key procedures outlined in 92.3% (n = 24) and materials required to deliver these procedures in 57.7% (n = 15). Despite the majority of studies reporting on key procedures and materials, these descriptions were often minimal or lacked sufficient detail, and therefore are unlikely to facilitate broader adoption or implementation. Several key details regarding intervention description and reporting are underreported, including, who delivered the intervention (n = 8, 30.8%), where the intervention was delivered (n = 7, 26.9%), tailoring of interventions (n = 5, 19.2%), modifications (n = 0, 0%), and planned and actual adherence (n = 5, 19.2%). These key reporting criteria are often underreported across a range of complex interventions in multiple disease settings, with the focus largely being on the actual intervention delivered. Key detail on the broader reporting standards of intervention delivery are essential for implementation of complex interventions such as a EmLap perioperative pathway, which is often delivered by several key members of the multidisciplinary team, at different timepoints and stages of the pathway, to a broad and heterogenous clinical population.

Three studies were identified to have excellent compliance with the TIDieR framework reporting. Vester-Andersen demonstrated variable compliance of 14.3–85.8% to key components of their complex intervention to improve post-operative EmLap care using intermediate care. However, when compared to standard care, the overall compliance to interventions was much higher due to the key reporting and educational components of the TIDieR framework [29]. Using a similar approach, Burcharth et al. were able to demonstrate overall compliance of 83% to 15 component interventions [42]. Boden et al. assessed the feasibility of implementing a complex intervention of intensive physiotherapy aimed at reducing postoperative pneumonia and improving physical recovery [23]. Through the use of the TIDieR framework the authors identified key interventions with poor compliance and implementation in clinical practice and the associated barriers/challenges. These three studies demonstrate the value of the TIDieR framework, using indepth intervention description and reporting in ensuring the delivery of effective and feasible interventions within the EmLap setting. Through robust and standardised reporting of interventions, complex interventions can be appropriately implemented into clinical practice. Transparent reporting is essential for pathway effectiveness research [51, 52] due to the complex nature of developing and implementing clinical pathways, which is further amplified in the emergency setting.This limits healthcare resource wastage through the early identification of undeliverable interventions and ensuring the delivery of concise, high-fidelity, clinically effective interventions within complex clinical settings.

This work contributes to the growing evidence-base in perioperative pathways in EmLap by identifying the content of these pathways and by identifying their associated reporting outcomes. However, our work is limited by the overall quality of the existing evidence-base, consisting primarily of moderately biased, non-randomised studies. We only identified ten RCTs for inclusion into this review. The disproportionate number of non-randomised studies is associated with inherent biases including selection bias and outcome reporting. This has a potential impact on determining the clinical effectiveness of the interventions and perioperative pathways reported within these studies. It is also important to note the limitations of the TIDIER checklist, as it has been designed for the generic use of intervention reporting across medicine and surgery leading to broad descriptors and the lack of thresholds to define adequate reporting.

Conclusion

Perioperative pathways in the EmLap setting are complex interventions, with variable design and structure, spanning across the entire perioperative pathway. This review identified 26 unique pathways delivering 400 individual component interventions across 24 domains, with a variety of outcome metrics used to assess their clinical effectiveness. These pathways are multimodal, consisting of multiple component interventions. Currently, they are reported and therefore implemented in a variable manner. Future studies in EmLap perioperative pathways should ensure in depth reporting of the design and delivery of the pathway, including an in-depth description of component interventions, using existing frameworks such at the TIDIER framework. This will help identify component interventions that are valuable, effective and feasible for implementation in the EmLap setting.

Data availability

No datasets were generated or analysed during the current study.

References

  1. Tengberg LT, Cihoric M, Foss NB, Bay-Nielsen M, Gögenur I, Henriksen R, et al. Complications after emergency laparotomy beyond the immediate postoperative period - a retrospective, observational cohort study of 1139 patients. Anaesthesia. 2017;72(3):309–16.

    Article  CAS  PubMed  Google Scholar 

  2. Tolstrup MB, Watt SK, Gögenur I. Morbidity and mortality rates after emergency abdominal surgery: an analysis of 4346 patients scheduled for emergency laparotomy or laparoscopy. Langenbecks Arch Surg. 2017;402(4):615–23.

    Article  PubMed  Google Scholar 

  3. Huddart S, Peden CJ, Swart M, McCormick B, Dickinson M, Mohammed MA, et al. Use of a pathway quality improvement care bundle to reduce mortality after emergency laparotomy. Br J Surg. 2015;102(1):57–66.

    Article  CAS  PubMed  Google Scholar 

  4. Quiney N, Huddart S, Peden C, Dickinson M. Use of a care bundle to reduce mortality following emergency laparotomy. Br J Hosp Med (Lond). 2015;76(6):358–62.

    Article  CAS  PubMed  Google Scholar 

  5. Aggarwal G, Peden CJ, Mohammed MA, Pullyblank A, Williams B, Stephens T, et al. Evaluation of the collaborative use of an Evidence-Based care bundle in emergency laparotomy. JAMA Surg. 2019;154(5):e190145.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Hajibandeh S, Bill V, Satyadas T. Meta-analysis of enhanced recovery after surgery (ERAS) protocols in emergency abdominal surgery. World J Surg. 2020;44(5):1336–48.

    Article  PubMed  Google Scholar 

  7. Harji DP, Griffiths B, Stocken D, Pearse R, Blazeby J, Brown JM. Protocolized care pathways in emergency general surgery: a systematic review and meta-analysis. Br J Surg. 2024;111(3).

  8. Peden CJ, Stephens T, Martin G, Kahan BC, Thomson A, Rivett K, et al. Effectiveness of a National quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial. Lancet. 2019;393(10187):2213–21.

    Article  PubMed  Google Scholar 

  9. Tew GA, Brabyn S, Cook L, Peckham E. The completeness of intervention descriptions in randomised trials of supervised exercise training in peripheral arterial disease. PLoS ONE. 2016;11(3):e0150869.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Evans S, Rauh S, Jellison S, Diener B, Agha R, Vassar M. Evaluation of the completeness of interventions reported in published randomized controlled trials in plastic surgery: A systematic review. Aesthet Surg J. 2021;41(6):707–19.

    Article  PubMed  Google Scholar 

  11. Torgerson T, Johnson AL, Jellison S, Tanghetti M, Langley JM, Nguyen LHP, et al. Reporting of clinical trial interventions published in leading Otolaryngology-Head and neck surgery journals. Laryngoscope. 2020;130(9):E507–14.

    Article  PubMed  Google Scholar 

  12. Jones EL, Lees N, Martin G, Dixon-Woods M. How well is quality improvement described in the perioperative care literature?? A systematic review. Jt Comm J Qual Patient Saf. 2016;42(5):196–206.

    PubMed  PubMed Central  Google Scholar 

  13. Hoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, Moher D, et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ. 2014;348:g1687.

    Article  PubMed  Google Scholar 

  14. Tume LN, Blackwood B, McAuley DF, Morris K, Peters MJ, Jordan J, et al. Using the tidier checklist to describe the intervention of the sedation and weaning in children (SANDWICH) trial. Nurs Crit Care. 2023;28(3):396–403.

    Article  PubMed  Google Scholar 

  15. Yamato T, Maher C, Saragiotto B, Moseley A, Hoffmann T, Elkins M, et al. The tidier checklist will benefit the physiotherapy profession. Physiother Theory Pract. 2017;33(4):267–8.

    Article  PubMed  Google Scholar 

  16. Rhon DI, Fritz JM, Kerns RD, McGeary DD, Coleman BC, Farrokhi S, et al. TIDieR-telehealth: precision in reporting of telehealth interventions used in clinical trials - unique considerations for the template for the intervention description and replication (TIDieR) checklist. BMC Med Res Methodol. 2022;22(1):161.

    Article  PubMed  PubMed Central  Google Scholar 

  17. (CRD). CfRaD. Systematic reviews: CRD’s guidance for undertaking reviews in health care. York, UK: CRD; 2009.

    Google Scholar 

  18. Higgins JGS. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011].

  19. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol. 2009;62(10):e1–34.

    Article  PubMed  Google Scholar 

  20. Sterne JA, Hernan MA, Reeves BC, Savovic J, Berkman ND, Viswanathan M, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016;355:i4919.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Higgins JP, Altman DG, Gotzsche PC, Juni P, Moher D, Oxman AD, et al. The Cochrane collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011;343:d5928.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Aggarwal A, Irrinki S, Kurdia KC, Khare S, Naik N, Tandup C, et al. Modified enhanced recovery after surgery (ERAS) protocol versus Non-ERAS protocol in patients undergoing emergency laparotomy for acute intestinal obstruction: A randomized controlled trial. World J Surg. 2023;47(12):2990–9.

    Article  PubMed  Google Scholar 

  23. Boden I, Sullivan K, Hackett C, Winzer B, Hwang R, Story D, et al. Intensive physical therapy after emergency laparotomy: pilot phase of the incidence of complications following emergency abdominal surgery get exercising randomized controlled trial. J Trauma Acute Care Surg. 2022;92(6):1020–30.

    Article  PubMed  Google Scholar 

  24. Pathrikar SG, Jadhav GS, Adhikari GR. The application of enhanced recovery after surgery protocols in patients with perforated duodenal ulcer. Cureus. 2023;15(3):e35760.

    PubMed  PubMed Central  Google Scholar 

  25. Masood A, Viqar S, Zia N, Ghani MU. Early oral feeding compared with traditional postoperative care in patients undergoing emergency abdominal surgery for perforated duodenal ulcer. Cureus. 2021;13(1):e12553.

    PubMed  PubMed Central  Google Scholar 

  26. Gonenc M, Dural AC, Celik F, Akarsu C, Kocatas A, Kalayci MU, et al. Enhanced postoperative recovery pathways in emergency surgery: a randomised controlled clinical trial. Am J Surg. 2014;207(6):807–14.

    Article  PubMed  Google Scholar 

  27. Mohsina S, Shanmugam D, Sureshkumar S, Kundra P, Mahalakshmy T, Kate V. Adapted ERAS pathway vs. Standard care in patients with perforated duodenal Ulcer-a randomized controlled trial. J Gastrointest Surg. 2018;22(1):107–16.

    Article  PubMed  Google Scholar 

  28. Saurabh K, Sureshkumar S, Mohsina S, Mahalakshmy T, Kundra P, Kate V. Adapted ERAS pathway versus standard care in patients undergoing emergency small bowel surgery: a randomized controlled trial. J Gastrointest Surg. 2020;24(9):2077–87.

    Article  PubMed  Google Scholar 

  29. Vester-Andersen M, Waldau T, Wetterslev J, Møller MH, Rosenberg J, Jørgensen LN, et al. Randomized multicentre feasibility trial of intermediate care versus standard ward care after emergency abdominal surgery (InCare trial). Br J Surg. 2015;102(6):619–29.

    Article  CAS  PubMed  Google Scholar 

  30. Pranavi AR, Sureshkumar S, Mahalakshmy T, Kundra P, Kate V. Adapted ERAS pathway versus standard care in patients undergoing emergency surgery for perforation Peritonitis-a randomized controlled trial. J Gastrointest Surg. 2022;26(1):39–49.

    Article  CAS  PubMed  Google Scholar 

  31. Sharma J, Kumar N, Huda F, Payal YS. Enhanced recovery after surgery protocol in emergency laparotomy: A randomized control study. Surg J (N Y). 2021;7(2):e92–9.

    Article  PubMed  Google Scholar 

  32. Jordan LC, Cook TM, Cook SC, Dalton SJ, Collins K, Scott J, et al. Sustaining better care for patients undergoing emergency laparotomy. Anaesthesia. 2020;75(10):1321–30.

    Article  CAS  PubMed  Google Scholar 

  33. Liska D, Novello M, Cengiz BT, Holubar SD, Aiello A, Gorgun E et al. Enhanced recovery pathway benefits patients undergoing nonelective colorectal surgery. Ann Surg. 2019.

  34. Lohsiriwat V. Enhanced recovery after surgery vs conventional care in emergency colorectal surgery. World J Gastroenterol. 2014;20(38):13950–5.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Møller MH, Adamsen S, Thomsen RW, Møller AM, group PUPPt. Multicentre trial of a perioperative protocol to reduce mortality in patients with peptic ulcer perforation. Br J Surg. 2011;98(6):802–10.

    Article  PubMed  Google Scholar 

  36. Shang Y, Guo C, Zhang D. Modified enhanced recovery after surgery protocols are beneficial for postoperative recovery for patients undergoing emergency surgery for obstructive colorectal cancer: A propensity score matching analysis. Med (Baltim). 2018;97(39):e12348.

    Article  Google Scholar 

  37. Tengberg LT, Bay-Nielsen M, Bisgaard T, Cihoric M, Lauritsen ML, Foss NB, et al. Multidisciplinary perioperative protocol in patients undergoing acute high-risk abdominal surgery. Br J Surg. 2017;104(4):463–71.

    Article  CAS  PubMed  Google Scholar 

  38. Viñas X, Macarulla E, Brugiotti C, Ramirez JM, Pedregosa A, Sanchez S, et al. Feasibility and effects of enhanced recovery vs. conventional care after emergency colon surgery for patients with left colon perforation. Sci Rep. 2020;10(1):7346.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Wisely JC, Barclay KL. Effects of an enhanced recovery after surgery programme on emergency surgical patients. ANZ J Surg. 2016;86(11):883–8.

    Article  PubMed  Google Scholar 

  40. Trangbæk RM, Burcharth J, Gögenur I. Implementing bundle care in major abdominal emergency surgery: Long-Term mortality and comprehensive complication index. World J Surg. 2022.

  41. Ceresoli M, Biloslavo A, Bisagni P, Ciuffa C, Fortuna L, La Greca A, et al. Implementing enhanced perioperative care in emergency general surgery: A prospective multicenter observational study. World J Surg. 2023;47(6):1339–47.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Burcharth J, Abdulhady L, Danker J, Ekeloef S, Jørgensen T, Lauridsen H, et al. Implementation of a multidisciplinary perioperative protocol in major emergency abdominal surgery. Eur J Trauma Emerg Surg. 2021;47(2):467–77.

    Article  PubMed  Google Scholar 

  43. Doyle JF, Sarnowski A, Saadat F, Samuels TL, Huddart S, Quiney N et al. Does the implementation of a quality improvement care bundle reduce the incidence of acute kidney injury in patients undergoing emergency laparotomy?? J Clin Med. 2019;8(8).

  44. Ebm C, Aggarwal G, Huddart S, Cecconi M, Quiney N. Cost-effectiveness of a quality improvement bundle for emergency laparotomy. BJS Open. 2018;2(4):262–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  45. Lohsiriwat V. Enhanced recovery after surgery for emergency colorectal surgery: are there any differences between intra-abdominal infection and other indications? J Visc Surg. 2019;156(6):489–96.

    Article  CAS  PubMed  Google Scholar 

  46. Fischer CP, Knapp L, Cohen ME, Ko CY, Reinke CE, Wick EC. Feasibility of enhanced recovery in emergency colorectal operation. J Am Coll Surg. 2021;232(2):178–85.

    Article  PubMed  Google Scholar 

  47. Ong MW, Goh SSN, Tung WMJ, Lim WW, Hu HH, Lim CY, et al. Initial emergency laparotomy outcomes following a transdisciplinary perioperative care pathway in Singapore. Acute Med Surg. 2021;8(1):e702.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Timan TJ, Karlsson O, Sernert N, Prytz M. Standardized perioperative management in acute abdominal surgery: Swedish SMASH controlled study. Br J Surg. 2023;110(6):710–6.

    Article  PubMed  PubMed Central  Google Scholar 

  49. Rotter T, de Jong RB, Lacko SE, Ronellenfitsch U, Kinsman L et al. Clinical pathways as a quality strategy. In: Busse R, Klazinga N, Panteli D, editors. Improving healthcare quality in Europe: Characteristics, effectiveness and implementation of different strategies [Internet]. Copenhagen (Denmark): European Observatory on Health Systems and Policies; 2019. (Health Policy Series, No. 53.) 12. Available from: https://www.ncbi.nlm.nih.gov/books/NBK549262/

  50. El Baz N, Middel B, van Dijk JP, Oosterhof A, Boonstra PW, Reijneveld SA. Are the outcomes of clinical pathways evidence-based? A critical appraisal of clinical pathway evaluation research. J Eval Clin Pract. 2007;13(6):920–9.

    Article  PubMed  Google Scholar 

  51. Van Herck P, Vanhaecht K, Deneckere S, Bellemans J, Panella M, Barbieri A, et al. Key interventions and outcomes in joint arthroplasty clinical pathways: a systematic review. J Eval Clin Pract. 2010;16(1):39–49.

    Article  PubMed  Google Scholar 

  52. Howell AM, Panesar SS, Burns EM, Donaldson LJ, Darzi A. Reducing the burden of surgical harm: a systematic review of the interventions used to reduce adverse events in surgery. Ann Surg. 2014;259(4):630–41.

    Article  PubMed  Google Scholar 

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Acknowledgements

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Funding

This work was funded through a National Institute of Health and Care Research Advanced Fellowship. DH received a NIHR Advanced Fellowship. RP, DS, JB and JMB are all supervisors of this Advanced Fellowship.

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Authors and Affiliations

  1. Manchester University NHS Foundation Trust, Manchester, UK

    Deena P. Harji & Ben Griffiths

  2. Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK

    Deena P. Harji, Deborah Stocken & Julia M. Brown

  3. Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK

    Rupert Pearse

  4. Bristol Centre for Surgical Research, Population Health Sciences, University of Bristol, Bristol, UK

    Jane Blazeby

  5. NIHR Bristol Biomedical research centre, Bristol, UK

    Jane Blazeby

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  1. Deena P. Harji
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  2. Ben Griffiths
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  3. Deborah Stocken
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  4. Rupert Pearse
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  5. Jane Blazeby
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  6. Julia M. Brown
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Contributions

DH conceptualisation, data collection, extraction and manuscript writing. BG Data collection and extraction - manuscript preparation and review. DS - conceptualisation, analysis and manuscript review. JB, RP, JMB - conceptualisation, overall project supervision and manuscript review.

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Correspondence to Deena P. Harji.

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Harji, D.P., Griffiths, B., Stocken, D. et al. Key interventions and outcomes in perioperative care pathways in emergency laparotomy: a systematic review. World J Emerg Surg 20, 20 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13017-025-00597-4

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13017-025-00597-4

Keywords

World Journal of Emergency Surgery

ISSN: 1749-7922