Enhanced recovery after surgery (ERAS), proposed by Danish surgeon Kehlet (1), is a perioperative improvement strategy aimed to minimize the stress response and organ dysfunction to accelerate postoperative recovery and reduce surgery-related complications.

In general surgery, the ERAS concept was initially applied in colorectal resection, which was recognized by the academic community for its ability to significantly shorten length of hospital stay (2). In recent years, the concept has been widely adopted in other departments, including orthopedics, thoracic surgery, obstetrics and gynecology, and urology. Laparoscopic technique has been widely used in hepatolithiasis surgery due to its less trauma and rapid postoperative recovery. With the advancements in surgical techniques, the indications for laparoscopic surgery have expanded, and a history of biliary surgery is no longer considered a contraindication. China is a high-incidence area for bile duct stones. Extrahepatic bile duct stones are characterized by complex conditions, high rates of residual/recurrent stones and multiple complications. Recurrent cholangitis caused by extrahepatic bile duct stones severely affects the quality of life of patients and exacerbates the economic burden on the healthcare system in China (3). Currently, surgical intervention remains the mainstream treatment for extrahepatic bile duct stones, and it is common for patients to undergo reoperation due to stone recurrence.

Although the ERAS concept has gradually been applied in hepatobiliary and pancreatic surgery, it has not yet been widely adopted. Particularly, there is still no consensus among experts, both domestically and internationally, on ERAS perioperative management strategies for reoperations involving extrahepatic bile duct stones. Many surgeons still believe that the impacts of first surgery often lead to severe intra-abdominal adhesions during reoperations, potentially resulting in inadvertent injury to the bile ducts or even the intestines. Consequently, surgeons often tend to opt for open surgery for reoperations to reduce the occurrence of surgical complications. However, as laparoscopic techniques have been introduced in China and have advanced over several decades, reoperations are no longer considered a contraindication for laparoscopic surgery. Data suggest that there is no significant difference in complications, such as bile duct injury, intestinal injury, and bile leakage, between open surgery and laparoscopic surgery, but laparoscopic surgery offers clear advantages in early postoperative ambulation, eating, and shorter length of hospital stays (4–6).

However, there is still insufficient evidence to support the application of the ERAS concept in laparoscopic biliary reoperation. In 2018, the Chinese Expert Consensus on ERAS also pointed out that laparoscopic surgery should be the first choice for suitable patients under strict indication control and with adequate consideration of equipment, technique, and patient conditions (7). Therefore, we attempted to apply the ERAS concept to the perioperative management of laparoscopic biliary reoperations for extrahepatic bile duct stones. Additionally, we conducted a randomized controlled trial comparing this strategy with the traditional perioperative management strategy of the same period to observe its clinical application effects.

ERAS refers to a set of perioperative management measures that are rigorously supported by evidence-based medicine to accelerate postoperative rehabilitation. In this study, the ERAS concept was adopted for the patients with extrahepatic bile duct stones undergoing reoperation in perioperative management. The results demonstrated that clinical rehabilitation indicators in the ERAS group were superior to those of patients treated with traditional perioperative management.

ERAS encompasses preoperative, intraoperative, and postoperative phases, and the adverse effects caused by various stressors should be avoided in each phase (8). In this study, the ERAS group received relevant education from the patient's hospitalization. Detailed information about the patient's condition and expected outcomes was provided by medical staff, ensuring that patients and their family members were well-informed about the entire treatment process. Additionally, appropriate guidance by nursing staff was offered to help patients quickly acclimate to their surroundings, thereby effectively alleviating anxiety and tension, increasing the subjective initiative of patients, and promoting their rehabilitation.

For preoperative preparation, the traditional concept holds that surgery for recurrent extrahepatic bile duct stones is an open surgery, and routine preoperative intestinal preparation should be performed for accidental intestinal injuries. However, this preparation, on the one hand, can increase patient anxiety and discomfort. On the other hand, it may lead to multiple conditions such as electrolyte imbalance and ectopia of intestinal flora, thereby increasing the incidence of postoperative complications and delaying the postoperative rehabilitation of patients (9, 10). Furthermore, preoperative placement of a nasogastric tube for decompression can not only cause throat discomfort but also hinder the normal physiological recovery of gastrointestinal function postoperatively (11, 12). In this study, the incidence of adverse events, such as abdominal distension, was not increased in the ERAS group without routine cleaning enema preoperatively. Additionally, no adverse events, including aspiration, occurred without nasogastric tube placement in the ERAS group. Furthermore, for gastric emptying to prevent aspiration, the ERAS group received oral administration of 10% glucose solution 2 h preoperatively, which was different from the traditional perioperative management requiring 12 h of fasting and 6 h of water deprivation. Such a method not only alleviated thirst, anxiety, hunger, and hypoglycemia but also increased liver glycogen reserves and reduced the incidence of insulin resistance (13, 14). In this study, no serious complications, such as aspiration, were caused by this method in the ERAS group. In addition to traditional recovery parameters, patients in the ERAS group achieved significantly earlier ambulation and oral intake, reflecting faster early postoperative functional recovery. Moreover, patient satisfaction at both discharge and 3-month follow-up was notably higher in the ERAS group. These findings indicate that ERAS not only accelerates physiological recovery but also improves the patient's subjective experience and acceptance of treatment.

Control of intraoperative fluid volume and rate, alongside maintaining body temperature, are critical factors for postoperative recovery (15). Intraoperative hypothermia exacerbates the body's stress responses, and the process of rewarming from hypothermia may lead to coagulation abnormalities and increase the risk of postoperative infections. Furthermore, such a process can further increase the cardiovascular burden to result in perioperative cardiovascular events. Additionally, the infusion of large volumes of hypothermal liquid intraoperatively can not only increase cardiopulmonary loads and interstitia fluid retention, but also decrease the liver metabolism metabolic function and coagulation function. Strict intraoperative fluid control and prevention of hypothermia can prevent the onset of aforementioned conditions, reduce the above risks, and promote the recovery of gastrointestinal function.

Regarding postoperative recovery, considering that reoperation is time-consuming, urinary catheters were placed in both groups. However, patients in the ERAS group did not require bladder function training for early removal of the catheter, and no cases of reinsertion were observed. In clinical practice, the main role of drainage tube placement was to drain intra-abdominal fluid accumulation. An abdominal drainage tube was routinely placed to observe whether there is intra-abdominal bleeding or bile leakage, particularly in patients undergoing primary suture of the common bile duct. Nevertheless, the retention of a drainage tube could increase the likelihood of postoperative pain and infection around the drainage site to some extent and exacerbate psychological and physiological burden. Such results could further affect the patient's motivation for early ambulation and oral intake, ultimately prolonging recovery time. Therefore, the postoperative drainage tube should be removed as early as possible in the absence of active bleeding, bile leakage, or excessive exudate. This study revealed that early removal of the abdominal drainage tube did not result in an increased incidence of postoperative intra-abdominal infections or bleeding; however, these treatments were based on precise surgical suturing techniques and minimal mild bile duct inflammation and edema, and the serious consequences caused by blind removal of the drainage tube should be avoided. Recent studies have emphasized the value of patient-centered outcomes, such as quality of life and satisfaction, in evaluating surgical strategies. In this study, ERAS patients scored significantly higher in several SF-36 domains—including physical functioning, vitality, and general health—at 4 weeks postoperatively, consistent with earlier reports that ERAS can improve early postoperative quality of life in open surgery.

Early ambulation postoperatively is beneficial for the recovery of gastrointestinal and pulmonary function and reduces the incidence of venous thrombosis. Effective pain management is a prerequisite for early mobilization and oral intake. A multimodal analgesia approach, including scheduled non-opioid agents combined with patient-controlled intravenous opioids, was employed in the ERAS group, whereas the control group received standard stepwise analgesia with on-demand non-opioid medications and rescue opioids. However, our ERAS protocol did not include advanced abdominal wall blocks and instead relied on wound infiltration plus systemic multimodal analgesia, which may have limited the full analgesic potential of contemporary ERAS pathways. This study demonstrated that postoperative wound pain was significantly better in the ERAS group compared to the control group (P < 0.05). Additionally, early ambulation can, to some extent, promote gastrointestinal peristalsis and prevent complications caused by long-term bedridden, such as hypostatic pneumonia, and lower extremity venous thrombosis (16). Furthermore, early postoperative oral intake, on the one hand, can accelerate the recovery of gastrointestinal peristalsis and maintain the integrity of the intestinal mucosal barrier; on the other hand, it can reduce the volume and duration of infusion, improve hepatic synthetic function and enhance overall nutritional status (17). PAB, synthesized by hepatocytes, has a short half-life of approximately 1.9 days. Hence, the measurement of PAB level in plasma is highly sensitive for understanding protein malnutrition and liver dysfunction. In this study, the PAB levels were comparable between the two groups on postoperative day 1. However, the control group exhibited a significant decrease in the PAB levels on postoperative days 3 and 5 compared to the ERAS group, caused by the continuous consumption of surgical stress and trauma and the inability to resume early oral intake. Therefore, in this study, postoperative time to first flatus and nutritional status was markedly better in the ERAS group than those in the control group, greatly greatly promoting recovery and improving nutritional status. In our protocol, IL-6, CRP, PAB and postoperative pain scores were intentionally measured only at postoperative time points as dynamic indicators of surgical stress and recovery, rather than as baseline characteristics. Although all patients underwent routine preoperative laboratory assessments and no obvious imbalance between the two groups was identified, the lack of detailed preoperative IL-6/CRP/PAB values and standardized pain scores means that a certain degree of residual confounding by preoperative status cannot be completely excluded. Although operation time did not reach statistical significance, the ERAS group had an average reduction of approximately 21 min. This trend may reflect differences in operative complexity and is acknowledged as a potential confounder that could influence postoperative recovery.

Regarding complications, this study revealed that there were no significant differences between the ERAS and control groups in the incidence of postoperative incision infection, pulmonary infection, or bile leakage. However, the incidence of severe postoperative nausea and vomiting was remarkably lower in the ERAS group. This reduction in nausea and vomiting may be attributed to the ERAS protocol's multimodal analgesic strategy, which relies primarily on non-opioid medications and consequently lowers overall opioid exposure, a recognized risk factor for postoperative nausea and vomiting. Additionally, postoperative serum CRP levels, an indicator of postoperative serological indicators, were remarkable lower in the ERAS group relative to the control group. This indicator, to some extent, reflects the body's inflammation and stress response, suggesting that the ERAS protocol in this study effectively mitigated postoperative inflammation and adverse stress response, thereby benefiting patient recovery.

This study explored the application of the ERAS concept in laparoscopic biliary reoperation for extrahepatic bile duct stones and achieved some positive results. However, there are some limitations in this study. For instance, only 60 patients were included in this study, which is a small sample size and may affect the generalizability of the findings. Large-scale multicenter studies are needed to further validate the effectiveness of the ERAS concept. The application of the ERAS concept in the surgery for extrahepatic bile duct stones should be further validated and refined.