TELAAH JURNAL

CLINICAL APPLICATION OF ENHANCED RECOVERY AFTER SURGERY

IN THE TREATMENT OF CHOLEDOCHOLITHIASIS BY ERCP

Anggi Arlinda Sari

NIM. 2211102412184

PROFESI NERS
UNIVERSITAS MUHAMMADIYAH KALIMANTAN TIMUR
2022

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 TELAAH JURNAL

I. DESKRIPSI UMUM
No Item : -
1. Judul Jurnal :
➢ “Clinical application of enhanced recovery after surgery in the treatment of
choledocholithiasis by ERCP” (2021)

2. Penulis Jurnal :
➢ Yue Zhang
➢ Zuhua Gong,
➢ Sisi Chen

3. Nama Jurnal/dipublikasikan oleh:

➢ Medicine 2021;100:8(e24730).
➢ ISSN:1943-8141/AJTR0126819

4. Penelaah/review jurnal :
➢ Anggi Arlinda Sari

5. Sistematika penulisan :
➢ Pendahuluan, metode penelitian, hasil, pembahasan, kesimpulan dan saran, daftar
pustaka

6. Referensi Daftar Pustaka :

➢ 16 referensi yang terdiri dari buku dan jurnal

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II. DESKRIPSI CONTENT :
No Komponen Item Question to help “Telaah Jurnal”
1 1. Apa Masalah Penelitian ?
Pemberian program ERAS (Enhanced Recovery After Surgery)
atau peningkatan pemulihan pada pasien CBD atau Common Bile
Duct (batu empedu) yang menjalani ERCP (Endoscopic
Retrograde Cholangiopancreatography)
2. Seberapa besar masalah tersebut ? (Prevelensi/insidensi)
Perubahan pola makan dan gaya hidup berkontribusi terhadap
peningkatan kejadian penyakit hepatobilier. Pembedahan adalah
yang paling umum pengobatan, tetapi beberapa pasien rentan
terhadap berbagai pascaoperasi komplikasi, jadi sangat penting
untuk memasukkan intervensi keperawatan selama operasi. ERAS
(Enhanced Recovery After Surgery) atau program peningkatan
Pendahuluan pemulihan setelah operasi terdiri dari serangkaian langkah-langkah
optimasi berbasis bukti yang dimasukkan ke dalam pengobatan
perioperatif. Perawatan multi-dimensi dan komprehensif,
dikombinasikan dengan teknik pembedahan dan anestesi, dapat
mengurangi stres traumatis fisiologis dan psikologis pasien,
menurunkan insiden komplikasi pasca operasi dan memungkinkan
pasien untuk pulih dengan cepat.

3. Dampak Masalah Jika Tidak diatasi ?

ERCP telah menjadi pilihan pertama bagi banyak pasien dengan

penyakit bilier dan pankreas dalam hal ini pasien dengan
cholelithiasis karena memiliki banyak keuntungan. Misalnya
minimal invasif, efektif, membutuhkan rawat inap yang singkat,
dan memiliki insiden rendah komplikasi, terutama untuk pasien
lanjut usia yang miskin kandidat untuk operasi terbuka.

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 Selama ERCP periode perioperatif, ada beberapa respons stres
yang berasal dari aspek psikologis dan fisiologis. Pankreatitis
adalah komplikasi yang paling umum berikut: ERCP, dan
didiagnosis dengan tingkat AMS (amylase serum). Penelitian
sebelumnya telah menunjukkan bahwa AMS hadir di sekitar 73%
dari pasien setelah ERCP, yang mungkin terkait dengan
peningkatan tekanan intrapankreas selama angiografi; namun,
kurang dari 7% pasien didiagnosis dengan klinis pankreatitis. Oleh
karena itu, penelitian difokuskan untuk mengamati perubahan
tanda-tanda pada perut pasien dan pekerjaan darah rutin.

4. Bagaimana kesenjangan yang terjadi?

Tidak ada kesenjangan yang terjadi pada penelitian ini. Hasil
penelitian ini telah sesuai dengan tujuan penelitian.

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 5. Berdasarkan masalah penelitian, apa tujuan dan hipotesis yang
ditetapkan oleh peneliti ?
➢ Tujuan:
Penelitian ini bertujuan untuk mengetahui pengaruh pemberian
program ERAS (Enhanced Recovery After Surgery) terhadap
pasien dengan CBD atau Common Bile Duct (batu empedu) yang
menjalani ERCP Endoscopic Retrograde
Cholangiopancreatography
➢ Hipotesis :
Terdapat pengaruh pengaruh pemberian program ERAS
terhadap proses pemulihan pasien dengan CBD atau Common
Bile Duct (batu empedu) yang menjalani ERCP
2 Metode
1. Desain penelitian apa yang digunakan ?
Penelitian ini merupakan penelitian kuantitatif, menggunakan desain
penelitian quasi experimental.

Untuk Desain Eksperimen :

a. Apakah menggunakan kelompok kontrol untuk menentukan
efektifitas suatu intervensi
Pada desain penelitian ini terdapat dua kelompok yaitu kelompok
intervensi dan kelompok kontrol.

b. Apakah peneliti melakukan random alokasi (randomisasi)?

1. Desain
Tidak dilakukan randomisasi.
Penelitian

c. jika peneliti melakukan randomisasi, bagaimana prosedurnya,

apakah dilakukan randomisasi sederhana, blok, stratifikasi?
Tidak dilakukan randomisasi.

d. Jika ternyata pada data dasar (base line) terdapat perbedaan

karakteristik/variabel perancu pada kedua kelompok, apakah
peneliti melakukan pengendalian pada uji statistik dengan
stratifikasi atau uji multivariate?
Tidak dijelaskan dalam penelitian.
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 e. Apakah peneliti melakukan masking atau penyamaran dalam
memberikan perlakuan pada responden (responden tidak
menyadari apakah sedang mendapatkan intervensi yang di uji
cobakan?
Tidak dilakukan masking atau penyamaran. Responden sepenuhnya
menyadari intervensi yang diberikan.

f. untuk menjamin kualitas pengukuran, apakah peneliti melakukan

blinding saat mengukur outcome? Blinding merupakan upaya
agar sampel atau peneliti tidak mengetahui kedalam kelompok
mana sampel dimasukkan (eksperimen atau kontrol ). Hal ini
menunjukkan upaya peneliti meningkatkan validitas informasi.
Peneliti tidak melakukan blinding.

1. Siapa populasi target dan populasi terjangkau ?

Pasien dengan diagnosa cholelithiasis.

2. Siapa sampel penelitian ? Apa kriteria inklusi dan ekslusi

sampel ?
Pasien dengan diagnosa CBD (batu empedu) yang menjalani
prosedur ERCP dengan kriteria inklusi dan eksklusi sebagai
berikut :
2. Populasi Kriteria inklusi penelitian:
1. Diagnosis batu saluran empedu yang dikonfirmasi oleh CT,
MRI, atau teknik pencitraan lainnya;
2. Tidak ada komplikasi kardiopulmoner yang serius;
3. Tidak ada riwayat operasi perut bagian atas sebelumnya;
4. Menandatangani informed consent

Kriteria eksklusi penelitian:

1. Choledocholithiasis dengan diameter lebih besar dari 2,5 cm;
2. Stenosis atau deformitas saluran empedu;
3. Penyakit tumor ganas dan disfungsi koagulasi;

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 3. bagaimana metode sampling yang digunakan untuk memilih
sampel dari populasi target ?
Teknik pengambilan sampel dilakukan dengan cara consecutive
sampling, yaitu pemilihan sampel dengan menentukan responden
yang memenuhi kriteria penelitian

4. berapa jumlah sampel yang digunakan dalam penelitian ? Metode

atau rumus apa yang digunakan untuk menentukan jumlah
sampel ?
Sebanyak 161 pasien yang menjalani operasi ERCP di rumah sakit
antara Januari 2017 dan Desember 2019 dan memenuhi kriteria
inklusi dimasukkan dalam penelitian ini. Tujuh puluh delapan pasien
dirawat dengan konsep ERAS di perioperatif keperawatan
(kelompok eksperimen), dan 83 dirawat dengan metode tradisional
(kelompok kontrol). Penelitian ini dihitung dengan menggunakan
rumus Federer.

1. variabel apa saja yang diukur dalam penelitian ?

Kehilangan darah intraoperatif, waktu untuk ambulasi
pascaoperasi pertama, waktu untuk buang air besar dan makan,
lamanya pemasangan selang nasobilier, lama rawat inap, dan biaya
rawat inap diamati dan dicatat untuk dua kelompok pasien. WBC
dan ASM serta terjadinya pasca operasi komplikasi seperti
kolangitis, pankreatitis, dan perdarahan diamati dan dicatat 24 jam
setelah operasi pada 2 kelompok.

2. Metode apa yang digunakan untuk mengumpulkan data ?

Pengukuran
Pengumpulan data dilakukan secara retrospektif dari Januari 2017
atau samapi Desember 2019 menggunakan rekam medis pasien.
Pengumpulan
3. Alat ukur apa yang digunakan untuk mengumpulkan data ?
Data
Peneliti menggunakan instrument penilaian dan lembar observasi.

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 4. bagaimana validitas dan realibilitas alat ukur/ instrumen yang
digunakan ? Apakah peneliti menguji validitas dan reliabilitas
alat ukur ? Jika dilakukan apa metode yang digunakan untuk
menguji
Instrumen yang digunakan peneliti telah teruji validitas dan
reliabilitasnya. Namun, peneliti tidak menjelaskan proses uji
validitas dan realibilas secara rinci di dalam jurnal.
5. Siapa yang melakukan pengukuran atau pengumpulan data ?
Apakah dilakukan pelatihan khusus untuk observer atau yang
melakukan pengukuran ?
Peneliti melakukan pengukuran secara langsung pada penelitian
tersebut.

1. Uji statistik apa yang digunakan untuk menguji hipotesis

atau menganalisis data ?
Uji Chi-Square
Analisis
2. untuk penelitian eksperimen apakah peneliti menggunakan
Data
metode intention to treat atau on treatment analysis?
Peneliti tidak menjelaskan metode intention to treat atau on
treatment analysis yang digunakan. Tetapi pada penelitian ini
semua responden mengikuti penelitian ini sampai akhir dan tidak
ada yang di drop out.

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 a. Intention To Treat adalah menganalisis semua sampel yang
mengikuti penelitian, baik yang drop out, loss of follow up atau
berhenti sebelum penelitian selesai. Sampel yang drop out
dianggap hasil intervensi yang gagal.
b. on treatment analysis hanya menganalisis sampel yang mengikuti
penelitian sampai selesai saja, sedangkan sampel drop out
dianggap tidak mengikuti penelitian dan tidak
diikutkan dalam analisis.
3. Program atau Software statistik apa yang digunakan peneliti
untuk menganalisis data ?
Peneliti menggunakan Software SPSS untuk mengolah dan
menganalisis data.

3 Hasil
1. Alur 1. bagaimana alur (flow) penelitian yang menggambarkan
penelitian dan responden yang mengikuti penelitian sampai selesai, drop out
data base line dan loss of follow up?
Responden dipilih sesuai dengan kriteria penelitian dengan Teknik
consecutive sampling. Klien kemudian dibagi ke dalam 2 kelompok
yaitu kelompok intervensi dan kelompok control. Kelompok kontrol
diberikan pelayanan keperawatan seperti biasa dan kelompok
intervensi diberikan program ERAS atau program peningkatan
pemulihan setelah operasi ERCP. Setelah itu kedua kelompok
dilakukan penilaian pada beberapa variabel seperti Kehilangan
darah intraoperatif, waktu untuk ambulasi pascaoperasi pertama,
waktu untuk buang air besar dan makan, lamanya pemasangan
selang nasobilier, lama rawat inap, dan biaya rawat inap diamati dan
dicatat untuk dua kelompok pasien.

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 2. Bagaimana karakteristik responden dan baseline data?
Karakteristik responden pada penelitian ini yaitu sebagian besar
responden adalah perempuan yaitu sebanyak 42 orang pada
kelompok kontrol dan 41 orang pada kelompok intervensi. Rata-
rata responden berusia 63 tahun pada kelompok kontrol dan 60
tahun pada kelompok intervensi. Sebagian kecil responden
memiliki hipertensi yaitu sebanyak 11 orang pada kelompok
kontrol dan 13 orang pada kelompok intervensi.
3. Pada penelitian eksperimen apakah variabel perancu
(counfounding variabel) dalam data base line tersebar
seimbang pada setiap kelompok? jika tidak seimbang apa
dilakukan peneliti untuk membuat penelitian bebas dari
pengaruh variabel perancu?
Tidak dijelaskan oleh peneliti di dalam jurnal.

1. Apa hasil utama dari penelitian? Jika peneliti melakukan uji

hipotesis, apakah hipotesis penelitian terbukti atau tidak
terbukti(bermakna atau tidak secara statistik)?apakah hasil
penelitian juga bermakna secara klinis?
Insiden komplikasi pasca operasi adalah 9,1% dikelompok
eksperimen dan 20,4% (17/83) pada kelompok kontrol.
2. Hasil
Komplikasi termasuk pankreatitis, kolangitis, dan perdarahan.
Penelitian Tidak ada komplikasi serius (mis., Pankreatitis berat akut)
terjadi pada kedua kelompok. Tidak ada perbedaan yang
signifikan antara kelompok dalam tingkat keparahan komplikasi
pasca operasi, tetapi insiden komplikasi secara signifikan lebih
rendah pada kelompok eksperimen.

Dalam penelitian kami, untuk pasien dalam eksperimen

kelompok, ekstubasi nasobiliary dilakukan setelah nasobiliary
kolangiografi ketika amilase darah berada dalam waktu 3 kali
lipat nilai normal dan tidak ada gejala yang jelas dari perut nyeri
24 jam setelah operasi. Sebaliknya, pada kelompok kontrol
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 pasien, ekstubasi dilakukan setelah nasobiliary cholangiography
ketika kadar AMS dalam batas normal, tanpa gejala nyeri perut
yang jelas. Hasil klinis kami menunjukkan bahwa ekstubasi dini
tidak meningkatkan kejadian efek samping pada kelompok
eksperimen. Hasil kami menunjukkan bahwa waktu untuk
ambulasi pasca operasi pertama berkurang ketika ERAS
keperawatan diterapkan. Pemberian makan oral awal juga
signifikan lebih awal pada kelompok eksperimen dibandingkan
pada kelompok kontrol, dan lama dan biaya rawat inap juga
signifikan berkurang (P<.05). Hasil ini konsisten dengan
sebelumnya studi.

2. Untuk penelitian eksperimen dengan variabel dependen

kategorik, apakah peneliti menjelaskan tentang nilai
kepentingan klinis dari hasil penelitian seperti number need
to treat (NNT), relative risk reduction(RRR) atau absolute
risk reduction (ARR).
Dalam penelitian ini tidak menjelaskan tentang nilai
kepentingan klinis seperti number need to treat (NNT), relative
risk reduction (RRR) atau absolute risk reduction (ARR).

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4 Diskusi (discuss) 1. Bagaimana interprestasi peneliti terhadap hasil penelitian?
Apakah peneliti membuat interprestasi yang rasional dan
ilmiah tentang hal-hal yang ditemukan dalam penelitian
berdasarkan teori terkini? Catatan : meskipun hasil
penelitian tidak sesuai dengan hipotesis, namun suatu
penelitian tetap berkualitas jika peneliti mampu
menjelaskan rasional secara ilmiah mengapa hipotesisnya
tidak terbukti.
Dari praktik klinis dan analisis data kami, kami menyimpulkan
bahwa menerapkan konsep ERAS untuk perioperatif
keperawatan secara signifikan dapat mengurangi waktu untuk
pertama pasca operasi ambulasi, waktu yang melelahkan, dan
waktu untuk buang air besar dan makan. Selain itu, kehilangan
darah intraoperatif, komplikasi pascaoperasi, rawat inap, dan
biaya rawat inap juga berkurang secara signifikan pada pasien
yang menerima ERAS, menunjukkan bahwa konsep aman dan
ekonomis dalam keperawatan perioperatif ERCP dan EST
untuk pengobatan kalkulus bilier, dan karena itu memiliki nilai
klinis yang penting. Peningkatan pemulihan setelah metode
operasi aman dan efektif dalam keperawatan perioperatif
setelah ERCP untuk pengobatan choledocholithiasis, dan
mereka dapat mempercepat pemulihan pasien dan mengurangi
kejadian komplikasi.
2. Bagaimana nilai kepentingan (importancy) hasil penelitian?
Peneliti dapat membuktikan bahwa pemberian program ERAS
memiliki pengaruh terhadap tingkat kepulihan pasien dengan
batu empedu yang menjalani ERCP.

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3. Bagaimana applicability hasil penelitian menurut
peneliti?apakah hasil penelitian dapat diterapkan pada
tatanan praktik keperawatan ditinjau dari aspek
fasilitas,pembiayaan, sumber daya manusia, dan aspek
legal?
Tidak dijelaskan mengenai applicability hasil penelitian di dalam
jurnal

4. Apakah mungkin penelitian ini direplukasi pada setting

praktik klinik lainnya?
Penelitian ini dapat diterapkan pada praktik klinik lainnya
karena hasil dari penelitian ini dirasa berpengaruh untuk
meningkatkan pemulihan pasien oasca menjalani ERCP.

5. Apakah peneliti menjelaskan kekuatan dan kelemahan

penelitian? Apakah kelemahan ini tidak menurunkan
validitas hasil penelitian?
Penelitian ini memiliki beberapa keterbatasan. Pertama, itu
adalah retrospektif studi yang dilakukan pada data dari database
pasien, jadi hasil kami harus ditafsirkan dengan hati-hati.
Mengingat kurangnya pengacakan, metode keperawatan
perioperatif yang berbeda mungkin telah mempengaruhi
pemulihan pasien pasca operasi. Kedua, meskipun pasien
berpengalaman baik metode keperawatan rutin dan metode
keperawatan ERAS, perawat berbeda dalam pendekatan
masing-masing. Ketiga, mengingat keterbatasan waktu tindak
lanjut, kami dapat tidak mengevaluasi dampak dari perawatan
perioperatif yang berbeda pendekatan pada kelangsungan hidup
jangka panjang pasien. Meskipun ini keterbatasan, penelitian ini
memberikan data yang berarti tentang keamanan dan
meningkatkan efektivitas pemulihan setelah perawatan bedah
koledokolitiasis oleh ERCP.

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 Observational Study Medicine ®

OPEN

Clinical application of enhanced recovery after

surgery in the treatment of choledocholithiasis by
ERCP
∗
Yue Zhang, BS, Zuhua Gong, BS, Sisi Chen, BS

Abstract
This study aims to investigate the effect of applying enhanced recovery after surgery methods (ERAS) in perioperative nursing of
choledocholithiasis following endoscopic retrograde cholangiopancreatography (ERCP) for treatment of biliary calculus.
Clinical data from 161 patients who underwent ERCP surgery in Wuhan Union Hospital from January 2017 to December 2019
were retrospectively analyzed. A total of 78 patients received perioperative nursing using the ERAS concept (experimental group) and
83 patients received conventional perioperative nursing (control group). Group differences were compared for the time to first
postoperative ambulation, exhausting time, time to first defecation and eating, intraoperative blood loss, postoperative complication
incidence (pancreatitis, cholangitis, hemorrhage), white blood cell (WBC), and serum amylase (AMS) values at 24 hours, duration of
nasobiliary duct indwelling, length of hospital stay, and hospitalization expenses.
No significant between-group differences were noted for demographic characteristics (age, sex, BMI, ASA score, and comorbidity)
(P > .05). Time to first ambulation, exhausting time, time to defecation and eating, and nasobiliary drainage time were shorter in the
experimental group than the control group, and the differences were statistically significant (P < .05). There was no significant
between-group difference in postoperative WBC values at 24 hours (P > .05), but the experimental group’s AMS values at 24 hours
postoperation were significantly lower than those of the controls (154.93 ± 190.01 vs 241.97 ± 482.64, P = .031). Postoperative
complications incidence was 9.1% in the experimental group, which was significantly lower than the 20.4% in the control group, and
this difference was statistically significant (P = .039). Compared with the control group, nasobiliary drainage time (26.53 ± 7.43 hours
vs 37.56 ± 9.91 hours, P < .001), hospital stay (8.32 ± 1.55 days vs 4.56 ± 1.38 days, P < .001), and hospitalization expenses (36800
± 11900 Yuan vs 28900 ± 6500 Yuan, P = .016) were significantly lower in the experimental group.
ERAS is a safe and effective perioperative nursing application in ERCP for treating choledocholithiasis. It can effectively accelerate
patients’ recovery and reduce the incidence of complications; therefore, it is worthy of being applied and promoted in clinical nursing.
Abbreviations: AMS = serum amylase, ASA score = American Society of Anesthesiologists score, BMI = body mass index,
ERAS = enhanced recovery after surgery, ERCP = endoscopic retrograde cholangiopancreatography, EST = endoscopic
sphincterotomy, WBC = white blood cell.
Keywords: choledocholithiasis, enhanced recovery after surgery, postoperative complications, retrograde cholangiopancreatog-
raphy

Editor: Mihnea-Alexandru Găman.

The datasets generated during and/or analyzed during the current study are
available from the corresponding author on reasonable request.
The authors have no conflicts of interests to disclose.
Department of Hepatobiliary Surgery, Union Hospital, Tongji Medical College,
Huazhong University of Science and Technology, Wuhan, China.
∗ complications, so it is particularly important to incorporate
Correspondence: Sisi Chen, Department of Hepatobiliary Surgery, Union
Hospital, Tongji Medical College, Huazhong University of Science and
Technology, 1277 JieFang Avenue, Wuhan 430022, China (e-mail:
wang_whuh@163.com).
Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.
This is an open access article distributed under the terms of the Creative
Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is
permissible to download, share, remix, transform, and buildup the work provided
it is properly cited. The work cannot be used commercially without permission
from the journal.
How to cite this article: Zhang Y, Gong Z, Chen S. Clinical application of
enhanced recovery after surgery in the treatment of choledocholithiasis by ERCP.
Medicine 2021;100:8(e24730).
Received: 21 May 2020 / Received in final form: 15 January 2021 / Accepted:
18 January 2021
http://dx.doi.org/10.1097/MD.0000000000024730
1. Introduction
Changes in diet and lifestyle are contributing to an increasing
incidence of hepatobiliary diseases. Surgery is the most common
treatment, but some patients are prone to a variety of postsurgical
nursing intervention during the operation.[1] ERAS comprises a
series of evidence-based optimization measures incorporated into
perioperative treatment.[2] Multi-dimensional and comprehen-
sive care, combined with surgery and anesthesia techniques, can
reduce patients’ physiological and psychological traumatic stress,
lowering the incidence of postoperative complications and
allowing patients to recover quickly.[3,4] ERAS has overturned
the perioperative management thinking formed over the past
hundred years, and several previous studies have reported
obvious advantages over traditional methods for shortening
hospital stays, lowering the incidence of postoperative compli-
cations and mortality, and reducing medical costs.[5] Currently,
ERAS concepts and measures are widely used in minimally
invasive surgery, but there are no unified standards or evaluations

1
Zhang et al. Medicine (2021) 100:8
for their application in ERCP surgery. Therefore, we retrospec-
tively analyzed the data of patients where the ERAS concept for
perioperative nursing during ERCP surgery was applied between
January 2017 and December 2019, with the aim of exploring the
effect of ERAS in perioperative nursing of patients with
choledocholithiasis treated by ERCP for treating biliary calculus.
2. Materials and methods
2.1. General information
A total of 161 patients who underwent ERCP surgery in our
hospital between January 2017 and December 2019 and met the
inclusion criteria were included in the study. Seventy eight
patients were treated with the ERAS concept in perioperative
nursing (experimental group), and 83 were treated with
traditional methods (control group). Inclusion criteria:
(1) diagnosis of common bile duct stones confirmed by CT, MRI,
or other imaging techniques;
(2) no serious cardiopulmonary complications;
(3) no previous history of upper abdominal surgery;
(4) complete clinical data;
(5) signed informed consent.
Exclusion criteria:
(1) choledocholithiasis with diameter greater than 2.5 cm;
(2) biliary tract stenosis or deformity;
(3) malignant tumor disease and coagulation dysfunction;
(4) mental disorders that interfered with cooperating with
surgery.
The study was approved by the ethics committee of Wuhan
Union Medical College Hospital (No. 2019S084) and carried out
in accordance with the Helsinki Declaration.
2.2. Method
Patients in the control group were given routine perioperative
nursing, including condition monitoring and medication guid-
ance. Patients in the experimental group received nursing
intervention for ERAS in the perioperative period. The specific
intervention measures were as follows:
1. Preoperative nursing: Psychological nursing: patients have
different degrees of anxiety and depression resulting from
negative cognitions of the disease and lack of relevant
knowledge; hence, psychological counseling is needed. In
accordance with the concept of ERAS in the perioperative
period, health education was provided to improve patients’
cooperation.
2. Preoperative preparation: patients were given 1000 ml glucose
solution (10%) on the night before the operation and 500 ml
glucose solution (10%) on the morning of the operation.
Patients were instructed to fast and drink no water for 4 to 6
hours before the operation, and that bowel preparation should
be performed at the same time to prevent intraoperative
intraperitoneal infection.
3. Intraoperative nursing: assisting patients to adjust their body
position, setting appropriate temperature and humidity before
and during surgery, keeping patients warm during surgery,
and strengthening nursing intervention on the nasobiliary duct
and catheter to prevent infection and abdominal distension.
2
Medicine
4. Postoperative care: patients were encouraged to get out of bed
6 hours after surgery, and medication was adjusted according
to patients’ pain scores. Antibiotics were administered 30
minutes before surgery and stopped 24 hours after surgery, if
the patient had no obvious biliary tract infection; cholangiog-
raphy was performed 24 hours after surgery, and the
nasobiliary tube was removed the next day. The amount of
fluid was controlled within 2000 ml of the physiological
requirement, with a drip rate of 250 ml/hour. Diet and
rehabilitation training were provided.[6,7]
2.3. Observation indicators
Intraoperative blood loss, time to first postoperative ambulation,
first exhausting time, time to defecation and eating, duration of
nasobiliary tube indwelling, length of stay, and hospitalization
costs were observed and recorded for the two groups of patients.
WBC and ASM as well as the occurrence of postoperative
complications such as cholangitis, pancreatitis, and bleeding were
observed and recorded 24 hours after operation in the 2 groups.
2.4. Data analysis
Continuous variables were presented as mean ± standard devia-
tion, and categorical variables were expressed as percentage.
Student t test was performed to compare the difference in
continuous variables between the experimental group and control
group. Chi-Squared test or Fisher exact test was used to compare
categorical variables between the 2 groups. All statistical analyses
were performed using SPSS version 24 (Chicago, IL) with two-
sided P < .05 considered statistically significant.
3. Results
3.1. Patient characteristics
Patients’ demographic data are presented in Table 1. There were
no statistically significant differences between the 2 groups for
age, sex, BMI, ASA score, and comorbidity (P > .05).
3.2. Between-group comparisons of related clinical
indexes
The time to first ambulation (8.74 ± 4.85 hours vs 16.35 ± 5.34
hours, P = .023), exhausting time (31.23 ± 5.20 hours vs 51.30 ±
5.36 hours, P < .001), defecation (48.31 ± 8.79 hours vs 59.46 ±
7.54 hours, P < .001) and eating (32.00 ± 18.33 hours vs 45.60 ±
30.34 hours, P = .001) of the experimental group was shorter
than that of the control group, and the difference was statistically
significant. Compared with the control group, duration of
nasobiliary drainage (26.53 ± 7.43 hours vs 37.56 ± 9.91 hours,
P < .001), length of hospital stay (8.32 ± 1.55 days vs 4.56 ± 1.38
days, P < .001), and hospitalization expenses (36800 ± 11900
Yuan vs 28900 ± 6500 Yuan, P = .016) were all lower in the
experimental group (Table 2).
3.3. Between-group comparisons of intraoperative blood
loss and postoperative complications
There were no significant differences in intraoperative blood loss
and WBC count 24 hours postoperative (P > .05), but the
experimental group’s AMS values 24 hours postoperative were
Zhang et al. Medicine (2021) 100:8 www.md-journal.com

Table 1
Demographic characteristics of patients.
Characteristics ERAS group (n = 78) n (%)/mean ± sd Control group (n = 83) n (%)/mean ± sd P
Age (year) 60.74 ± 17.85 63.49 ± 15.40 .359
Sex .295
Male 37 (47.4) 41 (49.4)
Female 41 (52.6) 42 (50.6)
∗
BMI 22.5 ± 3.06 22.5 ± 2.77 .697
∗
ASA .917
II 48 (61.5) 56 (67.5)
III 27 (34.6) 25 (30.1)
IV 3 (3.9) 2 (2.4)
Comorbidity 11 (14.1) 13 (15.7) 0.797
Hypertension 5 (6.4) 8 (9.6)
Diabetes 2 (2.6) 2 (2.4)
Coronary heart disease 2 (2.6) 4 (4.8)
Cerebral infarction 0 (0) 1 (1.2)
Schistosomiasis 0 (0) 2 (2.4)
Cirrhosis 0 (0) 1 (1.2)
Hypoalbuminemia 2 (2.6) 0 (0)
ASA = American Society of Anesthesiologists, BMI = body mass index.
∗ ∗
3-D XB represent 3-dimension x-ray beams, and EB represent electron beams.

Table 2
The comparison of related clinical indexes between the 2 groups.
Characteristics ERAS group (n = 78) n (%)/mean ± sd Control group (n = 83) n (%)/mean ± sd P
The time to first ambulation (h) 8.74 ± 4.85 16.35 ± 5.34 .023
Exhausting time (h) 31.23 ± 5.20 51.30 ± 5.36 <.001
The time to first of defecation (h) 48.31 ± 8.79 59.46 ± 7.54 <.001
The time to first of eating (h) 32.00 ± 18.33 45.60 ± 30.34 .001
duration of nasobiliary drainage (h) 26.53 ± 7.43 37.56 ± 9.91 <.001
Hospital stay (day) 4.56 ± 1.38 8.32 ± 1.55 <.001
Hospitalization expenses (yuan) 28900 ± 6500 36800 ± 11900 .016

significantly lower than that of the control group (154.93 ±
190.01 U/L vs. 241.97 ± 482.64 U/L, P = .031). Postoperative
complication incidence was 9.1% in the experimental group,
which was significantly lower than in the control group, whereas
20.4% (17 of 83 patients) experienced postoperative complica-
tions; this difference was statistically significant (P = .039)
(Table 3).
4. Discussion
ERAS is a concept of perioperative treatment proposed in 1997
by Kehlet, who aimed to optimize perioperative treatment
measures through a series of evidence-based medical interven-
tions. ERAS can reduce the adverse physiological and psycho-
logical stress caused by surgery and medical treatment, reduce the
negative effect on patients, and accelerate patients’ recovery after
surgery.[8–11] In 2001, Danish surgeons Wilmore et al reintro-
duced this concept and began to widely implement it in clinical
practice.[12,13] Currently, the ERAS concept is widely used in
colorectal, orthopedic, gynecological, gastric cancer, and thorac-
ic surgeries, and relevant studies have shown its significant
clinical effect.[14–21]
Although open surgery and laparoscopy are also suitable
treatments, ERCP has become the first choice for many patients

Table 3
The comparison of intraoperative blooding loss and postoperative complications between the 2 groups.
Characteristics ERAS group (n = 78) n (%)/mean ± sd Control group (n = 83) n (%)/mean ± sd P
Intraoperative blood loss (ml) 4.65 ± 1.631 5.27 ± 2.553 .359
WBC 6.47 ± 3.02 6.78 ± 4.23 .511
AMS 154.93 ± 190.01 241.97 ± 482.64 .031
Total complications 7 (9.1) 17 (20.4) .039
Cholangitis 1 (1.3) 4 (4.8)
Pancreatitis 3 (3.9) 7 (8.4)
Postoperative hemorrhage 0 (0) 1 (1.2)
Other 3 (3.9) 5 (6.0)
WBC = white blood cell values 24 hours postoperative (4–10  109/L), AMS = Serum amylase postoperative values 24 hours postoperative (U/L).

3
Zhang et al. Medicine (2021) 100:8
with biliary and pancreatic diseases because it has many
advantages.[22] For example, it is minimally invasive, effective,
requires a short hospital stay, and has a low incidence of
complications, especially for elderly patients who are poor
candidates for open surgery. With the development of medical
technology, the therapeutic effect of ERCP has occupied an
important medical position alongside the development of
minimally invasive technology. ERCP has become the first
choice for many patients with biliary and pancreatic diseases
because it is minimally invasive, effective, requires only a short
hospital stay, and has a low incidence of complications, and has
irreplaceable advantages.[23]
Kehlet et al believe that reducing the stress response is the
ERAS concept core principle and the basis for accelerating
patients’ postoperative rehabilitation.[24] During the ERCP
perioperative period, there are multiple stress responses stem-
ming from psychological and physiological aspects. In our study,
the main purpose of preoperative psychological nursing was to
help patients understand the process and effect of ERCP surgery,
which helped facilitate their cooperation during surgery, when
they are typically sedated. Preoperative preparation helps to
eliminate patients’ hunger state and relieve their anxiety.
Preoperative prophylactic rectal indomethacin administration
could replace pancreatic stent placement (PSP) in patients
undergoing high-risk ERCP, potentially improving clinical
outcomes and reducing healthcare costs.[25] During the opera-
tion, after successful ERCP catheterization, we made a small
incision in the papillary sphincter, about 0.3 to 0.5 cm, and then
expanded the balloon to 1.0 to 1.5 cm for stone extraction. The
small incision helps to retain as much of the papillary sphincter as
possible, and reduces the incidence of bleeding and intestinal
perforation, which also follows the ERAS concept.
Nelson et al found that median postoperative hospitalization
days decreased from 9.4. to 7.4 after applying accelerated
rehabilitation surgery measures, and there were no significant
changes in reoperation rates, readmission rates, or mortality
within 30 days, which confirmed the safety and effectiveness of
accelerated rehabilitation surgery.[26] Our results showed that the
time to first postoperative ambulation was reduced when ERAS
nursing was applied. Initial oral feeding was also significantly
earlier in the experimental group than in the control group, and
the length and cost of hospitalization were also significantly
reduced (P < .05). These results are consistent with previous
studies.
Pancreatitis is the most common complication following
ERCP, and is diagnosed by AMS levels.[27–28] Previous studies
have shown that AMS was present in approximately 73% of
patients after ERCP, which may be associated with a sudden
increase in intrapancreatic pressure during angiography; howev-
er, less than 7% of patients were diagnosed with clinical
pancreatitis.[29–32] Therefore, we focused on observing the
changes in patients’ abdominal signs and routine blood work.
If the patients had no obvious abdominal pain and the AMS was
within 3 to 5 times of the normal value 24 hours later, they started
drinking water and underwent nasobiliary drainage angiogra-
phy. If there were no residual stones, the nasobiliary drainage
tube could be extracted.
Early papillary edema after EST can lead to increased intrabile
duct pressure, and a small amount of bile can flow down the
common channel into the pancreatic duct, increasing the
incidence of pancreatitis. Therefore, nasobiliary drainage also
effectively reduces the incidence of pancreatitis.[33–34] The timing
4
Medicine
of nasal biliary drainage tube removal remains controversial. We
believe that if the intraoperative operation is successful and the
guidewire is not repeatedly inserted into the patient’s pancreatic
duct, the catheter can be extubated in advance without residual
stones showing on postoperative angiography, which not only
alleviates patients’ discomfort, but is an important link in the
ERAS concept. In our study, for patients in the experimental
group, nasobiliary extubation was performed after nasobiliary
cholangiography when the blood amylase was within 3 times the
normal value and there were no obvious symptoms of abdominal
pain 24 hours after surgery. By contrast, in control group
patients, extubation was performed after nasobiliary cholangi-
ography when AMS levels were within normal limits, with no
obvious symptoms of abdominal pain. Our clinical results
showed that early extubation did not increase the incidence of
adverse events in the experimental group.
Postoperative complication incidence was 9.1% in the
experimental group and 20.4% (17/83) in the control group.
Complications included pancreatitis, cholangitis, and hemor-
rhage. No serious complications (e.g., acute severe pancreatitis)
occurred in either group. There were no significant between-
group differences in postoperative complication severity, but
complication incidence was significantly lower in the experimen-
tal group. From our clinical practice and data analysis, we
concluded that applying the ERAS concept for perioperative
nursing can significantly reduce the time to the first postoperative
ambulation, exhausting time, and time to defecation and eating.
In addition, intraoperative blood loss, postoperative complica-
tions, hospital stay, and hospitalization expenses were also
significantly reduced in patients receiving ERAS, suggesting that
the concept is safe and economical in perioperative nursing of
ERCP and EST for treatment of biliary calculus, and therefore has
important clinical value.
This study has several limitations. First, it was a retrospective
study conducted on data from a patient database, so our results
must be interpreted with caution. Given the lack of randomiza-
tion, different perioperative nursing methods may have affected
patients’ postoperative recovery. Second, although patients
experienced both routine nursing methods and ERAS nursing
methods, the nurses differed in their individual approaches; this
lack of uniform criteria for treatment decisions may have biased
the results. Third, given the limitation of follow-up time, we could
not evaluate the impact of different perioperative nursing
approaches on patients’ long-term survival. Despite these
limitations, this study provides meaningful data on safety and
enhanced recovery effectiveness following surgical treatment of
choledocholithiasis by ERCP.
5. Conclusion
Enhanced recovery after surgery methods are safe and effective in
perioperative nursing after ERCP for the treatment of chol-
edocholithiasis, and they may accelerate patients’ recovery and
reduce the incidence of complications. ERAS methods should be
effectively applied and promoted in clinical nursing.
Author contributions
Conceptualization: Yue Zhang, Zuhua Gong.
Data curation: Yue Zhang.
Formal analysis: Zuhua Gong, Sisi Chen.
Investigation: Yue Zhang.
Zhang et al. Medicine (2021) 100:8
Methodology: Sisi Chen.
Project administration: Yue Zhang.
Resources: Yue Zhang.
Software: Yue Zhang, Zuhua Gong.
Validation: Sisi Chen.
Writing – original draft: Yue Zhang, Zuhua Gong, Sisi Chen.
Writing – review & editing: Zuhua Gong, Sisi Chen.
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