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Effect of an ERAS protocol and laparoscopic surgery on patient safety

Info: 2710 words (11 pages) Essay
Published: 23rd Sep 2019 in Nursing

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Evidence Based Practice and Applied Nursing Research

Evidence Table


 Zhu, Y., Xiang, J., Liu, W., Cao, Q., & Zhou, W. (2018). Laparoscopy Combined with Enhanced Recovery Pathway in Ileocecal Resection for Crohn’s Disease: A Randomized Study. Gastroenterology Research & Practice, 1–7. https://doi.org/10.1155/2018/9648674


The purpose of this article is to study the use of minimally invasive laparoscopic surgery coupled with an ERAS protocol and its effect on patient safety and short-term postoperative outcomes in patients with Crohn’s disease undergoing elective ileocecal resection (Zhu, 2018).


The author cites 23 articles that show the benefits of a laparoscopic versus open approach for colon resection as well as the benefits of using an ERAS protocol versus conventional perioperative care. In spite of the wealth of information available regarding the benefits of the laparoscopic surgical approach over open and the use of the ERAS protocol over conventional care, the researchers found that there was little evidence regarding the use of laparoscopy coupled with ERAS in the treatment of Crohn’s disease (Zhu, 2018).


This is a quantitative study that consists of a controlled, randomized single-blind trial. A consecutive cohort of 32 patients between the ages of 14 and 70 with histologically confirmed Crohn’s disease isolated to the terminal ileum or ileum and cecum were included. The study participants were randomized into 2 groups: both groups would undergo laparoscopic surgery, but one group would receive conventional perioperative care and the other would receive ERAS. The participants were blinded to which group they were sorted (Zhu, 2018).


The researchers prospectively recorded preoperative, operative, and postoperative data for all patients in both groups including age, BMI, sex, ASA score, length of surgery and complications, preoperative therapy type, compliance, length of stay, morbidity, mortality, hospital costs, and readmission. The intention to treat principle was used to analyze the data obtained, which was then presented as interquartile ranges and medians or means +/- standard deviation. Chi-squared tests were used to compare data and the Mann-Whitney U test for abnormal distribution. The independent sample t-test was used for data with normal distribution (Zhu, 2018).

Researcher’s Conclusion

The researchers concluded that using the ERAS protocol in conjunction with minimally invasive laparoscopic surgery for patients with Crohn’s disease requiring ileocectomy was safe and effective, and that patients had fewer complications, faster return of bowel function, and shorter hospital lengths of stay (Zhu, 2018).

Quantitative Researcher’s Conclusions

The researcher’s goal in conducting this study was to see if laparoscopic surgery in conjunction with using an ERAS protocol was safe, practicable, and beneficial in improving patient outcomes. The literature cited many studies comparing different surgical techniques and perioperative care, but very little information existed on laparoscopy coupled with ERAS and its outcomes. The study methodology and data analysis techniques used were consistent with our reading in Chapter 6. The evidence and data gathered in this study supports the researchers’ conclusion that laparoscopic surgery in combination with ERAS protocol is safe, effective, and improves patient postoperative outcomes (Zhu, 2018).

Quantitative: Protection and Considerations

This study was conducted under the guidelines of the Declaration of Helsinki and approved by the medical ethics review board at SRRSH hospital, Zhejiang University. All study participants were provided written informed consent. The study was registered with the government at ClinicalTrials.gov (Zhu, 2018).

Quantitative: Strengths and Limitations

The strength of this study is that it is a randomized, controlled trial that uses an internet randomization module to sort the study participants. The weaknesses are that it is single-blind as opposed to double-blind, and that the sample size is somewhat small. It is also limited in that it is the first study of its kind, performed at a single institution and limited to a patient population with a particular medical condition.

Quantitative: Evidence Application

The results of this study can inform nursing practice by further reinforcing the benefits of using the ERAS perioperative protocol in conjunction with laparoscopic surgical techniques to improve patient outcomes, reduce costs, and shorten in-hospital length of stay. As a perioperative/PACU nurse I have seen this protocol becoming a standard for elective colorectal surgeries in the last few years, and reading this study helped me to understand why it is becoming more popular for the surgeons to use. Using the ERAS protocol is labor intensive for the nursing staff, but it is gratifying to understand what the end goal of the therapy is and to see hard evidence that it really does work.

Evidence Table



Chang, Y.-L., & Tsai, Y.-F. (2017). Research paper: Early illness experiences related to unexpected heart surgery: A qualitative descriptive study. Australian Critical Care, 30, 279–285. https://doi.org/10.1016/j.aucc.2016.11.005


Many studies exist evaluating patients post discharge after undergoing emergency heart surgery, but very few have been conducted to study patient experiences after transferring out of ICU but prior to discharge. The purpose of this study is to gather information regarding patient’s experiences during this time period of early recovery from emergency heart surgery (Chang, 2017).


The author cites 44 reference articles covering topics ranging from emergency heart surgery and recovery afterwards to communication techniques, rehabilitation, depression, nightmares, memory loss, and the conducting of qualitative research as well as many others. Most of the studies conducted on patients post emergency heart surgery focused on how they were doing 8-18 months after discharge, and there were very few regarding the psychological impact of this life changing event (Chang, 2017).


The study was conducted under a qualitative descriptive design, meaning there was no control exerted over their behaviors and these were simply documented. 13 participants who underwent emergency cardiac surgery at a hospital in northern Taiwan were included in the study. The participants were over age 20 without cognitive issues who had had emergency heart surgery, an ICU stay of at least 3 days, had been on the surgical ward for at least 6 days, and were due to be discharged within 3 days. The patients were interviewed by a communications-trained cardiovascular nurse practitioner. The transcripts of the interviews were kept confidential by being assigned a number (Chang, 2017).


The conversations were transcribed word-for-word and qualitative content analysis was used to find common experiences in the interviews. The authors read, analyzed and discussed all interviews to reach a consensus on what the common themes were. All data was then translated from Mandarin to English by the first author, and the translated data was then reviewed by a bilingual expert in qualitative research (Chang, 2017).

Researcher’s Conclusion

The researchers concluded that interdisciplinary care and education should be provided early in the recovery period. They also concluded that good family relationships, inclusion of religious beliefs, and a strong relationship with their health care professionals were the biggest motivating factors to adapt healthy lifestyle changes that would improve their length and quality of life (Chang, 2017). They also stress the importance of effective management of pain and delirium, minimizing sedation to reduce ICU psychosis and PTSD, and promoting normal sleep patterns (Chang, 2017).

Qualitative Researcher’s Conclusions

The conclusion reached by the authors was reasonable. Based on the interviews conducted, they were able to identify 5 common themes experienced by patients who had undergone emergency cardiac surgery; 1) sudden serious symptoms, 2) nightmares, 3) pain/sleep disturbances/depression/shock/uncertainty about the future/wishing they would die, 4) starting a new life, and 5) adopting a new lifestyle. Subsequent research led them to the conclusion that early interdisciplinary education with family support, including religious values, and support from their medical providers would help exponentially in their recovery process (Chang, 2017).

Qualitative: Protection and Considerations

This study was approved by the Institutional Review Board. All participants received written informed consent including the purpose of the study, the procedures included, and their rights and responsibilities. The transcripts of the conducted interviews were kept confidential by excluding patient names and assigning each interview a number (Chang, 2017).

Qualitative: Strengths and Limitations

The strengths of this study include the triangulation of information sources using observation and interview, the creation of an audit trail, and membser checking. The interviews were halted once data saturation had occurred. The limitations of the study were that it was conducted in a single hospital in north Taiwan. This hospital may have different protocols than other hospitals and may not be representative of the country as a whole. There are also cultural considerations, given that the patient experiences in the study are from an Eastern perspective and may not be generalizable to Western culture and values (Chang, 2017).

Qualitative: Evidence Application

In spite of the cultural differences emphasized by the researchers, it seems reasonable that the experiences reported by the study participants would also be experienced by people of Western cultures, and that the support systems recommended would also apply. This study would inform nursing practice by emphasizing the importance of early education, pain control, minimizing delirium and sedation, promoting normal sleep patterns, including family/religious support systems, and developing a strong partnership with health care providers to promote the adaptation of healthy lifestyle changes that would increase length and quality of life for patients undergoing emergency cardiac surgery (Chang, 2017).


  • Chang, Y.-L., & Tsai, Y.-F. (2017). Research paper: Early illness experiences related to unexpected heart surgery: A qualitative descriptive study. Australian Critical Care, 30, 279–285. https://doi.org/10.1016/j.aucc.2016.11.005


  • Zhu, Y., Xiang, J., Liu, W., Cao, Q., & Zhou, W. (2018). Laparoscopy Combined with Enhanced Recovery Pathway in Ileocecal Resection for Crohn’s Disease: A Randomized Study. Gastroenterology Research & Practice, 1–7. https://doi.org/10.1155/2018/9648674



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