Enhanced Recovery After Surgery (ERAS) improves length of stay and decreases complications after resection of abdominal neuroblastoma

Enhanced Recovery After Surgery (ERAS) improves length of stay and decreases complications after resection of abdominal neuroblastoma | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL Pediatric Blood & Cancer This is a preprint and has not been peer reviewed. Data may be preliminary. 23 May 2025 V1 Latest version Share on Enhanced Recovery After Surgery (ERAS) improves length of stay and decreases complications after resection of abdominal neuroblastoma Authors : Sara Mansfield [email protected] , Meera Kotagal , Stephen J. Hartman , Andrew Murphy 0000-0001-6747-0355 , Brady Hogan , Darren Ha , Doralina Anghelescu 0000-0002-8521-2744 , Marc Mecoli , Nicholas Cost 0000-0002-5785-3704 , Andrew Davidoff , and Kyle O. Rove Authors Info & Affiliations https://doi.org/10.22541/au.174797837.73012967/v1 Published Pediatric Blood & Cancer Version of record Peer review timeline 822 views 258 downloads Contents Abstract Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract not-yet-known not-yet-known not-yet-known unknown Background: Enhanced recovery after surgery (ERAS) pathways are multi-disciplinary strategies to return patients to their physiologic baseline as efficiently as possible. This study aims to evaluate the feasibility and benefits of an ERAS pathway in children undergoing resection of abdominal neuroblastoma. Methods: After IRB approval, all patients >1 month old undergoing resection of an abdominal neuroblastoma at one of three children’s hospitals between 2020–2022 were offered enrollment. A standardized ERAS protocol was utilized at all institutions. Data were prospectively recorded. We compared the prospective cohort to a propensity matched historical cohort (2014–2020). Fisher’s exact and t testing were used, as appropriate. Results: The study included 23 patients in the ERAS group compared to 24 historic patients. Post-operative nasogastric tube use decreased from 91.7% pre-ERAS to 16.7% in the ERAS cohort. ERAS patients were advanced to regular diets and ambulated 3 days earlier than pre-ERAS. Post-operative opioid consumption decreased from 0.54 to 0.21 MME mg/kg/day (p=0.047). All but one patient (23, 96%) in the pre-ERAS cohort experienced at least one post-operative complication, compared to only 9 (39.1%) in the ERAS cohort (p<0.001). Average length of stay was 3.7 days with ERAS compared to 6.9 days pre-ERAS (p=0.004). Discussion: ERAS is associated with improvements in length of stay and a decrease in complications following resection of abdominal neuroblastoma. Children with neuroblastoma stand to benefit considerably from the benefits associated with the use of an ERAS protocol given their intensive treatment, complex surgeries, and need for expeditious recovery. Introduction Enhanced Recovery After Surgery (ERAS) pathways are being increasingly utilized in pediatric surgery [1,2]. This holistic approach incorporates evidence-based practices into a standardized pathway for common operations. The components of the pathway are aimed to minimize complications and expedite recovery. Common themes are decreasing opioid utilization via multi-modal analgesic regimens, minimizing NPO durations, maintaining euvolemia, and promoting early mobility [3,4]. ERAS use is associated with a decrease in complications and shorter lengths of stay for several adult populations [5,6]. While the use of ERAS in pediatric surgical oncology has been increasing, there is still some apprehension about instituting ERAS for more complex and variable operations such as neuroblastoma resections. Frequently, retroperitoneal or abdominal neuroblastomas require extensive resections with visceral rotations and major vascular dissections. While ERAS principles are informally utilized at various institutions, robust literature is lacking regarding the feasibility in neuroblastoma patients. A recent multicenter, prospective study demonstrated the feasibility of an ERAS pathway in pediatric surgical oncology patients [2]. This study included a diverse group of abdominal tumor types. The complexity involved in performing an oophorectomy or a unilateral nephrectomy compared to a neuroblastoma resection with image-defined risk factors is expected to be quite different. Therefore, the aim of this study is to specifically study the use of ERAS in children undergoing resection of abdominal, retroperitoneal, or pelvic neuroblastomas. Methods Study design and setting This was a prospective case control study. The STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) guidelines were used in the preparation of this report [7]. A formal ERAS pathway was developed after engagement of study teams and stakeholders. The rationale for the protocol and definitions are more thoroughly discussed in a prior publication [8]. A prospective, multi-center study was designed: The Pediatric Oncology Recovery after Tumor Surgery (PORTS) study. IRB approval was obtained at the host center (Children’s Hospital Colorado, IRB 19-0964). IRB approval was then obtained at St. Jude Children’s Research Hospital (IRB 19-0366) and Cincinnati Children’s Medical Center (IRB 2020-0330). This study was registered through the National Institutes of Health clinical trial registry (NCT04344899). The study centers were all free-standing children’s hospitals. Our prospective ERAS cohort was compared to retrospective historical controls undergoing similar operations from 2014 – 2020. These patients were propensity-matched by confounding variables, including: age, sex, prior surgery, and other comorbidities such as immunosuppression, chronic kidney disease (CKD), and weight/height/BMI. Of note, neuroblastoma-specific details such as image-defined risk factors (IDRFs) or risk classification were not included in the original PORTS study and were not part of propensity-matching schema. Patient population All patients older than 1 month of age undergoing an abdominal, retroperitoneal, or pelvic tumor resection between 2020 - 2022 were included in the overarching study. Informed consent was obtained prior to enrollment. From that group, patients undergoing resection of neuroblastoma were included in this analysis. Neuroblastoma was confirmed on the final pathologic report. Study Objectives The primary outcome was 90-day complications per patient. Complications were graded based on the Clavien-Dindo classification [9], and formally listed in previous reports [2, 8]. Secondary outcomes included: ERAS protocol adherence, LOS or time to transfer to the oncology service, time to clearance for chemotherapy, time to chemotherapy, postoperative emergency room (ER) visits, readmissions, reoperations, pain scores, and opioid usage. Data collection For the ERAS cohort, data were collected prospectively and input into a Research Electronic Data Capture (REDCap) database. All data points were collected regardless of how many ERAS process measures were achieved. Data points included oncologic and surgical details, pre-operative co-morbidities, prior operations, chemotherapy, and radiation. Intraoperative fluids (type and volume), opioids (type and doses), operating room time, regional analgesia details, temperature, and complications were collected. For each post-operative day, opioid consumption, pain scores, mobility, diet, and complications were recorded. Length of stay or days until transfer to the oncology service for chemotherapy were recorded. Time to clearance for adjuvant cancer therapies and start dates were recorded. For this analysis of only patients with neuroblastoma, IDRFs were retrospectively. These were collected from cross-sectional imaging obtained immediately before surgery (i.e. after neoadjuvant chemotherapy for high-risk patients). Amount of opioid consumed was converted to IV morphine milligram equivalents (MME) normalized to body weight using standard conversion factors that were used uniformly for all patients [10]. All pain scores were collected and the type of score (FLACC, revised FACES, or numeric) was noted. Inpatient data points were collected for each post-operative day (POD) up to day seven. The Clavien-Dindo classification for complications was utilized [8, 9]. Patients that had both higher-grade and a lower-grade complications were only coded according to the higher-grade complication, not both, unless > 72 hours separated the occurrences (e.g., ileus requiring nasogastric (NG) tube with nausea/vomiting is a grade II complication; such a complication was not coded with grade I – nausea/vomiting). Readmission and ED visits were considered if they were related to surgery. Readmissions to resume adjuvant chemotherapy were not recorded. Generally, fevers, electrolyte issues, and nausea-related complaints after chemotherapy were resumed were not considered in the complication list for this study. Statistical Analysis The statistical methods for the main PORTS study have been previously reported. Descriptive analyses were performed, with measures reported as median and interquartile range, except where noted. Fisher’s exact or t testing was utilized where appropriate with p values <0.05 considered significant. Results Cohort Demographics The study included 23 patients in the ERAS group compared to 24 patients in the control group (historic cohort). There was no difference in median age between the two groups (2.3 vs 2.1 years, p = 0.943). There was no difference in neoadjuvant chemotherapy rates between the two groups (87% ERAS vs 75% historic, p = 0.461). No patients had received pre-operative radiation in either group. There were no patients in either cohort with pre-existing kidney disease or renal insufficiency pre-operatively. Additional cohort characteristics are included in Table 1 ). Tumor Characteristics There was no difference in pre-operative tumor size between the ERAS cohort (5.9, IQR 3.6-8.0 cm) compared to the historic cohort (6.0, IQR 4.9-7.5 cm). IDRF data were available for 21 ERAS patients and 22 historic patients. There was one patient in the ERAS group and one patient in the baseline cohort that had zero IDRFs at the time of surgery. There was no difference in the average number of IDRFs per patient in the ERAS cohort (2.3 ± 2.1) compared to historic (3.4 ± 2.1, p = 0.104). Specific abdominal IDRFs are listed in Table 2 . Protocol Compliance Out of the 20 process measures included in the ERAS protocol, a median of 16 (IQR: 16-19) were obtained in the prospective cohort. Table 3 outlines how this compared to the historic cohort. All patients in the ERAS cohort were given pre-operative education and counseling regarding the protocol and expectations. Twenty-one (91.3%) ERAS patients consumed the recommended clear carbohydrate load on the morning of surgery. Pre-operative acetaminophen was given in 1 (4.2%) historic patient and 9 (39.1%) of ERAS patients (p = 0.004). Gabapentin was not utilized at the time of this study. Pre-operative bowel preparation was not used for either group. One patient older than 10 years in the historic cohort did not have sequential compression device (SCD) on during the operation. All other patients older than 10 years had SCDs. Patients remained normothermic (36-38°C) more frequently in the ERAS cohort (73.9%) compared to the historic cohort (16.7%)(P<0.001). A significantly higher proportion of ERAS patients met euvolemia goals of 3-7 mg/kg/hr of intravenous fluids administered during skin-to-skin operating time (69.6% vs 4.2%, p<0.001). Additionally, a greater proportion met the opioid goal of <0.3 mg/kg IV MME intraoperatively in the ERAS cohort (91.3% vs 4.2%, p<0.001). In the ERAS cohort, 6 (26.1%) patients underwent laparoscopic neuroblastoma resection. All of these patients received one-time infiltration of local anesthetic. Two received transversus abdominus plane block and the remaining four received 10 ml of 0.25% bupivacaine infiltration at the laparoscopic port sites. Regional analgesia catheters were left in place for post-operative pain control in 16 (70.0%) ERAS patients. The majority were epidural catheters (n=15) and one erector spinae catheter. All but two of the regional catheters were placed prior to surgery (i.e. pre-incision) and were utilized during the case. In the historic cohort, 2 (8.3%) patients underwent laparoscopic neuroblastoma resection. Both of these patients received one-time local anesthetic blocks (one infiltration of wound, one quadratus lumborum block). Epidural analgesia was utilized in 17 (70.8%) of the baseline group. Post-operatively, diets were advanced to regular diet by POD#1 at the latest in 16 (69.6%) ERAS patients compared to 1 (4.2%) historic patients (p<0.001). IV Fluids were discontinued by POD#2 in 17 (73.9%) ERAS patients compared to 2 (8.3%) historic patients (p<0.001). Patients met the mobilization goal of being out of bed by POD#1 in 19 (82.6%) ERAS patients compared to 2 (8.3%) baseline patients (p<0.001). Abdominal drains were not part of the practice for neuroblastoma resections in either cohort. Tylenol and NSAIDs were utilized in every ERAS patient compared to only 2 (8.3%) in the baseline cohort (p<0.001). Nausea medications were routinely ordered in both cohorts. Post-operative opioid goals (<0.15 mg/kg/day IV MME) were met in 17 (73.9%) ERAS patients compared to 4 (16.7%) historic patients (p<0.001). Peri-Operative Outcomes The average duration of follow-up for the ERAS cohort was 1.1 ± 0.8 year. Follow-up for the historic cohort was 5.5 ± 2.0 years. Average length of stay was significantly shorter in ERAS cohort (6.9 ± 4.6 vs 3.7 ± 2.3 days, p = 0.004). As shown in Table 4 , ERAS patients received less intraoperative IVF and opioids. Post-operatively, ERAS patients were advanced to regular diet approximately three days earlier. Mobilization and bowel function were also improved. NSAIDS and acetaminophen were used significantly more often in the ERAS cohort. Post-operative opioid consumption was significantly lower in ERAS patients 0.21 ± 0.56 vs 0.54 ± 0.51 mg/kg/day, p = 0.047). Despite the decrease in opioids, pain scores were significantly lower in the ERAS group on POD 0 and POD 1 ( Figure 1 ). There was no difference in pain scores on subsequent hospital days. Intraoperative fluid administration was significantly lower in the ERAS cohort 7.0 ± 4.8 compared to baseline (16.9 ± 5.8, p < 0.001). Creatinine values were available pre-operatively (outpatient) and on post-operative day #1 for 23 (95.8%) historic patients and 18 (78.3%) ERAS patients. Despite less fluid in the OR and more NSAID utilization, there was no difference in creatinine change from the historic cohort. The average change from pre-op to post-op creatinine was +0.10 mg/dl (range -0.02 to +0.39) for historic patients and +0.07 mg/dl (range -0.06 to +0.33) for ERAS patients. There were also no significant differences on post-operative day 2 (0.09 historic vs 0.04 mg/dl ERAS, p = 0.135) or post-operative day 3 (0.06 vs 0.02 mg/dl, p = 0.109). Patients were cleared to resume adjuvant chemotherapy at an average of 9.7 ± 3.5 days in the historic group. Time to clearance was slightly shorter in the ERAS group (7.6 ± 2.8 days, p = 0.037). However, there was no difference in the time to actual administration of chemotherapy post-operatively (13.4 vs 12.7 days, p = 0.782). The number of patients experiencing any complication was significantly lower in the ERAS cohort (95.8% vs 39.1%, p< 0.001). The majority of these were grade 1 or grade 2 as shown in Table 4 . The most common complication was post-operative fever ≥38°C in 19 (79.2%) of historic patients compared to 2 (8.7%) ERAS patients (p<0.001). Other complications of note included 4 (16.7%) patients with post-operative blood transfusions in the baseline cohort, compared to 2 (8.7%) in the ERAS cohort (p=0.666). Post-operative vomiting (grade 1) was significantly higher in the historic cohort (12, 50%) compared to the ERAS cohort (4, 17.4%, p = 0.030). Vomiting requiring a nasogastric tube to be inserted (grade 2) occurred in 6 (25%) historic patients compared to 0 ERAS patients (p = 0.022). There were 8 infectious complications (2 bacteremia, 3 UTI, 2 wound, and 1 gastrointestinal) in the historic cohort. There were zero in the ERAS cohort (p = 0.004). There were no chyle leaks in either cohort. In the historic cohort, there were 4 (16.7%) ED visits and 3 (12.5%) readmissions. In the ERAS cohort there was 1 (4.3%) ED visit and 2 (8.7%) readmissions. Neither were significantly different. In the historic cohort, there were 4 (16.7%) re-operations within 30 days. Three were line related issues (2 re-positioning, 1 infectious). However, there was one re-opening laparotomy on POD#3 for intussusception which was reduced without need for bowel resection. There were no re-operations in the ERAS cohort. Discussion ERAS is feasible even in complex tumor resections such as IDRF-positive neuroblastoma resections. The use of such a pathway improves LOS, decreases opioid requirements, expedites ambulation, and minimizes NPO durations. Avoidance of nasogastric tubes and early diet advancement does not increase vomiting when performed in the context of an ERAS pathway. Additionally, NSAID use does not seem to impact bleeding risk or negatively impact renal function. Compared to the original cohort utilized in the PORTS study, neuroblastoma resections seemed to have benefited significantly from this ERAS pathway. Reduction in complications was similar to the larger cohort, but improvement in LOS was better for the neuroblastoma subset. This could be because ERAS principles had informally been adopted prior to this study for less complex cases (unilateral nephrectomies, and oophorectomies, for example). Therefore, the improvement from our historic cohort was not as robust. However, fewer ERAS principles were followed prior to this study for complex neuroblastoma resections. Other groups have studied ERAS for neuroblastoma resections. He et al. reported the use of ERAS in localized abdominal and thoracic neuroblastoma resections [11]. There was not a discussion on presence or absence of IDRFs, which impact neuroblastoma risk stratification and are associated with surgical complexity and related complications. Their cohort excluded patients with perioperative blood transfusions, which was a specific point of interest in the current study. In He et al., nasogastric tubes were still left post-operatively even in the ERAS cohort. Of note, the historic cohort in this study had urinary and nasogastric tubes placed on the ward prior to going to the operating room. Abdominal drains were routinely left in situ. Despite a less aggressive protocol, they similarly found an improvement in LOS from 8 to 11 days without worsening readmissions. Zhu et al. demonstrated similar results with the same pathway for retroperitoneal neuroblastoma resections [12]. Lee et al. evaluated the safety of nasogastric tube avoidance in children undergoing resection of high-risk neuroblastoma [13]. This led to an improved time to oral intake without any apparent worsening of complications. This study included neuraxial pain regimens, but did not have many other formal ERAS components. In this cohort, there was no difference in LOS. The PORTS study was the first multi-center study to evaluate a formal ERAS pathway for abdominal tumor resections [8]. The incorporation of all tumor types allowed analysis of the generalizability of the protocol. However, each resection type has unique challenges and complication profiles. Thus, there is an opportunity to fine-tune the protocol to specific operations. The challenge lies in the small numbers of any one tumor-type at individual institutions. This makes formal analysis difficult. Similarly, without repetition, team/provider comfort may vary. In that regard, one general pathway may be advantageous. There are several limitations inherent to use of retrospective chart reviews for the historic cohort. Mobility appears greatly improved with ERAS, which has been shown in other studies. However, this may be an overestimate, as precise documentation of ambulation was not always certain in the historic cohort. Similarly, return of bowel function is expected to be improved in the setting of less opioid use, earlier mobility, and euvolemia. However, the results may be slightly skewed if not all stools were recorded in the historic cohort’s output records. To adequately correct these limitations, a prospective randomized control would be needed. However, given the mounting evidence to support ERAS principles, there is likely not equipoise to withhold many of the interventions outlined in this study. Prospectively comparing institutions with and without ERAS pathways is another option for future evaluation. Resumption of chemotherapy in a timely manner is of utmost importance for patients with high-risk neuroblastoma. As the PORTS study was an evaluation of all abdominal tumor resections, neuroblastoma-specific details such as risk groupings were not included. The urgency for adjuvant therapy is not the same across other tumor types. Therefore, specific process measures to improve time-to-chemotherapy were not included in this pathway. One could infer that if patients were eating, ambulating, and discharged sooner that they may be ready for chemotherapy sooner. However, the exact date to resume therapy can be impacted by numerous psychosocial and logistical factors. So, while there was no difference in time-to-chemotherapy in this study, it is our hope that patients were in better physiologic shape when they resumed. In conclusion, ERAS is feasible for neuroblastoma resections, including those with IDRFs. ERAS may improve time to oral intake, mobility, opioid consumption, pain scores, and LOS. A safe and expeditious recover is exceedingly important for certain subsets of pediatric surgical oncology such as high-risk neuroblastoma. The goal of ERAS is to improve peri-operative stress and return patients to physiologic baseline. Whether this improves patients’ tolerance of intensive adjuvant therapies warrants further study. Figure Legend Figure 1 : A) Population median of daily maximum pain scores of ERAS patients (black) and historic controls (gray) with 95% confidence interval bars. * indicates p<0.05 via Mann-Whitney U test. References 1. Short HL, Heiss KF, Burch K, Travers C, Edney J, Venable C, Raval MV. Implementation of an enhanced recovery protocol in pediatric colorectal surgery. J Pediatr Surg. 2018 Apr;53(4):688-692. doi: 10.1016/j.jpedsurg.2017.05.004. Epub 2017 May 12. PMID: 28545764. 2. Mansfield SA, Kotagal M, Hartman SJ, Murphy AJ, Davidoff AM, Hogan B, Ha D, Anghelescu DL, Mecoli M, Cost NG, Rove KO. Enhanced Recovery After Surgery for Pediatric Abdominal Tumor Resections: A Prospective Multi-institution Study. J Pediatr Surg. 2025 Feb;60(2):162046. doi: 10.1016/j.jpedsurg.2024.162046. Epub 2024 Oct 31. PMID: 39520824. 3. Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth. 1997 May;78(5):606-17. doi: 10.1093/bja/78.5.606. PMID: 9175983. 4. Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg. 2008 Aug;248(2):189-98. doi: 10.1097/SLA.0b013e31817f2c1a. PMID: 18650627. 5. Kehlet H, Mogensen T. Hospital stay of 2 days after open sigmoidectomy with a multimodal rehabilitation programme. Br J Surg. 1999 Feb;86(2):227-30. doi: 10.1046/j.1365-2168.1999.01023.x. PMID: 10100792. 6. Gustafsson UO, Hausel J, Thorell A, Ljungqvist O, Soop M, Nygren J; Enhanced Recovery After Surgery Study Group. Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Arch Surg. 2011 May;146(5):571-7. doi: 10.1001/archsurg.2010.309. Epub 2011 Jan 17. PMID: 21242424. 7. Elm E von, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for Reporting Observational Studies. Plos Med 2007;4:e296. doi:10.1371/journal.pmed.0040296 8. Mansfield SA, Kotagal M, Hartman S, Murphy AJ, Davidoff AM, Anghelescu DL, Mecoli M, Cost N, Hogan B, Rove KO. Development of an enhanced recovery after surgery program for pediatric solid tumors. Front Surg. 2024 May 22;11:1393857. doi: 10.3389/fsurg.2024.1393857. PMID: 38840973; PMCID: PMC11150694. 9. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004 10. Berde CB, Sethna NF. Analgesics for the treatment of pain in children. N Engl J Med. 2002 Oct 3;347(14):1094-103. doi: 10.1056/NEJMra012626. Erratum in: N Engl J Med. 2011 May 5;364(18):1782. Dosage error in article text. PMID: 12362012. 11. He J, Wang Z, Yu X, Su Y, Hong M, Zhu K. Promoting application of enhanced recovery after surgery protocols during perioperative localized abdominal and thoracic neuroblastomas. Pediatr Surg Int. 2024 Nov 2;40(1):286. doi: 10.1007/s00383-024-05884-w. PMID: 39487870. 12. Zhu K, He J, Chen T, Yu X, He X, Su Y. Retroperitoneal localized neuroblastoma in children: a comparison of enhanced recovery after surgery versus traditional care. Pediatr Surg Int. 2023 Jun 1;39(1):208. doi: 10.1007/s00383-023-05493-z. PMID: 37261573. 13. Lee WG, Lascano D, Palmer SB, Chen SY, Mack SJ, Sudharshan R, Han JS, Kim ES. Optimizing the Postoperative Management of Children Undergoing Resection of High-Risk Abdominal Neuroblastoma. Am Surg. 2024 Jun;90(6):1290-1297. doi: 10.1177/00031348241227199. Epub 2024 Jan 20. PMID: 38243794. Supplementary Material File (eras nbl tables - pbc.docx) Download 21.47 KB Information & Authors Information Version history V1 Version 1 23 May 2025 Peer review timeline Published Pediatric Blood & Cancer Version of Record 8 Aug 2025 Published Copyright This work is licensed under a Non Exclusive No Reuse License. Collection Pediatric Blood & Cancer Keywords anesthesia neuroblastoma surgery Authors Affiliations Sara Mansfield [email protected] St Jude Children's Research Hospital View all articles by this author Meera Kotagal Cincinnati Children's Hospital Medical Center Division of Pediatric General and Thoracic Surgery View all articles by this author Stephen J. Hartman Cincinnati Children's Hospital Medical Center Division of Pediatric General and Thoracic Surgery View all articles by this author Andrew Murphy 0000-0001-6747-0355 St Jude Children's Research Hospital View all articles by this author Brady Hogan Children's Hospital Colorado View all articles by this author Darren Ha Children's Hospital Colorado View all articles by this author Doralina Anghelescu 0000-0002-8521-2744 St Jude Children's Research Hospital View all articles by this author Marc Mecoli Cincinnati Children's Hospital Medical Center View all articles by this author Nicholas Cost 0000-0002-5785-3704 Children's Hospital Colorado View all articles by this author Andrew Davidoff St Jude Children's Research Hospital View all articles by this author Kyle O. Rove Children's Hospital Colorado View all articles by this author Metrics & Citations Metrics Article Usage 822 views 258 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Sara Mansfield, Meera Kotagal, Stephen J. Hartman, et al. Enhanced Recovery After Surgery (ERAS) improves length of stay and decreases complications after resection of abdominal neuroblastoma. Authorea . 23 May 2025. DOI: https://doi.org/10.22541/au.174797837.73012967/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu . 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