An ERAS-Informed Pathway for Emergency Laparoscopic Repair of Gastroduodenal Perforation: A Pragmatic Pilot Randomized Trial

This single-center pragmatic pilot randomized trial aimed to assess the feasibility of implementing an Enhanced Recovery After Surgery (ERAS)-informed pathway during emergency laparoscopic repair for gastroduodenal perforation and to describe preliminary safety and recovery outcomes. Between October 2023 and March 2025, 66 patients were allocated using a random-number table to an ERAS group (n = 35) or a control group (n = 31). All patients underwent laparoscopic repair. The primary feasibility outcome was adherence to prespecified ERAS pathway components. Postoperative complications graded according to the Clavien–Dindo classification were assessed as safety outcomes. Inflammatory markers, pain scores, nutritional indices, recovery milestones, and length of hospital stay (LOS) were analyzed as exploratory clinical outcomes. Adherence to the ERAS-informed pathway was partial: preoperative carbohydrate loading was completed in 35 of 35 patients, and criteria-based early nasogastric tube removal was achieved in 25 of 35 patients, whereas ambulation within 6 h and clear-liquid intake by postoperative day 1 were not achieved in either group. Exploratory clinical comparisons showed lower postoperative inflammatory marker levels and pain scores, earlier recovery milestones, shorter LOS, and smaller short-term nutritional declines in the ERAS group. Postoperative complications did not differ significantly between groups. In selected, hemodynamically stable patients, several components of an ERAS-informed pathway could be implemented during emergency laparoscopic repair without an apparent safety signal in this pilot cohort. The observed recovery differences should be viewed as preliminary clinical signals rather than definitive evidence of efficacy.