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Enhanced Recovery After Surgery Guidelines and Hospital Length of Stay, Readmission, Complications, and Mortality

Khara M. Sauro, Christine Smith, Seremi Ibadin and 6 more

JAMA Network Open · 2024 · Meta-analysis

doi:10.1001/jamanetworkopen.2024.17310

Abstract

Question. Does the adoption of enhanced recovery after surgery (ERAS) guidelines decrease hospital length of stay, hospital readmission, complications, and mortality?

Findings. In this meta-analysis of 74 randomized clinical trials with 9076 participants, the ERAS guidelines were associated with decreased hospital length of stay and complications. Type of surgery and number of ERAS elements were associated with estimates of length of stay.

Meaning. These findings suggest that the ERAS guidelines were associated with decreasing hospital length of stay and complications; future research should focus on improving implementation and compliance with ERAS guidelines to improve patient outcomes.

Importance. A comprehensive review of the evidence exploring the outcomes of enhanced recovery after surgery (ERAS) guidelines has not been completed.

Objective. To evaluate if ERAS guidelines are associated with improved hospital length of stay, hospital readmission, complications, and mortality compared with usual surgical care, and to understand differences in estimates based on study and patient factors.

Data Sources. MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central were searched from inception until June 2021.

Study Selection. Titles, abstracts, and full-text articles were screened by 2 independent reviewers. Eligible studies were randomized clinical trials that examined ERAS-guided surgery compared with a control group and reported on at least 1 of the outcomes.

Data Extraction and Synthesis. Data were abstracted in duplicate using a standardized data abstraction form. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Risk of bias was assessed in duplicate using the Cochrane Risk of Bias tool. Random-effects meta-analysis was used to pool estimates for each outcome, and meta-regression identified sources of heterogeneity within each outcome.

Main Outcome and Measures. The primary outcomes were hospital length of stay, hospital readmission within 30 days of index discharge, 30-day postoperative complications, and 30-day postoperative mortality.

Results. Of the 12 047 references identified, 1493 full texts were screened for eligibility, 495 were included in the systematic review, and 74 RCTs with 9076 participants were included in the meta-analysis. Included studies presented data from 21 countries and 9 ERAS-guided surgical procedures with 15 (20.3%) having a low risk of bias. The mean (SD) Reporting on ERAS Compliance, Outcomes, and Elements Research checklist score was 13.5 (2.3). Hospital length of stay decreased by 1.88 days (95% CI, 0.95-2.81 days; I2 = 86.5%; P <.001) and the risk of complications decreased (risk ratio, 0.71; 95% CI, 0.59-0.87; I2 = 78.6%; P <.001) in the ERAS group. Risk of readmission and mortality were not significant.

Conclusions and Relevance. In this meta-analysis, ERAS guidelines were associated with decreased hospital length of stay and complications. Future studies should aim to improve implementation of ERAS and increase the reach of the guidelines.

Full text

From PubMed Central, U.S. National Library of Medicine, as current on Oct 20, 2026. Paragraph numbers are ours, so an answer can point at one.

Introduction

Globally, more than 313 million people undergo lifesaving or life-prolonging surgery yearly and that number is increasing., While surgery is essential to maintain health and quality of life, it consumes significant health care resources and is not without complications. The mean length of hospital stay for surgery is 5 days equating to more than 7.5 million patient days each year at a cost of at least $1200 per day. The length of hospital stay increases for patients undergoing surgery who experience complications postoperatively.,,,,,,, More than a third of patients undergoing surgery experience complications,,, placing these patients at higher risk of complications than patients not undergoing surgery.,,,, Patients who experience complications are also more likely to require additional interventions, be readmitted to hospital, and die, which are all associated with increased costs.,,, An estimated 50% of complications are preventable, which provides an opportunity to use evidence-based strategies to improve outcomes for patients and health care systems.,,,,,,, Moreover, improving surgical outcomes and reducing health care resources can increase the capacity for patients to access surgical care.,

As the need for surgery continues to exceed health care capacity, strategies are needed to ensure care is effective, efficient, and safe. One option is implementing the enhanced recovery after surgery (ERAS) guidelines. There are currently ERAS guidelines for 23 types of surgery and implementation programs active in more than 20 other types of surgery. ERAS guidelines provide recommendations for perioperative care and have been found to reduce complications, length of hospital stay, and cost., Several surgery-specific systematic reviews have found positive or mixed effects on outcomes after adopting ERAS guidelines.,,,,,, However, a comprehensive review of ERAS efficacy across surgical areas and within heterogenous populations has not been conducted. To our knowledge, there are no systematic reviews examining these outcomes across the breadth of ERAS-guided surgical procedures or comparing outcomes by surgery type, which could provide a better understanding of ERAS efficacy. The objective of this study is to synthesize the evidence on the efficacy of ERAS and determine if the adoption of ERAS guidelines improves hospital length of stay, hospital readmission, mortality, and postoperative complications compared with usual surgical care?

Methods

This systematic review and meta-analysis is reported using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. The protocol was registered with the PROSPERO registry of systematic reviews (CRD42021255973).

Search Strategy

The search strategy combined controlled vocabulary and keywords for the population (patients undergoing surgery), the intervention (ERAS, fast track, enhanced recovery) and outcomes (length of hospital stay, hospital readmission, complications, mortality) and was run in MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central Register of Controlled Trials on June 18, 2021 (eAppendix 1 in Supplement 1). The search strategy was not limited by publication date or language.

Eligibility Criteria

Studies were included if they reported at least 1 of the outcomes among adult patients undergoing surgery before and after ERAS guidelines were implemented. Studies that implemented ERAS guidelines, including ERAS-based guidelines (eg, ERAS, fast-track, enhanced recovery protocol), were included if the protocols contained elements that were ERAS-based. Any study design that compared the intervention (ERAS guidelines) and the comparator group (usual care) were included in the overall systematic review, but only randomized clinical trials were included in the meta-analysis.

Studies with only pediatric patients or those that did not stratify estimates by adults and children were excluded. Studies that did not provide estimates or sufficient data to calculate estimates were excluded. Conference proceedings or abstracts, reviews, guidelines, and commentaries were excluded. Studies with less than 50 patients total were excluded due to the high risk of bias in these studies. Studies published in any language were included; however, it was excluded if we could not translate the article. For studies with multiple manuscripts, the manuscript with the most comprehensive dataset was included and the others were excluded (duplicate data).

Study Selection

Covidence was used to manage study selection. At each stage of screening a sample of titles and abstracts (n = 5), and full texts (n = 10) were screened by all reviewers to ensure consistency between reviewers and additional studies were reviewed together until a κ of 0.8 was achieved. Titles, abstracts, and full texts were screened for eligibility by 2 independent reviewers. During the title and abstract screening, references included by at least 1 reviewer were included for full-text screening to decrease the risk of incorrectly excluding studies. Disagreement between reviewers was resolved through discussion or consulting a third reviewer.

Data Collection Process

A standardized database (Microsoft Excel) was used to abstract data from included studies. The data abstraction database was pilot tested on 2 studies. Prior to full data abstraction all reviewers were trained by completing data abstraction for the same 5 studies; training continued until a κ of 0.8 was achieved. Data were abstracted by a single reviewer and 65% of the data were double-checked by an independent reviewer. The data dictionary for the standardized data abstraction form is available in eAppendix 2 in Supplement 1.

Variables

The primary outcome variables were hospital length of stay, readmission within 30 days of index hospital discharge, postoperative complications within 30 days of surgery, and mortality within 30 days of surgery. While the primary outcome variables were limited to 30 days from surgery or index hospitalization, data for other time periods were abstracted as secondary outcomes.

Additional data items abstracted from the studies included bibliographic information, study characteristics, patient data, type of protocol evaluated (ERAS, enhanced recovery, fast-track, other), number of ERAS elements included in the protocol (count) even if compliance was not reported for each element, and data on compliance. A full list of data items abstracted is included in the data dictionary (eAppendix 2 in Supplement 1).

Risk of Bias in Individual Studies

The risk of bias of individual studies was evaluated using the Cochrane Risk of Bias Tool (version 2), by 2 independent reviewers with graduate training in epidemiology. Any disagreements between reviewers were resolved through discussion. The Reporting on ERAS Compliance, Outcomes, and Elements Research (RECOvER) checklist assessed completeness of reporting.

Data Analysis

Study characteristics were described using descriptive statistics as appropriate. A random effects meta-analysis was used to pool estimates for each outcome variable (metan package)., The I2 quantified the magnitude of between-study heterogeneity, and the Cochrane Q statistic determined the significance of heterogeneity. Risk ratios (RR) were calculated for data reported as proportions (ie, mortality, complications, and readmission), and mean differences were calculated for data reported as means (ie, hospital length of stay). Estimates reported as median (IQR) were converted to mean (SD) using the Wan method and were pooled.

Meta-regression explored potential sources of heterogeneity for each outcome. The potential sources of heterogeneity included patient age and sex, year(s) of data collection, type of surgery, number of ERAS elements included in the protocol, type of protocol (eg, ERAS, enhanced recovery protocol, fast-track, or other), and RECOvER scores. Publication bias was assessed through visual inspection of a funnel plot and statistically using Egger linear regression method. All analyses were performed in Stata 20.0 (StataCorp)., Data were analyzed from September 2023 to February 2024. Statistical tests were 2-sided, and significance was set at P <.05.

Results

The search strategy yielded 12 047 unique references, of which 1493 were reviewed in full-text, 495 were included in the overall systematic review (eFigure in Supplement 1) and 74 RCTs,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, were included in the meta-analysis. The characteristics of each individual study are included in eTable 1 in Supplement 1. The included studies represent 9076 patients with 4577 patients in the control (non-ERAS) group and 4375 patients in the ERAS group. In the 54 studies that included age, the mean (SD) age was 50.0 (12.6) years for patients in the control group and 49.2 (12.6) years among patients in the ERAS group.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,

Study Characteristics

The median (range) year of publication was 2019 (2009-2021). Most studies were conducted in high income and high-middle income countries (57 [80.3%]); 22 (29.7%) were published in China,,,,,,,,,,,,,,,,,,,,, 8 (10.8%) in India,,,,,,,, 5 (6.8%) in the US.,,,,

Most of the 74 studies examined the outcomes of ERAS in patients undergoing gastrointestinal surgery (32 [43.2%]),,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, and gynecological surgical procedures (11 [14.9%]),,,,,,,,,, with only 1 (1.4%) in cardiac surgery, and 2 (2.7%) in urology., Most of the 74 studies evaluated the outcomes of ERAS guidelines (37 [50.0%]),,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, whereas 23 (31.1%) evaluated enhanced recovery protocols,,,,,,,,,,,,,,,,,,,,,,, 13 (17.6%) evaluated fast-track protocols,,,,,,,,,,,,,, and 1 (1.4%) evaluated other types of protocols or pathways based on ERAS principles. The mean (SD) number of ERAS elements included in the interventions (ERAS, enhanced protocols, fast-track, other) was 11.1 (3.0) elements of a possible 16. Commonly early mobilization (71 [96.0%]), postoperative analgesia management (64 [86.5%]), postoperative diet and bowel management (63 [85.1%]), and drain and tube management (63 [85.1%]) were included (Figure 1). Protocols classified as ERAS included more elements than those classified as fast-track but were no different than enhanced recovery protocols (F1,493 = 9.58; P =.002). The mean (SD) number of elements among studies of ERAS was 11.8 (2.8), compared with 8.9 (2.3) in fast-track protocols, 10.6 (3.7) in enhanced recovery protocols, and 11.4 (3.2) elements with other types of protocols. Compliance with ERAS protocols was reported in 17 (20.3%) studies,,,,,,,,,,,,,,,, but was inconsistently reported and could not be pooled; the mean (SD) compliance reported was 74.7% (10.2%) from the 9 studies from which we could synthesize the data.,,,,,,,,

Length of Stay

Of the 74 included studies, 44 studies (62.2%) reported an overall median or mean estimate of hospital length of stay.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, The pooled mean length of hospital stay was 1.88 days (95% CI, 0.95-2.81 days; I2 = 86.5%; P <.001) shorter in the ERAS groups compared with control groups. ERAS also decreased the postoperative hospital length of stay (22 studies; mean difference, 2.83 days; 95% CI, 2.10-3.55 days; I2 = 0%; P <.001) compared with control groups. Publication bias was not significant.,,,,,,,,,,,,,,,,,,,,,

Hospital Readmission

Nineteen of 74 studies (41.3%) reported 30-day hospital readmissions. The pooled RR of 30-day hospital readmission was 1.04 (95% CI, 0.81-1.35; I2 = 0%; P =.74),,,,,,,,,,,,,,,,,,; with a protective effect when the time period was not specified (11 studies, RR, 0.61; 95% CI, 0.41-0.93; I2 = 0%; P =.02).,,,,,,,,,, Publication bias was not significant.

Complications

Fourteen of 74 studies (18.9%) reported an overall (unstratified) estimate of complications with a pooled estimate of 0.71 (95% CI, 0.59-0.87; I2 = 78.6%; P <.001),,,,,,,,,,,,,, favoring ERAS compared with control groups. Of the nine studies that reported 30-day complications, the pooled RR was 0.73 (95% CI, 0.56-0.94; I2 = 86.3%; P <.02),,,,,,,,, favoring ERAS over control groups. There was evidence of publication bias using the Egger test for small study effects (t = 2.24; 95% CI, 0.14-2.15; P =.003); however, estimates were symmetrically distributed upon visual inspection of the funnel plot.

Mortality

There were 19 of 74 studies that reported 30-day postoperative mortality, with a pooled risk of 0.95 (95% CI, 0.48-1.88) with no heterogeneity between estimates (I2 = 0%; P =.89).,,,,,,,,,,,,,,,,,, Because many studies reported estimates of 0 mortality, a continuity correction was applied to calculate RRs. Publication bias was not significant.

Sources of Heterogeneity Determined by Meta-Regression

There were no differences in the pooled estimates of hospital length of stay based on country income, RECOvER checklist score, year of publication, number of ERAS elements included in the protocol, or risk of bias. The type of surgery accounted for heterogeneity in the estimate of hospital length of stay (coefficient, 0.32; 95% CI, 0.17-0.48; P <.001). The pooled estimate of mean difference in length of hospital stays for patients undergoing pancreatic, orthopedic, and gastrointestinal surgery was larger than other surgical procedures (Figure 2). None of the variables explored accounted for variance in the pooled estimate of 30-day hospital readmission, complications, or mortality. These findings can be found in Figure 3 and Figure 4.

Risk of Bias and RECOvER

Among the 74 included studies, 40 (54.1%) had some risk of bias, 19 (25.7%) had high risk of bias, and 15 (20.3%) had low risk of bias. Missingness of outcome data were considered a source of low risk of bias among 64 studies (86.5%) while deviations from the per-protocol intervention was considered a source of high risk of bias in 17 studies (23.0%) (eTable 2 in Supplement 1).

The mean (SD) number of RECOvER checklist items that were included in the studies was 13.5 (2.3). Commonly reported items included providing context and importance within the background (74 [100.0%]), explaining the significance of the study (73 [98.7%]), and reporting the protocol used (72 [97.3%]) (Figure 1). The least commonly reported items were auditing of outcomes (10 [13.5%]), examining associations between outcomes and other variables (13 [17.6%]), and reporting compliance with the ERAS guidelines (20 [27.0%] (Figure 1).

Discussion

This study found that using the ERAS guidelines were associated with a decrease in the length of hospital stay and complications. Hospital length of stay varied by surgery type. There were many studies included, but some evidence gaps remain. For example, there was a paucity of evidence for some surgical procedures (none for head and neck and breast, and few studies for cardiac), fewer studies reported mortality, and compliance was reported inconsistently and poorly.

While the ERAS guidelines were established with the publication of the ERAS Society guideline for perioperative care of patients undergoing colonic surgery, enhanced recovery as a concept was based on previously described fast-track protocols.,, Accordingly, it is not surprising that many included studies were labeled as fast-track and that a large proportion were focused on gastrointestinal surgery. However, this study did not identify any differences in estimates of hospital length of stay, readmission, complications, or mortality related to the protocol name. While the name given to the protocol examined did not account for heterogeneity between estimates, the number of ERAS elements included in the protocols did for length of hospital stay. This suggests that the number of elements included in the protocol is likely more important than the branding of the protocol, which is supported by previous studies., Encouragingly, most studies reported their protocol elements (90%), which is important for evaluating ERAS outcomes, but very few studies reported compliance with each element. Unfortunately, most studies included less than 70% (11) of the traditional ERAS elements. While the number of ERAS elements included in the protocol is important, it was not possible to assess what elements are most important for the outcomes of ERAS. Future studies should focus on evaluating the relative outcomes of each ERAS element to understand the core elements required to achieve the benefits of ERAS. This will simplify ERAS and promote adoption in lower-resource settings.,

Like with other guidelines, ERAS outcomes depends on adoption of ERAS guidelines.,, Indeed, greater compliance with ERAS has been shown to improve outcomes.,, Since only about 20% of included studies reported compliance with ERAS, and reporting of these estimates were too heterogeneous to include in the analysis, it is likely that mean compliance was lower than 75% and that our findings underestimate the outcomes of ERAS. If compliance is important for ERAS outcomes, how can compliance be improved? Strategies for implementing ERAS have been outlined, with a focus on team building and audit of compliance-and-feedback., These strategies are aligned with principles of implementation science, and evidence-informed strategies for effective guideline implementation., Additional strategies that should be considered when implementing ERAS include identifying barriers and facilitators to implementation, including end-users in developing strategies, education, and prompts-and-reminders.,, Taken together, future work should focus on strategies to improve implementation of and compliance with ERAS guidelines; the importance of which has been noted. Additionally, in agreement with the RECOvER checklist, we advocate for improved reporting of overall compliance and compliance with each ERAS element in studies exploring the outcomes of ERAS guidelines.

Limitations

This study has limitations. While the search strategy was developed by a librarian with expertise in systematic reviews, some studies may not have been identified. Using the Egger statistic and a visual assessment of funnel plots, we did not find evidence of bias toward studies with large effect sizes. While the comprehensiveness of the systematic review is a strength, it can also be limiting because included studies were heterogeneous based on the type of ERAS protocol, surgery type, and outcomes. Additionally, analysis is limited by the data provided within the included studies. As such, variables that may be associated with our outcome variables, including socioeconomic status, insurance status, and surgical complexity, were not accounted for in the analysis. Similarly, patients undergoing ERAS-guided surgical procedures may be a highly selected group, which we could not control for. Finally, these findings may not be generalized to all types of surgery because most studies explored the efficacy of ERAS in colorectal surgery and obstetric or gynecologic surgery. Indeed our findings suggested that the type of surgery was associated with length of hospital stay, but the reason for the variation was unclear.

Conclusions

This meta-analysis found that ERAS was associated with a decreased length of hospital stay (without a significant increase in hospital readmissions) and complications. Given the improvements across specialties, future research should aim to apply ERAS to new surgical specialties and in more clinical settings globally.

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    Baluku M, Bajunirwe F, Ngonzi J, Kiwanuka J, Ttendo S. A randomized controlled trial of enhanced recovery after surgery versus standard of care recovery for emergency cesarean deliveries at Mbarara Hospital, Uganda. Anesth Analg. 2020;130(3):769-776

    Not in our library10.1213/ane.0000000000004495

  44. 44.

    Bansal D, Nayak B, Singh P, Nayyar R, Ramachandran R, Kumar R,. Randomized controlled trial to compare outcomes with and without the enhanced recovery after surgery protocol in patients undergoing radical cystectomy. Indian J Urol. 2020;36(2):95-100

    Not in our library10.4103/iju.iju_11_20

  45. 45.

    Chndan MN, Khakholia M, Bhuyan K. Enhanced recovery after surgery (ERAS) versus standard care in patients undergoing emergency surgery for perforated peptic ulcer. Indian J Surg. 2020;82(6):1044-1049

    Not in our library10.1007/s12262-020-02195-x

  46. 46.

    Cui H, Sun Z, Ruan J, Yu Y, Fan C. Effect of enhanced recovery after surgery (ERAS) pathway on the postoperative outcomes of elbow arthrolysis: a randomized controlled trial. Int J Surg. 2019;68(101228232):78-84.

    Not in our library10.1016/j.ijsu.2019.06.010

  47. 47.

    Damadi AA, Lax EA, Smithson L, Pearlman RD. Comparison of therapeutic benefit of bupivacaine HCL transversus abdominis plane (TAP) block as part of an enhanced recovery pathway versus traditional oral and intravenous pain control after minimally invasive colorectal surgery: a prospective, randomized, double-blind trial. Am Surg. 2019;85(12):1363-1368

    Not in our library10.1177/000313481908501230

  48. 48.

    Dambaev GT, Shefer NA, Ena II, Kondaurov AG, Strezh VA. [ERAS protocol for perioperative management of patients with non-small cell lung cancer]. Khirurgiia (Mosk). 2020;(12):52-58

    Not in our library10.17116/hirurgia202012152

  49. 49.

    Dickson EL, Stockwell E, Geller MA,. Enhanced recovery program and length of stay after laparotomy on a gynecologic oncology service: a randomized controlled trial. Obstet Gynecol. 2017;129(2):355-362

    Not in our library10.1097/aog.0000000000001838

  50. 50.

    Fei Y, Zong G-q, Chen J, Liu R-m. Fast-track protocols in devascularization for cirrhotic portal hypertension. Rev Assoc Med Bras 1992. 2015;61(3):250-257

    Not in our library10.1590/1806-9282.61.03.250

  51. 51.

    Feng F, Li XH, Shi H,. Fast-track surgery combined with laparoscopy could improve postoperative recovery of low-risk rectal cancer patients: a randomized controlled clinical trial. J Dig Dis. 2014;15(6):306-313

    Not in our library10.1111/1751-2980.12142

  52. 52.

    Ferrari F, Forte S, Sbalzer N, Zizioli V, Mauri M, Maggi C,. Validation of an enhanced recovery after surgery protocol in gynecologic surgery: an Italian randomized study. Am J Obstet Gyn. 2020;223(4):543.e1-543.e14

    Not in our library10.1016/j.ajog.2020.07.003

  53. 53.

    Forsmo HM, Pfeffer F, Rasdal A, Ostgaard G, Mohn AC, Korner H,. Compliance with enhanced recovery after surgery criteria and preoperative and postoperative counselling reduces length of hospital stay in colorectal surgery: results of a randomized controlled trial. Colorectal Dis. 2016;18(6):603-611

    Not in our library10.1111/codi.13253

  54. 54.

    Forsmo HM, Pfeffer F, Rasdal A, Sintonen H, Korner H, Erichsen C. Pre- and postoperative stoma education and guidance within an enhanced recovery after surgery (ERAS) programme reduces length of hospital stay in colorectal surgery. Int J Surg. 2016;36(Pt A):121-126

    Not in our library10.1016/j.ijsu.2016.10.031

  55. 55.

    Han H, Guo S, Jiang H, Wu X. Feasibility and efficacy of enhanced recovery after surgery protocol in Chinese elderly patients with intracranial aneurysm. Clin Interv Aging. 2019;14(101273480):203-207

    Not in our library10.2147/cia.s187967

  56. 56.

    He F, Lin X, Xie F, Huang Y, Yuan R. The effect of enhanced recovery program for patients undergoing partial laparoscopic hepatectomy of liver cancer. Clin Transl Oncol. 2015;17(9):694-701

    Not in our library10.1007/s12094-015-1296-9

  57. 57.

    Hwang DW, Kim HJ, Lee JH,. Effect of enhanced recovery after surgery program on pancreaticoduodenectomy: a randomized controlled trial. J Hepatobiliary Pancreat Sci. 2019;26(8):360-369

    Not in our library10.1002/jhbp.641

  58. 58.
    Enhanced recovery protocol versus standard protocol for patients undergoing radical cystectomy: results of a prospective randomized study · 2020
    Not checked
  59. 59.

    Ionescu D, Iancu C, Ion D,. Implementing fast-track protocol for colorectal surgery: a prospective randomized clinical trial. World J Surg. 2009;33(11):2433-2438

    Not in our library10.1007/s00268-009-0197-x

  60. 60.

    Iyer SP, Kareem Z. Fast-track protocol versus conventional protocol on patient outcome: a randomized clinical trial. Niger J Surg. 2019;25(1):36-41

    Not in our library10.4103/njs.njs_34_17

  61. 61.

    Jones CN, Morrison BL, Kelliher LJ,. Hospital costs and long-term survival of patients enrolled in an enhanced recovery program for open liver resection: prospective randomized controlled trial. JMIR Perioper Med. 2021;4(1):e16829

    Not in our library10.2196/16829

  62. 62.

    Kang SH, Lee Y, Min SH,. Multimodal enhanced recovery after surgery (ERAS) program is the optimal perioperative care in patients undergoing totally laparoscopic distal gastrectomy for gastric cancer: a prospective, randomized, clinical trial. Ann Surg Oncol. 2018;25(11):3231-3238

    Not in our library10.1245/s10434-018-6625-0

  63. 63.

    Kapritsou M, Korkolis DP, Giannakopoulou M, Kaklamanos I, Konstantinou M, Katsoulas T,. Fast-track recovery program after major liver resection: a randomized prospective study. Gastroenterol Nurs. 2018;41(2):104-110

    Not in our library10.1097/sga.0000000000000049

  64. 64.

    Kapritsou M, Papathanassoglou ED, Konstantinou EA, Korkolis DP, Mpouzika M, Kaklamanos I,. Effects of the enhanced recovery program on the recovery and stress response in patients with cancer undergoing pancreatoduodenectomy. Gastroenterol Nurs. 2020;43(2):146-155

    Not in our library10.1097/sga.0000000000000417

  65. 65.

    Kilpiö O, Härkki PSM, Mentula MJ, Väänänen A, Pakarinen PI. Recovery after enhanced versus conventional care laparoscopic hysterectomy performed in the afternoon: a randomized controlled trial. Int J Gynaecol Obstet. 2020;151(3):392-398

    Not in our library10.1002/ijgo.13382

  66. 66.

    Lavu H, McCall NS, Winter JM,. Enhancing patient outcomes while containing costs after complex abdominal operation: a randomized controlled trial of the whipple accelerated recovery pathway. J Am Coll Surg. 2019;228(4):415-424

    Not in our library10.1016/j.jamcollsurg.2018.12.032

  67. 67.

    Lemanu DP, Singh PP, Berridge K,. Randomized clinical trial of enhanced recovery versus standard care after laparoscopic sleeve gastrectomy. Br J Surg. 2013;100(4):482-489

    Not in our library10.1002/bjs.9026

  68. 68.

    Li M, Zhang J, Gan TJ, Qin G, Wang L, Zhu M,. Enhanced recovery after surgery pathway for patients undergoing cardiac surgery: a randomized clinical trial. Eur J Cardiothorac Surg. 2018;54(3):491-497

    Not in our library10.1093/ejcts/ezy100

  69. 69.

    Liang X, Ying H, Wang H,. Enhanced recovery care versus traditional care after laparoscopic liver resections: a randomized controlled trial. Surg Endosc. 2018;32(6):2746-2757

    Not in our library10.1007/s00464-017-5973-3

  70. 70.

    Liu B, Liu S, Wang Y,. Neurosurgical enhanced recovery after surgery (ERAS) programme for elective craniotomies: are patients satisfied with their experiences: a quantitative and qualitative analysis. BMJ Open. 2019;9(11):e028706

    Not in our library10.1136/bmjopen-2018-028706

  71. 71.

    Liu B, Liu S, Wang Y,. Enhanced recovery after intraspinal tumor surgery: a single-institutional randomized controlled study. World Neurosurg. 2020;136(101528275):e542-e552

    Not in our library10.1016/j.wneu.2020.01.067

  72. 72.

    Liu G, Jian F, Wang X, Chen L. Fast-track surgery protocol in elderly patients undergoing laparoscopic radical gastrectomy for gastric cancer: a randomized controlled trial. Onco Targets Ther. 2016;9(101514322):3345-3351.

    Not in our library10.2147/ott.s107443

  73. 73.

    Mari G, Costanzi A, Crippa J, Falbo R, Miranda A, Rossi M,. Surgical stress reduction in elderly patients undergoing elective colorectal laparoscopic surgery within an ERAS protocol. Chirurgia (Bucur). 2016;111(6):476-480

    Not in our library10.21614/chirurgia.111.6.476

  74. 74.

    Mari GM, Costanzi A, Maggioni D,. Fast-track versus standard care in laparoscopic high anterior resection: a prospective randomized-controlled trial. Surg Laparosc Endosc Percutan Tech. 2014;24(2):118-121

    Not in our library10.1097/sle.0b013e3182a50e3a

  75. 75.

    Mingjie X, Luyao Z, Ze T, YinQuan Z, Quan W. Laparoscopic radical gastrectomy for resectable advanced gastric cancer within enhanced recovery programs: a prospective randomized controlled trial. J Laparoendosc Adv Surg Tech A. 2017;27(9):959-964

    Not in our library10.1089/lap.2016.0057

  76. 76.

    Mohsina S, Shanmugam D, Sureshkumar S, Kundra P, Mahalakshmy T, Kate V. Adapted ERAS pathway vs. standard care in patients with perforated duodenal ulcer-a randomized controlled trial. J Gastrointest Surg. 2018;22(1):107-116

    Not in our library10.1007/s11605-017-3474-2

  77. 77.

    Muller S, Zalunardo MP, Hubner M, Clavien PA, Demartines N; Zurich Fast Track Study Group. A fast-track program reduces complications and length of hospital stay after open colonic surgery. Gastroenterology. 2009;136(3):842-847

    Not in our library10.1053/j.gastro.2008.10.030

  78. 78.

    Nakanishi W, Miyagi S, Tokodai K,. Effect of enhanced recovery after surgery protocol on recovery after open hepatectomy: a randomized clinical trial. Ann Surg Treat Res. 2020;99(6):320-328

    Not in our library10.4174/astr.2020.99.6.320

  79. 79.

    Nunez-Venzor A, Trejo-Avila M, Cardenas-Lailson E, Valenzuela-Salazar C, Herrera-Esquivel J, Moreno-Portillo M. Effect of enhanced recovery after surgery on laparoscopic appendectomy outcomes in patients with complicated appendicitis: a randomized controlled trial. SN Compr Clin Med. 2021;3(2):646-653

    Not in our library10.1007/s42399-021-00788-5

  80. 80.

    Ostermann S, Morel P, Chalé JJ,. Randomized controlled trial of enhanced recovery program dedicated to elderly patients after colorectal surgery. Dis Colon Rectum. 2019;62(9):1105-1116

    Not in our library10.1097/dcr.0000000000001442

  81. 81.
    Improvement in the Quality of Early Postoperative Course After Endoscopic Transsphenoidal Pituitary Surgery: Description of Surgical Technique and Outcome · 2020
    Not checked
  82. 82.

    Peng J, Dong R, Jiao J,. Enhanced recovery after surgery impact on the systemic inflammatory response of patients following gynecological oncology surgery: a prospective randomized study. Cancer Manag Res. 2021;13(101512700):4383-4392

    Not in our library10.2147/cmar.s294718

  83. 83.

    Pirzada MT, Naseer F, Haider R,. Enhanced recovery after surgery (ERAS) protocol in stoma reversals. J Pak Med Assoc. 2017;67(11):1674-1678.

    Not in our library

  84. 84.

    Prabhakaran S, Misra S, Magila M,. Randomized controlled trial comparing the outcomes of enhanced recovery after surgery and standard recovery pathways in laparoscopic sleeve gastrectomy. Obes Surg. 2020;30(9):3273-3279

    Not in our library10.1007/s11695-020-04585-2

  85. 85.

    Qu L, Liu B, Zhang H,. Management of postoperative pain after elective craniotomy: a prospective randomized controlled trial of a neurosurgical enhanced recovery after surgery (ERAS) program. Int J Med Sci. 2020;17(11):1541-1549

    Not in our library10.7150/ijms.46403

  86. 86.

    Rao JH, Zhang F, Lu H,. Effects of multimodal fast-track surgery on liver transplantation outcomes. Hepatobiliary Pancreat Dis Int. 2017;16(4):364-369

    Not in our library10.1016/s1499-3872(17)60020-1

  87. 87.

    Ren L, Zhu D, Wei Y,. Enhanced recovery after surgery (ERAS) program attenuates stress and accelerates recovery in patients after radical resection for colorectal cancer: a prospective randomized controlled trial. World J Surg. 2012;36(2):407-414

    Not in our library10.1007/s00268-011-1348-4

  88. 88.

    Ruiz-Tovar J, Garcia A, Ferrigni C, Gonzalez J, Castellon C, Duran M. Impact of implementation of an enhanced recovery after surgery (ERAS) program in laparoscopic Roux-en-Y gastric bypass: a prospective randomized clinical trial. Surg Obes Relat Dis. 2019;15(2):228-235

    Not in our library10.1016/j.soard.2018.11.002

  89. 89.

    Sanchez-Iglesias JL, Carbonell-Socias M, Perez-Benavente MA, Monreal Clua S, Manrique-Munoz S, Garcia Gorriz M,. PROFAST: a randomised trial implementing enhanced recovery after surgery for highcomplexity advanced ovarian cancer surgery. Eur J Cancer. 2020;136:149-158

    Not in our library10.1016/j.ejca.2020.06.011

  90. 90.

    Sanchez-Iglesias JL, Gomez-Hidalgo NR, Perez-Benavente A, Carbonell-Socias M, Manrique-Munoz S, Serrano MP,. Importance of enhanced recovery after surgery (ERAS) protocol compliance for length of stay in ovarian cancer surgery. Ann Surg Onc. 2021;28(13):8979-8986

    Not in our library10.1245/s10434-021-10228-2

  91. 91.

    Saurabh K, Sureshkumar S, Mohsina S, Mahalakshmy T, Kundra P, Kate V. Adapted ERAS pathway versus standard care in patients undergoing emergency small bowel surgery: a randomized controlled trial. J Gastrointest Surg. 2020;24(9):2077-2087

    Not in our library10.1007/s11605-020-04684-6

  92. 92.

    Sazhin AV, Nechay TV, Titkova SM,. Fast-track rehabilitation for acute cholecystitis: intermediate outcomes of prospective randomized trial. Khirurgiia (Mosk). 2018;(12):13-20

    Not in our library10.17116/hirurgia201812113

  93. 93.

    Sazhin AV, Nechay TV, Titkova SM,. Comparison of standard and fast track rehabilitation in patients with acute appendicitis: intermediate results of multicenter prospective randomized trial. Khirurgiia (Mosk). 2018;(9):15-23

    Not in our library10.17116/hirurgia2018090115

  94. 94.

    Scioscia M, Ceccaroni M, Gentile I,. Randomized trial on fast track care in colorectal surgery for deep infiltrating endometriosis. J Minim Invasive Gynecol. 2017;24(5):815-821

    Not in our library10.1016/j.jmig.2017.04.004

  95. 95.

    Serclova Z, Dytrych P, Marvan J, Nova K, Hankeova Z, Ryska O,. Fast-track in open intestinal surgery: prospective randomized study. Clin Nutr. 2009;28(6):618-624.

    Not in our library10.1016/j.clnu.2009.05.009

  96. 96.

    Serclova Z, Dytrych P, Marvan J, Nova K, Hankeova Z, Ryska O,. Tolerance of accelerated postoperative rehabilitation following intestinal resections. Rozhl Chir. 2009;88(4):178-184.

    Not in our library

  97. 97.

    Sharma J, Kumar N, Huda F, Payal YS. Enhanced recovery after surgery protocol in emergency laparotomy: a randomized control study. Surg J (N Y). 2021;7(2):e92-e99

    Not in our library10.1055/s-0041-1725156

  98. 98.

    Shetiwy M, Fady T, Shahatto F, Setit A. Standardizing the protocols for enhanced recovery from colorectal cancer surgery: are we a step closer to ideal recovery? Ann Coloproctol. 2017;33(3):86-92

    Not in our library10.3393/ac.2017.33.3.86

  99. 99.

    Soffin EM, Beckman JD, Tseng A,. Enhanced recovery after lumbar spine fusion: a randomized controlled trial to assess the quality of patient recovery. Anesthesiology. 2020;133(2):350-363

    Not in our library10.1097/aln.0000000000003346

  100. 100.

    Swaminathan N, Kundra P, Ravi R, Kate V. ERAS protocol with respiratory prehabilitation versus conventional perioperative protocol in elective gastrectomy- a randomized controlled trial. Int J Surg. 2020;81:149-157

    Not in our library10.1016/j.ijsu.2020.07.027

  101. 101.

    Takagi K, Yoshida R, Yagi T, Umeda Y, Nobuoka D, Kuise T,. Effect of an enhanced recovery after surgery protocol in patients undergoing pancreaticoduodenectomy: a randomized controlled trial. Clin Nutr. 2019;38(1):174-181

    Not in our library10.1016/j.clnu.2018.01.002

  102. 102.

    Tanaka R, Lee S-W, Kawai M, Tashiro K, Kawashima S, Kagota S,. Protocol for enhanced recovery after surgery improves short-term outcomes for patients with gastric cancer: a randomized clinical trial. Gastric Cancer. 2017;20(5):861-871

    Not in our library10.1007/s10120-016-0686-1

  103. 103.

    Taupyk Y, Cao X, Zhao Y, Wang C, Wang Q. Fast-track laparoscopic surgery: a better option for treating colorectal cancer than conventional laparoscopic surgery. Oncol Lett. 2015;10(1):443-448

    Not in our library10.3892/ol.2015.3166

  104. 104.

    Teigen NC, Sahasrabudhe N, Doulaveris G, Xie X, Negassa A, Bernstein J,. Enhanced recovery after surgery at cesarean delivery to reduce postoperative length of stay: a randomized controlled trial. Am J Obstet Gynecol. 2020;222(4):372.e1-372.e10

    Not in our library10.1016/j.ajog.2019.10.009

  105. 105.

    Trejo-Ávila ME, Romero-Loera S, Cárdenas-Lailson E,. Enhanced recovery after surgery protocol allows ambulatory laparoscopic appendectomy in uncomplicated acute appendicitis: a prospective, randomized trial. Surg Endosc. 2019;33(2):429-436

    Not in our library10.1007/s00464-018-6315-9

  106. 106.

    Vlad O, Catalin B, Mihai H,. Enhanced recovery after surgery (ERAS) protocols in patients undergoing radical cystectomy with ileal urinary diversions: A randomized controlled trial. Medicine (Baltimore). 2020;99(27):e20902

    Not in our library10.1097/md.0000000000020902

  107. 107.

    Wang Y, Liu B, Zhao T,. Safety and efficacy of a novel neurosurgical enhanced recovery after surgery protocol for elective craniotomy: a prospective randomized controlled trial. J Neurosurg. 2018;130(5):1-12.

    Not in our library10.3171/2018.1.jns171552

  108. 108.

    Wu XF, Kong WF, Wang WH,. Enhanced recovery after surgery protocols in functional endoscopic sinus surgery for patients with chronic rhinosinusitis with nasal polyps: a randomized clinical trial. Chin Med J (Engl). 2019;132(3):253-258

    Not in our library10.1097/cm9.0000000000000060

  109. 109.

    Yang G, Chen W, Chen W, Tang X, Huang Y, Zhang L. Feasibility and safety of 2-day discharge after fast-track total hip arthroplasty: a Chinese experience. J Arthroplasty. 2016;31(8):1686-1692.e1

    Not in our library10.1016/j.arth.2016.02.011

  110. 110.

    Yilmaz G, Akça A, Aydin N. Enhanced recovery after surgery (ERAS) versus conventional postoperative care in patients undergoing abdominal hysterectomies. Ginekol Pol. 2018;89(7):351-356

    Not in our library10.5603/gp.a2018.0060

  111. 111.

    Yilmaz G, Akca A, Kiyak H, Salihoglu Z. Comparison of enhanced recovery protocol with conventional care in patients undergoing minor gynecologic surgery. Wideochir Inne Tech Maloinwazyjne. 2020;15(1):220-226

    Not in our library10.5114/wiitm.2019.85464

  112. 112.

    Zhao G, Cao S, Cui J. Fast-track surgery improves postoperative clinical recovery and reduces postoperative insulin resistance after esophagectomy for esophageal cancer. Support Care Cancer. 2014;22(2):351-358

    Not in our library10.1007/s00520-013-1979-0

  113. 113.

    Pan J, Hei Z, Li L,. The advantage of implementation of enhanced recovery after surgery (ERAS) in acute pain management during elective cesarean delivery: a prospective randomized controlled trial. Ther Clin Risk Manag. 2020;16(101253281):369-378

    Not in our library10.2147/tcrm.s244039

  114. 114.

    Liu XX, Pan HF, Jiang ZW,. Fast-track and minimally invasive surgery for gastric cancer. Chin Med J (Engl). 2016;129(19):2294-2300

    Not in our library10.4103/0366-6999.190659

  115. 115.

    Pang Q, Duan L, Jiang Y, Liu H. Oncologic and long-term outcomes of enhanced recovery after surgery in cancer surgeries: a systematic review. World J Surg Oncol. 2021;19(1):191

    Not in our library10.1186/s12957-021-02306-2

  116. 116.
    Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science · 2009
    No notice
  117. 117.
    Enhanced recovery after surgery (ERAS) in elective intertrochanteric fracture patients result in reduced length of hospital stay (LOS) without compromising functional outcome · 2019
    Not checked
  118. 118.

    Wei JJ, Lin EX, Shi JD,. Meta-analysis with zero-event studies: a comparative study with application to COVID-19 data. Mil Med Res. 2021;8(1):41

    Not in our library10.1186/s40779-021-00331-6

  119. 119.

    Fearon KC, Ljungqvist O, Von Meyenfeldt M,. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr. 2005;24(3):466-477

    Not in our library10.1016/j.clnu.2005.02.002

  120. 120.

    Engelman RM, Rousou JA, Flack JE III,. Fast-track recovery of the coronary bypass patient. Ann Thorac Surg. 1994;58(6):1742-1746

    Not in our library10.1016/0003-4975(94)91674-8

  121. 121.

    Bardram L, Funch-Jensen P, Jensen P, Crawford ME, Kehlet H. Recovery after laparoscopic colonic surgery with epidural analgesia, and early oral nutrition and mobilisation. Lancet. 1995;345(8952):763-764

    Not in our library10.1016/s0140-6736(95)90643-6

  122. 122.

    Møiniche S, Bülow S, Hesselfeldt P, Hestbaek A, Kehlet H. Convalescence and hospital stay after colonic surgery with balanced analgesia, early oral feeding, and enforced mobilisation. Eur J Surg. 1995;161(4):283-288.

    Not in our library

  123. 123.

    ERAS Compliance Group. The impact of enhanced recovery protocol compliance on elective colorectal cancer resection: results from an international registry. Ann Surg. 2015;261(6):1153-1159

    Not in our library10.1097/sla.0000000000001029

  124. 124.

    Wijk L, Udumyan R, Pache B, Altman AD, Williams LL, Elias KM,. International validation of enhanced recovery after surgery society guidelines on enhanced recovery for gynecologic surgery. Am J Obstet Gynecol. 2019;221(3):237.e1-237.e11

    Not in our library10.1097/sga.0000000000000417

  125. 125.

    Oodit R, Biccard B, Brindle M, Ljungqvist O, Nelson G. ERAS Society recommendations for improving perioperative care in low- and middle-income countries through implementation of existing tools and programs: an urgent need for the surgical safety checklist and enhanced recovery after surgery. World J Surg. 2022;46(5):1247

    Not in our library10.1007/s00268-022-06450-y

  126. 126.

    Ljungqvist O, de Boer HD, Balfour A,. Opportunities and challenges for the next phase of enhanced recovery after surgery: a review. JAMA Surg. 2021;156(8):775-784

    Not in our library10.1001/jamasurg.2021.0586

  127. 127.

    Grimshaw JM, Thomas RE, MacLennan G,. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess. 2004;8(6):iii-iv, 1-72

    Not in our library10.3310/hta8060

  128. 128.

    Peters S, Sukumar K, Blanchard S,. Trends in guideline implementation: an updated scoping review. Implement Sci. 2022;17(1):50

    Not in our library10.1186/s13012-022-01223-6

  129. 129.

    Gustafsson UO, Oppelstrup H, Thorell A, Nygren J, Ljungqvist O. Adherence to the ERAS protocol is associated with 5-year survival after colorectal cancer surgery: a retrospective cohort study. World J Surg. 2016;40(7):1741-1747

    Not in our library10.1007/s00268-016-3460-y

  130. 130.

    Twomey R, Matthews TW, Nakoneshny S,. Impact of early mobilization on recovery after major head and neck surgery with free flap reconstruction. Cancers (Basel). 2021;13(12):2852

    Not in our library10.3390/cancers13122852

  131. 131.

    Twomey R, Matthews TW, Nakoneshny SC,. From pathways to practice: impact of implementing mobilization recommendations in head and neck cancer surgery with free flap reconstruction. Cancers (Basel). 2021;13(12):2890

    Not in our library10.3390/cancers13122890

  132. 132.

    Francis NK, Walker T, Carter F,. Consensus on training and implementation of enhanced recovery after surgery: a Delphi study. World J Surg. 2018;42(7):1919-1928

    Not in our library10.1007/s00268-017-4436-2

  133. 133.

    Cabana MD, Rand CS, Powe NR,. Why don’t physicians follow clinical practice guidelines: a framework for improvement. JAMA. 1999;282(15):1458-1465

    Not in our library10.1001/jama.282.15.1458

  134. 134.

    Farquhar CM, Kofa EW, Slutsky JR. Clinicians’ attitudes to clinical practice guidelines: a systematic review. Med J Aust. 2002;177(9):502-506

    Not in our library10.5694/j.1326-5377.2002.tb04920.x

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