The American Journal of Surgery 219 (2020) 530e534

Contents lists available at ScienceDirect

The American Journal of Surgery

journal homepage: www.americanjournalofsurgery.com

Enhanced recovery after surgery: A clinical review of implementation

across multiple surgical subspecialties
Thomas W. Smith Jr. *, Xuanji Wang, Marc A. Singer, Constantine V. Godellas,
Faaiza T. Vaince
Department of Surgery, Loyola University Medical Center, Maywood, IL, United States

a r t i c l e i n f o a b s t r a c t

Article history: Enhanced recovery after surgery (ERAS) is a multimodal protocol applied towards perioperative patient
Received 26 September 2019 care. ERAS programs are implemented by a multidisciplinary team centered around the patient, incor-
Received in revised form porating outpatient clinical staff, preoperative nurses, anesthesiologists, operative nurses, postoperative
6 November 2019
recovery staff, floor inpatient nurses, dieticians, physical therapists, social workers, and surgeons. Initial
Accepted 7 November 2019
studies on perioperative care measures focused on cardiac surgery. Subsequently, the development of the
ERAS Study Group in 2001 focused on colorectal surgery and postoperative outcome measures. Today,
ERAS protocols have been implemented across many surgical subspecialties including: bariatric, breast,
plastic, cardiac, colorectal, esophageal, head and neck, hepatic, gynecologic, neurosurgical, orthopedic,
pancreatic, thoracic, and urologic surgery. The goal of ERAS programs is to promote rapid recovery as
quantified by decreasing the length of hospital stay, complications, and cost of specific surgical in-
terventions. In the setting of the opioid crisis in America, there is also an increasing focus on minimizing
perioperative narcotic use. The purpose of this review is to compare ERAS protocols across surgical
subspecialties, focusing on quantified metrics of improvement, and to provide a clear and concise
summary of the literature in regards to current ERAS practices and success rates.
© 2019 Elsevier Inc. All rights reserved.

Principles of ERAS
Enhanced recovery after surgery (ERAS) has progressed far from
its infancy in cardiac surgery and development within colorectal
surgery, now incorporating most surgical subspecialties including
bariatric, breast, plastic, cardiac, colorectal, esophageal, head and
neck, hepatic, gynecologic, neurosurgical, orthopedic, pancreatic,
thoracic, and urologic surgery.1 The ERAS Study Group of 2001 led
to the development of the ERAS Society (erassociety.org) which
focuses on publishing evidence based consensus guidelines and
protocols (that draw on randomized controlled trials, meta-
analyses, and large prospective cohort studies reviewed by the
Grading of Recommendations, Assessment, Development and
Evaluation (GRADE) System).2
Regardless of the surgical subspecialty, all ERAS protocols share
the same objectives: preoperative patient optimization, decrease in
perioperative stress, maintenance of postoperative physiologic
* Corresponding author. Loyola University Medical Center, Department of Sur-
gery, 2160 South First Avenue, Maywood, IL, 60153, United States
E-mail address: thomas.w.smith@lumc.edu (T.W. Smith).
function, and accelerated recovery time after surgery.3 This is
accomplished by a multidisciplinary team providing multimodal
perioperative patient care. The multidisciplinary team incorporates
outpatient clinical staff, pre-operative nurses, anesthesiologists,
operative nurses, postoperative recovery staff, floor nurses, di-
eticians, physical therapists, social workers, and surgeons.3 The
multidisciplinary efforts focus on preoperative, intraoperative, and
postoperative phases of care (Fig. 1). These multi-setting phases of
care employ recommendations and guidelines described by the
ERAS Society as strong or weak based on recommendation grade
and research evidence level (high, moderate, low, very low).2,3
In the preoperative setting, ERAS care elements are further
subdivided into pre-admission and post-admission elements. In the
pre-admission setting, the care is focused on patient optimization
including management of comorbidities, surgical information/
counseling, nutritional assessments/supplementation, abstinence
from excessive alcohol consumption, and smoking cessation.4 In a
colorectal study that encompassed stoma education as part of the
ERAS pre-admission education, total hospital stay was shorter as
patients were able to anticipate their post-surgical needs and
subsequent changes in daily life.5 Beyond basic nutrition, many of

https://doi.org/10.1016/j.amjsurg.2019.11.009
0002-9610/© 2019 Elsevier Inc. All rights reserved.
 T.W. Smith Jr. et al. / The American Journal of Surgery 219 (2020) 530e534
Fig. 1. Phases of ERAS care protocol elements.
the ERAS surgical subspecialty guidelines focus on supplementa-
tion with oral immunonutrition in the 7 days prior to surgery,
however, evidence levels are low to moderate.2,3 Studies show that
amino acids such as arginine, glutamine, omega-3-fatty acids, and
ribo-nucleic acid modulate the immune system and regulate in-
flammatory responses.6 Arginine protects against ischemia and
reperfusion injury, promotes T-cell maturation, and increases ni-
trogen balance. Glutamine supplies energy for gut mucosa and is
used in metabolic processes of immunological cells. Omega-3-fatty
acids modulate the production of lipids and proteins as well as
reduce systemic inflammation. Nucleotides serve in protein syn-
thesis, facilitate intestinal cell maturation, and regulate T-cell im-
mune response. Since the first clinical study of immunonutrition by
Daly in 1992, immunonutrition formulation has been altered to
optimize nutritional support.7
Previous teaching focused on a minimum of 6 hours of fasting to
decrease gastric residuals and limit the risk of aspiration with in-
duction of anesthesia and intubation. Strong recommendations
now support intake of clear liquids (including immunonutrition) up
to 2 hours prior to surgery, with no increased risk of aspiration.2,3
Furthermore, it has been shown that fasting leads to a catabolic
metabolic state that results in reduced liver glycogen stores as well
as increased insulin resistance and post-operative stress.8 It has
been well documented that postoperative hyperglycemia is asso-
ciated with increased morbidity (i.e. infections, neuropathy, renal
failure) and mortality; thus strict glycemic control is a critical
component of post-surgical care. Even in patients with type 2
diabetes, the administration of a carbohydrate-rich drink likely
induces endogenous insulin release prior to onset of surgery, and
thus promoting an anabolic rather than a catabolic metabolic
state.9 When patients were given a 12.5% carbohydrate-rich drink,
there was no evidence of delayed gastric emptying and glucose
concentration returned to baseline, making it safe for administra-
tion of clear liquid immunonutrition up to 3 h before anesthesia.10
Another advantage of using preoperative low osmolar
carbohydrate-rich drink is to decrease overall gastrointestinal
discomfort, leading to a reduction in postoperative nausea and use
of antiemetics.11 Other preoperative recommendations include
bowel preparations, thromboembolic prophylaxis, nausea prophy-
laxis, and skin preparation/antimicrobial prophylaxis.4
Intraoperative ERAS protocol guidelines focus on minimizing
531
the stress of surgery by encouraging minimally invasive tech-
niques/incisions, avoiding hypothermia, maintaining fluid euvole-
mia, strict glycemic control, and decreased utilization of surgical
drains and nasogastric tubes.2,3 Nevertheless, there are some spe-
cialty specific nuances. For example, intraoperative fluid manage-
ment is quite difficult to study as it is variable based on the
anesthesiologist. Multiple observational studies have highlighted
the concept of a U-shaped distribution to avoid complications
related to hypovolemia and fluid overload.12 Institutional guide-
lines in fluid management in the form of ERAS protocols will
standardize resuscitation approaches and avoid variations in
volemic status.
Neuraxial anesthesia and anatomical anesthetic blocks are also
useful intraoperative components of ERAS protocols to minimize
narcotics use. A meta-analysis of randomized controlled trials show
a significant reduction in narcotics use in patients receiving pe-
ripheral nerve blocks (PNB). Patients receiving PNBs report less
pain at rest and on movement 72 hours postoperatively, which
promotes a shorter hospital stay and increased physical therapy.13
Furthermore, patients undergoing single limb orthopedic proced-
ures (i.e. total knee arthroplasty, anterior cruciate ligament repair,
etc) rate lower pain scores even when they use a combination of
PNB and narcotics. Other modalities of regional pain control such as
transverse abdominis plane (TAP) block (with either liposomal
bupivacaine or bupivacaine) is also beneficial to reducing narcotics
use.14 Preventative blocks have demonstrated results not only in
the perioperative period, but also long-lasting effects. Establishing
sufficient afferent blockade prior to surgical incision reduces the
nociceptive barrage that leads to central sensitization and subse-
quent development of chronic pain15.
Postoperative recommendations focus on early return to func-
tion, with immediate mobilization and immediate/early return to
oral nutritional intake. These goals are accomplished by focusing on
multimodal pain control, while minimizing narcotics thus
decreasing postoperative nausea/vomiting and potential ileus. This
is further supplemented with multi-modal nausea prophylaxis and
gastrointestinal mu-receptor antagonists, allowing for increased
early oral intake.2,3 The traditional training of keeping patients nil
per os (NPO) with a slow progressive diet is rooted in fears around
complications such as nausea/vomiting, aspiration, and anasto-
motic breakdown. Increasing evidence supports that postoperative
532 T.W. Smith Jr. et al. / The American Journal of Surgery 219 (2020) 530e534
nutrition in as early as 24 hours is associated with a reduction in
morality and no harm related to anastomotic leak.16,17 In addition to
glucose administration, protein intake is key in achieving anabolic
metabolism to support post-surgical recovery. In patients who
meet clinical criteria for malnutrition, enteral feeding within 24
hours is recommended and nutrition support should be maintained
for at least 4 weeks. In the elective surgery population, patient
receiving a high-protein diet (>60% of daily protein requirements)
in postoperative days 0e3 are found to have reduced length of
hospital stay.18
Finally, success of ERAS protocols are dependent on a multi-
disciplinary team including physical therapists, dieticians, and so-
cial workers in the postoperative phase. A meta-analysis
highlighted the importance of collaboration, communication, and
thorough staff education for ease of program implementation.19 For
bariatrics patients undergoing laparoscopic sleeve gastrectomy or
Roux-en-Y gastric bypass, a multidisciplinary follow-up program
including a postoperative day 7 phone call from the physician’s
office was crucial to the protocol.20 The authors even attribute
much of their high-volume center success to the team model to
educate patients, families, and staff in order to avoid complications
due to misunderstandings.
Outcomes analysis and research
The principle tenant of ERAS protocols is based on clinical out-
comes and analysis of improvement metrics. The ERAS Society
provides a strong recommendation grade to the systematic audit of
guidelines, allowing for determination of clinical success and
continued focus on evidence based protocols. The collection of
protocol specific data facilitates analysis of center-specific data and
comparison to other ERAS centers; allowing for refining of pro-
tocols to improve outcomes.
Clinical success and improvement is measured quantitatively
and includes data collection for a multitude of postoperative out-
comes as exemplified by the ERAS protocol data for elective colo-
rectal surgery (Table 1). These clinical outcomes can be compared
to the compliance of colorectal ERAS components (Table 2).
Univariate and multivariate analysis can be performed using a
multitude of patient factors (sex, age, American Society of Anes-
thesiologist (ASA) classification, body mass index (BMI), comor-
bidities) and operative components (neoadjuvant treatment,
procedure type, and surgical approach).21
The ERAS society maintains an online database, ERAS Interactive
Audit System, allowing for large multicenter data collection.21 Re-
sults from this database have been published in multiple
Table 1
Postoperative outcome of colorectal surgery.
Postoperative Outcomes Colorectal Surgery
 Length of hospital stay
 Readmission
 Reoperation
 Surgical complication Anastomotic leak
Ureteral Injury
Wound dehiscence
Intraoperative hemorrhage
Postoperative hemorrhage
Bowel obstruction
 Cardiovascular complication
 Respiratory complication
 Infectious complication Wound infection
Urinary tract infection
Intra-abdominal abscess
Sepsis
 Any complication
Table 2
Colorectal ERAS component compliance.
Colorectal ERAS Component Compliance (Yes/No)
 Preadmission patient education  Preoperative carbohydrate drinks
 Avoidance of premedication  Selective bowel preparation
 Antibiotic prophylaxis  Thromboembolic prophylaxis
 Intraoperative epidural  Postoperative nausea and vomiting
analgesia prophylaxis
 Upper-body air heating  Postoperative laxative
 Avoidance of nasogastric tubes  Restrictive intravenous fluids on day
of surgery
 Avoidance of intra-abdominal
drains
installments across multiple surgical specialties, including a large
cohort review from 2008 to 2013 of 2352 colorectal surgeries
performed at over 13 different medical centers across 6 countries.
This study showed that the increase in ERAS protocol compliance
led to decreased hospital stay and fewer complications (Table 2).21
Patients with greater than 90% compliance to ERAS protocols had a
25% shorter hospital stay when compared to patients with less than
50% ERAS compliance. Patients undergoing laparoscopic surgery
showed decreased hospital stay and overall decreased complica-
tions.21 This data has been externally validated by a multitude of
reviews, including a Cochrane Review analyzing 4 separate ran-
domized controlled trials (RCTs), showing decreased overall com-
plications and shorter hospital stays with ERAS protocol
compliance.22
ERAS was initially designed in the setting of elective
colorectal cancer resection; however, the tenants and protocols
designed apply across multiple surgical subspecialities. The ERAS
Society currently has 22 separate consensus reviews and recom-
mendations, including: cardiac, gynecologic oncology, thoracic,
esophagectomy, breast, head/neck, bariatric, pelvic, pan-
creaticoduodenectomy, bladder, gastrectomy, and gastrointestinal
surgeries.1 Similarly, the data continues to show a statistically sig-
nificant decreased length of hospital stay with a trend towards
decreased complications with ERAS implementation. A subsequent
Cochrane Review published in 2016, (focusing on major upper
gastrointestinal, liver, and pancreatic surgery) included 10 RCTs
with collectively over 1000 patients undergoing surgery (499
randomly assigned to ERAS protocol and 515 previous standard of
care), continued to replicate previous results showing decreased
hospital stay with increased ERAS compliance.23 In addition to
reducing length of hospital stay, ERAS protocols have been linked to
reduced overall healthcare costs. In an orthopedic model looking at
total hip or knee joint replacements, the mean hospital length of
stay was less for those in the ERAS protocol compared to standard
treatments. The reduction in health care costs associated with the
ERAS protocol was also significant based on cost of ambulatory
surgery, hospital care per day, and physical therapy sessions,
despite the additional cost of drugs.24
Aside from early recovery and decreased hospital stays, ERAS
protocol goals include decreased intraoperative and postoperative
narcotic usage. Multimodal narcotic-sparing pain control is the
central tenet of all ERAS guidelines which encourages utilization of
non-steroidal anti-inflammatory agents, acetaminophen, gaba-
pentinoids, regional/neuraxial anesthetics, and intravenous keta-
mine or lidocaine infusions.25 Multimodal postoperative pain
control efforts allow for early mobilization without the side-effects
of narcotics such as postoperative nausea/vomiting or constipation.
In patients undergoing mastectomy (with immediate subpectoral
implant-based reconstruction) a multi-modal, opioid-sparing ERAS
protocol has been shown to significantly reduce the amount of
narcotic use in postoperative days 0e2.26 The mastectomy specific
 T.W. Smith Jr. et al. / The American Journal of Surgery 219 (2020) 530e534
ERAS protocol focused heavily on preoperative administration of
gabapentin in conjunction with postoperative use of ibuprofen,
acetaminophen, and ondansetron. Similarly, the 2015 Mayo Clinic
trial demonstrated significantly less narcotics use in postoperative
days 0e3 for patients undergoing free-flap breast reconstruction
using an abdominal donor site.27 Interestingly, even though pa-
tients in ERAS and traditional care after surgery groups reported
similar pain scores, there was a 71% decrease in the amount of oral
morphine equivalent used in the ERAS cohort. Moreover this is
validated across surgical subspecialties. Implementation of ERAS
multimodal analgesia during ventral hernia repair have shown a
decreased opioid requirement postoperatively with near elimina-
tion of need for patient controlled analgesia.28 A meta-analysis of
27 randomized clinical trials showed while 50% of colorectal pa-
tients still used narcotics in hospitals, most did not need narcotics
after discharge. The challenge in analyzing pain control with ERAS
is that the current data does not show explicit correlation between
ERAS protocol compliance and post-discharge narcotic usage.25
Patient selection may also be biased due to opioid exposure, body
mass index, and history of chronic pain diagnosis; further studies
are needed in this setting.27
Future directions
ERAS protocols have been created for and implemented across a
growing list of surgical subspecialties, new development and
research has expanded into acute care and trauma surgery, with
most of literature surrounding urgent colectomy.29 In a similar
fashion, ERAS protocols are gaining traction within the obstetric
field particularly with caesarean sections, whereby discharge can
be considered on postoperative day one.29 Beyond expansion into
other surgical subspecialities, ERAS protocols are gaining increased
validity and credibility with long term follow-up extending over 10
years and an increasing number of randomized controlled trials
supporting the practices. New studies are concentrating on out-
comes beyond the perioperative period, including overall mortal-
ity.3 Specialty specific outcomes are receiving more research
attention, including oncologic specific data pertaining to time to
adjuvant treatment, cancer recurrence, and cancer free survival.29
Certain early in-vivo animal models have suggested that
increased systemic stress/pain and potentially narcotic usage can
promote tumor growth and metastases, thereby underlying the
importance of ERAS protocols with multi-modal pain control with
opioid sparing alternatives.29 Though data is lacking on whether
ERAS protocols can enable a decrease in narcotics usage and
dependence following discharge, this should receive more research
attention in the coming years, given the increased pertinence of
this agenda in the setting of the current opiate epidemic in America.
Limitations
Major limitations to ERAS protocols’ success hinge on imple-
mentation capacity within a medical center and compliance to
protocol guidelines. Applying a standardized perioperative care
regimen across multiple settings (including outpatient clinics,
preoperative clinics, operating rooms, post-anesthesia recovery
rooms, and inpatient wards) requires significant coordination
within a preset multidisciplinary team.30 Multiple studies have
shown lack of ERAS protocol compliance within one of the multi-
disciplinary phases of care. A large multi-center study involving
greater that 400 patients undergoing colorectal surgery show
increased compliance within the preoperative and operative pe-
riods, however there is significant variations from protocol in the
postoperative period.31 A multinational study involving over 1000
patients undergoing colorectal surgery demonstrates that nearly
533
50% of patients has a nasogastric tube left postoperatively, even
though ERAS colorectal protocols call for removal after the opera-
tions.32 ERAS protocols have been validated across multiple surgical
subspecialties, however a major limitation to successful practice
has been and continues to be compliance throughout all phases of
patient care.
Conclusions
ERAS protocols employ multimodal and multidisciplinary ef-
forts to optimize patient care in the preoperative, operative, and
postoperative setting. These protocols have gained acceptance and
utilization across all surgical subspecialties and are supported by an
increasing amount of clinical outcome data with constant analysis
of guidelines for quantifiable success. ERAS protocols are continu-
ously revised to help increase protocol compliance and improve
recovery metrics following surgery. Ideally, this will improve clin-
ical outcomes and control healthcare costs.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Declaration of competing interest
None.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.amjsurg.2019.11.009.
References
1. ERAS society list of guidelines [internet]. [cited 2019Sep.24]. Available from:
http://erassociety.org/.
2. Gustafsson UO, Scott MJ, Hubner M, et al. Guidelines for perioperative care in
elective colorectal surgery: enhanced recovery after surgery (ERAS((R))) society
recommendations: 2018. World J Surg. 2019;43(3):659e695.
3. Ljungqvist O, Scott M, Fearon KC. Enhanced recovery after surgery: a review.
JAMA Surg. 2017;152(3):292e298.
4. Dang JT, Szeto VG, Elnahas A, et al. Canadian consensus statement: enhanced
recovery after surgery in bariatric surgery. Surg Endosc. 2019.
5. 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):121e126.
6. Helminen H, Raitanen M, Kellosalo J. Immunonutrition in elective gastroin-
testinal surgery patients. Scand J Surg. 2007;96(1):46e50.
7. Daly JM, Weintraub FN, Shou J, Rosato EF, Lucia M. Enteral nutrition during
multimodality therapy in upper gastrointestinal cancer patients. Ann Surg.
1995;221(4):327e338.
8. Bisch S, Nelson G, Altman A. Impact of nutrition on enhanced recovery after
surgery (ERAS) in gynecologic oncology. Nutrients. 2019;11(5).
9. Svanfeldt M, Thorell A, Nygren J, Ljungqvist O. Postoperative parenteral
nutrition while proactively minimizing insulin resistance. Nutrition.
2006;22(5):457e464.
10. Gustafsson UO, Nygren J, Thorell A, et al. Pre-operative carbohydrate loading
may be used in type 2 diabetes patients. Acta Anaesthesiol Scand. 2008;52(7):
946e951.
11. Yilmaz N, Cekmen N, Bilgin F, Erten E, Ozhan MO, Cosar A. Preoperative car-
bohydrate nutrition reduces postoperative nausea and vomiting compared to
preoperative fasting. J Res Med Sci. 2013;18(10):827e832.
12. Makaryus R, Miller TE, Gan TJ. Current concepts of fluid management in
enhanced recovery pathways. Br J Anaesth. 2018;120(2):376e383.
13. Joshi G, Gandhi K, Shah N, Gadsden J, Corman SL. Peripheral nerve blocks in the
management of postoperative pain: challenges and opportunities. J Clin Anesth.
2016;35:524e529.
14. Guerra L, Philip S, Lax EA, Smithson L, Pearlman R, Damadi A. Transversus
abdominis plane blocks in laparoscopic colorectal surgery: better pain control
and patient outcomes with liposomal bupivacaine than bupivacaine. Am Surg.
2019;85(9):1013e1016.
15. Searle RD, Simpson KH. Chronic post-surgical pain. Cont Educ Anaesth Crit Care
534 T.W. Smith Jr. et al. / The American Journal of Surgery 219 (2020) 530e534
Pain. 2010;10(1):12e14.
16. Wischmeyer PE, Carli F, Evans DC, et al. American society for enhanced re-
covery and perioperative quality initiative joint consensus statement on
nutrition screening and therapy within a surgical enhanced recovery pathway.
Anesth Analg. 2018;126(6):1883e1895.
17. Andersen HK, Lewis SJ, Thomas S. Early enteral nutrition within 24h of colo-
rectal surgery versus later commencement of feeding for postoperative com-
plications. Cochrane Database Syst Rev. 2006;4:CD004080.
18. Yeung SE, Hilkewich L, Gillis C, Heine JA, Fenton TR. Protein intakes are asso-
ciated with reduced length of stay: a comparison between Enhanced Recovery
after Surgery (ERAS) and conventional care after elective colorectal surgery. Am
J Clin Nutr. 2017;106(1):44e51.
19. Cohen R, Gooberman-Hill R. Staff experiences of enhanced recovery after
surgery: systematic review of qualitative studies. BMJ Open. 2019;9(2),
e022259.
20. Trotta M, Ferrari C, D’Alessandro G, Sarra G, Piscitelli G, Marinari GM. Enhanced
recovery after bariatric surgery (ERABS) in a high-volume bariatric center. Surg
Obes Relat Dis. 2019 Oct;15(10):1785e1792. https://doi.org/10.1016/
j.soard.2019.06.038. Epub 2019 Jul 9.
21. Group EC. The impact of enhanced recovery protocol compliance on elective
colorectal cancer resection: results from an international registry. Ann Surg.
2015;261(6):1153e1159.
22. Spanjersberg WR, Reurings J, Keus F, van Laarhoven CJ. Fast track surgery
versus conventional recovery strategies for colorectal surgery. Cochrane
Database Syst Rev. 2011;(2):CD007635.
23. Bond-Smith G, Belgaumkar AP, Davidson BR, Gurusamy KS. Enhanced recovery
protocols for major upper gastrointestinal, liver and pancreatic surgery.
Cochrane Database Syst Rev. 2016;2:CD011382.
24. Vendittoli PA, Pellei K, Desmeules F, et al. Enhanced recovery short-stay hip
and knee joint replacement program improves patients outcomes while
reducing hospital costs. Orthop Traumatol Surg Res. 2019 Nov;105(7):
1237e1243. https://doi.org/10.1016/j.otsr.2019.08.013. Epub 2019 Oct 3.
25. Wick EC, Grant MC, Wu CL. Postoperative multimodal analgesia pain man-
agement with nonopioid analgesics and techniques: a review. JAMA Surg.
2017;152(7):691e697.
26. Kennedy GT, Hill CM, Huang Y, et al. Enhanced recovery after surgery (ERAS)
protocol reduces perioperative narcotic requirement and length of stay in
patients undergoing mastectomy with implant-based reconstruction. Am J
Surg. 2019 Oct 12. https://doi.org/10.1016/j.amjsurg.2019.10.007. pii: S0002-
9610(19)31154-7.
27. Batdorf NJ, Lemaine V, Lovely JK, et al. Enhanced recovery after surgery in
microvascular breast reconstruction. J Plast Reconstr Aesthet Surg. 2015;68(3):
395e402.
28. Warren JA, Stoddard C, Hunter AL, et al. Effect of multimodal analgesia on
opioid use after open ventral hernia repair. J Gastrointest Surg. 2017;21(10):
1692e1699.
29. Bugada D, Bellini V, Fanelli A, et al. Future perspectives of ERAS: a narrative
review on the new applications of an established approach. Surg Res Pract.
2016;2016:3561249.
30. Kahokehr A, Sammour T, Zargar-Shoshtari K, Thompson L, Hill AG. Imple-
mentation of ERAS and how to overcome the barriers. Int J Surg. 2009;7(1):
16e19.
31. Maessen J, Dejong CH, Hausel J, et al. A protocol is not enough to implement an
enhanced recovery programme for colorectal resection. Br J Surg. 2007;94(2):
224e231.
32. Kehlet H, Buchler MW, Beart Jr RW, Billingham RP, Williamson R. Care after
colonic operation-is it evidence-based? Results from a multinational survey in
Europe and the United States. J Am Coll Surg. 2006;202(1):45e54.