Since 2016, more than 800 studies and research articles have been published on the topic of enhanced recovery after surgery (ERAS), a medical focus that has strengthened in recent years. In a recent JAMA article,1 Stavros G. Memtsoudis, MD, PhD, MBA, of the Department of Anesthesiology, Critical Care, and Pain Management at the Hospital for Special Surgery, and colleagues discussed the current lack of sufficient rigorous studies outlining a clear approach for ERAS.

Various protocols have been developed to accelerate postsurgical healing times, including protocols that target processes such as deranged fluid homeostasis and vascular responsiveness, pain pathology, anemia, and systemic inflammatory and catabolic responses of organ systems. A total of 5 components were originally included in the preoperative ERAS patient education, including use of epidural analgesia in open colectomies, avoiding nasogastric tubes, early mobilization and early feeding, and fluid therapy that targets euvolemia.

The majority of scientific publications on ERAS currently lack scientific rigor, Dr Memtsoudis and colleagues argued, considering that most use data from cohort studies instead of from clinical trials. Additionally, many studies tend to report on length of stay rather than on complications, both of which are important to know when optimizing postintervention recovery. “Although it is likely that most patients would prefer a shorter hospital stay,” the authors wrote, “a focus on inpatient [length of stay] ignores the full process of rehabilitation since much of recovery is shifting from hospitals to other acute care settings such as skilled nursing facilities.”

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Evidence-based practice for ERAS is essential, and the medical community cannot rely on the limited evidence that exists. “ERAS was founded as an evidence-based science whose outcomes were patient-centered,” said Dr Memtsoudis in a press release. “It should not be replaced with the empiric addition of poorly-studied interventions and medications whose success is measured with outcomes that are primarily economic in nature.”2

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The researchers concluded that more high-quality research evaluating ERAS protocols is necessary. “Such research will become increasingly important in the context of payment reform in health care as standardization of (surgical and rehabilitation) care in a variety of surgeries holds great promise in improving outcomes while reducing costs.”


  1. Memtsoudis SG, Poeran J, Kehlet H. Enhanced recovery after surgery in the United States: from evidence-based practice to uncertain science? [published online February 28, 2019]. JAMA. doi:10.1001/jama.2019.1070
  2. Hospital for Special Surgery. Enhanced Recovery After Surgery Procedures Need Evidence-Based Practices for Success, HSS Anesthesiologist Advises [news release]. Published March 1, 2019. Accessed March 11, 2019.