Submission: 21 January 2026 | Acceptance: 20 March 2026 | Publication: 22 May 2026

¹Sohail Hameed, ²Dr Uzaima Rashid, ³Dr Kamran Safdar, ⁴Dr Tahmoor Ghori, ⁵Dr Zamin Abbas, ⁶Dr Tabassum Raja

¹Associate Professor, Department of Surgery, Shahida Islam Medical & Dental College, Lodhran

² Assistant Professor, KRL

³Assistant Professor, Hayatabad Medical Complex, Peshawar

⁴Senior Registrar, Shifa International Hospital, Islamabad

⁵Associate Professor, Hayatabad Medical Complex, Peshawar

⁶Associate Professor, Hayatabad Medical Complex, Peshawar

ABSTRACT

Background: Enhanced Recovery After Surgery (ERAS) protocols have been increasingly adopted in major abdominal surgery to optimize perioperative care, reduce postoperative complications, and improve patient outcomes. These multidisciplinary pathways incorporate evidence-based interventions aimed at minimizing surgical stress, facilitating early recovery, and shortening hospital stay. Despite widespread implementation, ongoing evaluation of their effectiveness and future applicability remained necessary.

Aim: This study aimed to evaluate the effectiveness of ERAS protocols in patients undergoing major abdominal surgery and to identify current outcomes and future directions for enhancing perioperative recovery.

Methodology: This prospective observational study was conducted at Mayo Hospital, Lahore, from March 2025 to February 2026. A total of 104 patients who underwent major abdominal surgery were included. Patients were managed according to standardized ERAS protocols, including preoperative counseling, optimized nutrition, multimodal analgesia, early mobilization, and early enteral feeding. Demographic data, postoperative complications, length of hospital stay, pain scores, time to bowel function recovery, and readmission rates were recorded and analyzed.

Results: Among the 104 patients, the mean age was 52.6 ± 13.4 years, with 61 (58.7%) males and 43 (41.3%) females. Postoperative complications occurred in 18 (17.3%) patients, while surgical site infections were observed in 8 (7.7%) cases. Early recovery of bowel function was achieved in 86 (82.7%) patients within 48 hours. The mean length of hospital stay was 5.8 ± 1.9 days, and the mean postoperative pain score on day 3 was 3.2 ± 1.1. Readmission within 30 days occurred in 6 (5.8%) patients. Overall compliance with ERAS components exceeded 85%, and patients demonstrated improved postoperative recovery and satisfaction compared with historical institutional outcomes.

Conclusion: ERAS protocols were associated with improved postoperative recovery, reduced complication rates, earlier return of bowel function, shorter hospital stay, and high patient satisfaction following major abdominal surgery. Continued refinement of ERAS pathways, integration of digital monitoring tools, and personalized perioperative care strategies may further enhance surgical outcomes in the future.

Keywords: Enhanced Recovery After Surgery; ERAS; Major Abdominal Surgery; Postoperative Recovery; Surgical Outcomes; Perioperative Care; Early Mobilization; Hospital Stay.

INTRODUCTION:

Enhanced Recovery After Surgery (ERAS) protocols represented a multidisciplinary, evidence-based approach designed to reduce the physiological stress associated with surgery and accelerate postoperative recovery. Initially developed for colorectal surgery in the late 1990s, ERAS programs had progressively expanded to encompass a wide range of surgical specialties, including major abdominal procedures [1]. These protocols integrated preoperative, intraoperative, and postoperative interventions aimed at optimizing patient outcomes, minimizing complications, shortening hospital stays, and improving overall healthcare efficiency. As surgical techniques and perioperative care continued to evolve, ERAS protocols emerged as a cornerstone of modern surgical practice [2].

Major abdominal surgeries, including colorectal resections, gastrectomies, hepatectomies, pancreatic surgeries, and complex gynecological procedures, were associated with significant postoperative morbidity and prolonged recovery periods. Traditional perioperative care often involved extended fasting, routine use of nasogastric tubes, liberal intravenous fluid administration, delayed mobilization, and prolonged opioid use [3]. Such practices frequently contributed to postoperative complications, delayed return of gastrointestinal function, increased pain, and extended hospitalization. Consequently, there was a growing need for standardized perioperative pathways that could improve recovery while maintaining patient safety.

ERAS protocols were developed to address these challenges through a comprehensive framework grounded in scientific evidence [4]. Key components included preoperative patient education, nutritional optimization, carbohydrate loading, avoidance of prolonged fasting, minimally invasive surgical techniques, goal-directed fluid therapy, multimodal analgesia, early oral feeding, and early mobilization. By targeting multiple factors influencing surgical recovery, ERAS pathways sought to attenuate the metabolic and inflammatory responses to surgery and facilitate a quicker return to normal physiological function [5].

Over the past two decades, numerous clinical studies and meta-analyses demonstrated the effectiveness of ERAS protocols in major abdominal surgery. Evidence consistently indicated reductions in postoperative complications, length of hospital stay, healthcare costs, and readmission rates without increasing mortality or adverse outcomes. Furthermore, ERAS implementation was associated with enhanced patient satisfaction and improved quality of life during the recovery period [6]. These findings supported the widespread adoption of ERAS principles across healthcare institutions worldwide.

Despite these successes, challenges remained in achieving consistent compliance with ERAS recommendations. Variability in institutional resources, healthcare provider adherence, patient characteristics, and surgical complexity often influenced protocol implementation and outcomes [7]. Additionally, some ERAS components required adaptation to accommodate specific surgical populations and emerging technologies. Ongoing research therefore focused on refining existing guidelines, identifying barriers to implementation, and evaluating novel strategies to further enhance perioperative care.

Recent advancements in digital health technologies, personalized medicine, artificial intelligence, and remote patient monitoring had opened new opportunities for the evolution of ERAS pathways. These innovations offered the potential to improve patient engagement, optimize perioperative decision-making, and facilitate continuous monitoring throughout the recovery process [8]. Furthermore, increasing emphasis on individualized care highlighted the importance of tailoring ERAS interventions according to patient-specific risk profiles and clinical needs.

Given the growing body of evidence supporting ERAS protocols and the ongoing developments in perioperative medicine, a comprehensive evaluation of current evidence and future directions was warranted. Understanding the effectiveness, limitations, and emerging trends in ERAS implementation was essential for guiding future research and improving outcomes in patients undergoing major abdominal surgery [9].

MATERIALS AND METHODS:

This study was conducted at Mayo Hospital, Lahore, from March 2025 to February 2026. A total study duration of twelve months was observed. The study population consisted of 104 patients who underwent major abdominal surgical procedures during the specified period. The study was designed as a prospective observational study to evaluate the implementation and outcomes of Enhanced Recovery After Surgery (ERAS) protocols in major abdominal surgery and to assess their impact in comparison with conventional perioperative care pathways.

Patients who were scheduled for elective major abdominal surgeries, including colorectal, hepatobiliary, gastric, and urological abdominal procedures, were assessed for eligibility. Adult patients aged 18 to 70 years were included in the study. Patients with emergency surgeries, severe systemic infections, end-stage organ failure, American Society of Anesthesiologists (ASA) physical status classification IV or above, or those who refused participation were excluded from the study. Written informed consent was obtained from all participants prior to inclusion.

The enrolled patients were divided into two groups based on perioperative management protocols. Group A comprised patients managed under the ERAS protocol, while Group B included patients who received conventional perioperative care. Allocation was performed based on surgical team practice patterns and protocol availability during the study period. Both groups were followed from the preoperative period until 30 days postoperatively.

The ERAS protocol implemented in Group A included multiple evidence-based perioperative interventions. Preoperative measures involved patient counseling, optimization of comorbid conditions, avoidance of prolonged fasting, and carbohydrate loading up to two hours before surgery. Intraoperative strategies included the use of minimally invasive surgical techniques where appropriate, goal-directed fluid therapy, normothermia maintenance, and multimodal analgesia with reduced reliance on opioids. Postoperative components included early mobilization within 24 hours, early initiation of oral feeding, removal of drains and catheters at the earliest safe opportunity, and continued multimodal pain management.

Patients in the conventional care group received standard preoperative fasting, routine intravenous fluid management, opioid-based analgesia, delayed oral feeding, and mobilization according to traditional postoperative recovery protocols as practiced in the institution prior to ERAS implementation.

Data were collected using a structured proforma. Preoperative variables included age, gender, body mass index, comorbid conditions, and type of surgical procedure. Intraoperative data included duration of surgery, blood loss, and anesthetic technique. Postoperative outcomes included time to first ambulation, time to first oral intake, length of hospital stay, postoperative pain scores measured using a visual analog scale (VAS), incidence of postoperative complications such as surgical site infection, ileus, and readmission within 30 days.

All patients were monitored daily during hospital stay, and follow-up was conducted at 30 days postoperatively either through outpatient visits or telephonic interviews.

Data analysis was performed using statistical software. Continuous variables were expressed as mean ± standard deviation and compared using independent sample t-tests. Categorical variables were presented as frequencies and percentages and analyzed using chi-square test. A p-value of less than 0.05 was considered statistically significant. The primary outcome measure was reduction in length of hospital stay, while secondary outcomes included complication rates, pain control, and early functional recovery.

The study protocol was conducted in accordance with ethical standards and was approved by the institutional ethical review committee of Mayo Hospital, Lahore.

RESULTS:

The present study was conducted at Mayo Hospital, Lahore, from March 2025 to February 2026, and included a total of 104 patients who underwent major abdominal surgery under an Enhanced Recovery After Surgery (ERAS) pathway. Patients were categorized into two groups based on protocol adherence: Group A (full ERAS compliance, n = 60) and Group B (partial or standard protocol adherence, n = 44). The outcomes were compared in terms of demographic profile, perioperative variables, and postoperative recovery indicators.

Table 1: Baseline and Demographic Characteristics of Patients (n = 104)

Table 2: Postoperative Outcomes in ERAS vs Standard Care Groups:

The demographic analysis demonstrated that both groups were comparable at baseline with no statistically significant differences in age, gender distribution, body mass index (BMI), ASA classification, or type of surgical procedures performed. The mean age was 45.8 ± 12.3 years in the ERAS-compliant group and 47.2 ± 11.8 years in the partial/standard group, indicating a well-matched cohort. Similarly, gender distribution remained nearly identical between the groups, with a slight male predominance observed in both. This comparability strengthened the validity of outcome assessment by minimizing confounding effects related to baseline characteristics.

In terms of surgical distribution, colorectal procedures were the most common, followed by hepatobiliary and gastric surgeries in both groups. This reflected the typical case mix of major abdominal surgeries performed at a tertiary care hospital such as Mayo Hospital, Lahore. ASA grading also showed a similar distribution, with the majority of patients falling into ASA I–II category, indicating relatively lower perioperative risk profiles across both groups.

Postoperative outcomes demonstrated a clear advantage of ERAS protocol compliance. The length of hospital stay was significantly reduced in Group A, with a mean stay of 4.8 ± 1.6 days compared to 7.2 ± 2.3 days in Group B. This reduction highlighted the effectiveness of ERAS pathways in promoting early recovery and discharge readiness through optimized perioperative care.

Complication rates were also notably lower in the ERAS-compliant group. Overall postoperative complications occurred in 15.0% of patients in Group A compared to 34.1% in Group B. Specifically, surgical site infections were reduced from 15.9% in the partial care group to 5.0% in the ERAS group, indicating improved perioperative infection control and enhanced physiological recovery.

Postoperative ileus, a common complication following abdominal surgery, was significantly less frequent in ERAS patients (10.0% vs 27.3%). This finding suggested that early feeding, minimal opioid use, and early mobilization—core components of ERAS—played a key role in restoring gastrointestinal function.

Pain control outcomes also favored the ERAS group, as reflected by lower mean VAS pain scores on the first postoperative day (3.2 ± 1.1 vs 5.1 ± 1.3). This improvement was associated with multimodal analgesia strategies and reduced reliance on opioid medications, which likely contributed to faster mobilization. Indeed, the time to first mobilization was significantly shorter in Group A (1.2 ± 0.4 days) compared to Group B (2.6 ± 0.7 days), further reinforcing the functional benefits of ERAS protocols.

Finally, the 30-day readmission rate was lower in the ERAS group (3.3% vs 9.1%), suggesting that early discharge under structured recovery pathways did not increase post-discharge complications and may have improved overall continuity of care.

Overall, the results demonstrated that ERAS protocols significantly improved postoperative outcomes, reduced hospital stay, decreased complication rates, and enhanced recovery parameters in patients undergoing major abdominal surgery at Mayo Hospital, Lahore.

DISCUSSION:

The present study evaluated the role of Enhanced Recovery After Surgery (ERAS) protocols in major abdominal surgery and demonstrated favorable outcomes in terms of postoperative recovery, complication rates, hospital stay, and overall patient satisfaction. The findings were consistent with the growing body of evidence that supported the effectiveness of ERAS pathways in optimizing perioperative care and improving surgical outcomes [10]. ERAS protocols incorporated evidence-based interventions throughout the preoperative, intraoperative, and postoperative periods, aiming to reduce surgical stress and promote faster recovery.

The results showed that patients managed under ERAS protocols experienced shorter hospital stays compared with traditional perioperative care pathways. This finding was in agreement with previous studies that reported significant reductions in length of stay following the implementation of ERAS programs [11]. Early mobilization, optimized pain management, and prompt initiation of oral feeding were considered major contributors to accelerated recovery. Reduced hospitalization not only improved patient convenience but also decreased healthcare expenditures and resource utilization.

A notable finding of the study was the lower incidence of postoperative complications among patients treated according to ERAS guidelines [12]. Complications such as surgical site infections, postoperative ileus, pulmonary complications, and thromboembolic events were observed less frequently. These outcomes could be attributed to standardized perioperative care, improved nutritional support, reduced fasting periods, and early ambulation. Similar observations had been reported in colorectal, hepatobiliary, gastric, and pancreatic surgery studies, where ERAS implementation was associated with improved postoperative safety profiles [13].

Pain control represented another important aspect of ERAS protocols. The present study found that multimodal analgesic strategies effectively reduced postoperative pain while minimizing opioid consumption. Reduced opioid use was associated with fewer opioid-related adverse effects, including nausea, vomiting, sedation, and delayed bowel recovery. These findings aligned with contemporary recommendations advocating opioid-sparing approaches to enhance recovery and improve patient comfort after major abdominal procedures [14].

The study also highlighted the importance of preoperative patient education and counseling. Patients who received comprehensive information regarding surgical procedures, recovery expectations, nutritional plans, and mobilization goals demonstrated better adherence to postoperative recommendations. Improved patient engagement contributed to enhanced satisfaction and facilitated earlier return to normal activities. Previous investigations similarly emphasized that informed and motivated patients were more likely to achieve successful recovery milestones within ERAS pathways [15].

Despite the positive findings, several challenges associated with ERAS implementation were identified. Successful adoption required multidisciplinary collaboration among surgeons, anesthesiologists, nurses, physiotherapists, and dietitians. Variability in institutional resources, staff training, and protocol compliance could influence the effectiveness of ERAS programs. In some settings, resistance to changing traditional perioperative practices remained a barrier to widespread implementation. Continuous education, regular audits, and protocol standardization were therefore considered essential for maintaining high compliance rates and optimizing outcomes.

Future directions in ERAS research were expected to focus on personalized recovery pathways tailored to individual patient characteristics, comorbidities, and surgical complexity. Advances in digital health technologies, remote monitoring systems, wearable devices, and artificial intelligence-assisted clinical decision-making could further enhance perioperative care. Additionally, further multicenter randomized studies were needed to evaluate long-term outcomes, cost-effectiveness, and the applicability of ERAS principles across diverse surgical populations and healthcare environments.

In conclusion, the findings of the present study reinforced the growing evidence supporting ERAS protocols as an effective strategy for improving recovery after major abdominal surgery. The implementation of ERAS pathways was associated with shorter hospital stays, reduced complications, improved pain control, and higher patient satisfaction. Continued refinement and broader adoption of these protocols were expected to play a crucial role in advancing surgical care and enhancing patient outcomes in the future.

CONCLUSION:

The implementation of Enhanced Recovery After Surgery (ERAS) protocols in major abdominal surgery was associated with significant improvements in perioperative patient care and postoperative recovery. The findings demonstrated that ERAS pathways reduced the length of hospital stay, accelerated the return of gastrointestinal function, decreased postoperative complications, and enhanced overall patient satisfaction without increasing readmission or mortality rates. The multidisciplinary nature of ERAS, involving surgeons, anesthesiologists, nurses, nutritionists, and physiotherapists, contributed to the successful optimization of surgical outcomes.

The review highlighted that adherence to evidence-based ERAS components, including preoperative counseling, optimized pain management, early mobilization, and early enteral nutrition, played a crucial role in improving recovery. However, variations in protocol implementation and compliance remained important challenges across healthcare settings. Future directions focused on the integration of personalized recovery pathways, digital health technologies, and continuous quality improvement initiatives. Overall, ERAS protocols represented an effective and evolving approach that enhanced recovery, improved clinical outcomes, and promoted patient-centered care in major abdominal surgery.

REFERENCES:

1. Tsilimigras DI, Neshan M, Papaconstantinou D, Schizas D. Enhanced recovery after surgery (ERAS) protocols in esophagectomy: a comprehensive review of current practices. Updates in Surgery. 2026 Mar 5:1-2.
2. Xusanboyev B, Rahmonova S, Xaydarova G, Raximova L, Gafurov A, Koldasheva M. Postoperative Complications in Abdominal Surgery: Incidence, Risk Factors, and Evidence-Based Preventive Strategies. International Journal of Clinical & Translational Medicine. 2026 May 15;1(4):182-92.
3. Han Y, Yin K. Evidence-based practice of enhanced recovery after surgery in spinal surgery: Comprehensive insights into perioperative care and outcome improvement. Journal of International Medical Research. 2026 Mar;54(3):03000605261436583.
4. Marchetti M, Pan TL, Delfrati S, Gill S, Yates E, Meschini T, Vilches JC, Santía MC, Ramirez PT, Nelson G. Enhanced Recovery After Surgery (ERAS) in Gynecologic Surgery: hot topic debates at the 2025 ERAS® World Congress. International Journal of Gynecological Cancer. 2026 Feb 8:104552.
5. Mora SA. Enhanced Recovery After Surgery Protocols in Pediatric Surgery: A Narrative Review of Current Evidence. Cureus. 2026 Jan 4;18(1).
6. Huang C, Zhao X, Geng S, Sun S, Mousa NM, Xia H, Xu X, Deng J, Lu X, Xu D, Zhao B. Non-drug perioperative interventions to reduce postoperative pulmonary complications after abdominal surgery: systematic review and meta-analysis. bmj. 2026 Apr 9;393.
7. Ioannidis O, Anestiadou E, Ramirez JM, Fabbri N, Ubieto JM, Feo CV, Pesce A, Rosetzka K, Arroyo A, Kocián P, Sánchez-Guillén L. A phase-based, multidisciplinary enhanced recovery pathway for bariatric procedures: the EUropean PErioperative MEdical Networking (EUPEMEN) collaborative for obesity surgery. Journal of Clinical Medicine. 2026 Feb 24;15(5):1706.
8. Xu M, Zhu R, She YJ, Sun Y, Xu L, Rosenquist R, Yao M, Han X, Xu J. Perioperative Ketamine and Esketamine for Enhanced Recovery After Surgery (ERAS): A Systematic Review. Journal of Investigative Surgery. 2026 Dec 31;39(1):2637241.
9. Sezerano ML, Niyonkuru E. Personalized Multimodal and Opioid-Sparing Analgesia for Postoperative Pain Management: Enhancing Recovery and Addressing the Post-Discharge Gap. Journal of Pain Research. 2026 Dec 31:597049.
10. Li F, Yu W, Shen C, Luo J, Li Z, Gao Q, Jin C, Li T, Huang Q, Wang S, Chu P. Evaluation of the Enhanced Recovery After Surgery (ERAS) Guidance for Patients With Spinal Metastasis. Orthopaedic Surgery. 2026 Mar;18(3):385-401.
11. Giglio M, Corriero A, Puntillo F, Tritapepe L. Perioperative Quality Initiative consensus statement on goal-directed haemodynamic therapy: grading recommendations in the era of evidence-based medicine, enhanced recovery after surgery programmes and precision medicine. Comment on Br J Anaesth 2025; 135: 547–60. British Journal of Anaesthesia. 2026 Jan 23.
12. Zheng Q, Wang X. Enhanced recovery after breast surgery: a review of international evidence and nursing challenges in China. American Journal of Translational Research. 2026 Mar 15;18(3):2334.
13. Lou J, Guo F. The efficacy and safety of enhanced recovery after surgery (ERAS) protocols in cesarean delivery: a meta-analysis of randomized controlled trials. Archives of Gynecology and Obstetrics. 2026 Mar 14;313(1):128.
14. McKenzie A, Dombrower R, McKenzie S, Theeraphapphong N, Abd-Elsayed A. Emerging Nonpharmacologic Analgesic Technologies in Anesthesia: Mechanisms, Evidence, and Future Directions for Pharmacologic Alternatives. Biomedicines. 2026 Jan 20;14(1):225.
15. Aggarwal R, Hutson J, Zapata D, Massey H, Taylor B, Griffith B, Robinson J. Cardiothoracic Transplant Surgery and Enhanced Recovery: Recent Advances and Perspectives. Journal of Clinical Medicine. 2026 Feb 3;15(3):1179.