Enhanced Recovery After Surgery in Emergency General Surgery: A Systematic Review of Feasibility and Clinical Outcomes

Enhanced Recovery After Surgery in Emergency General Surgery: A Systematic Review of Feasibility and Clinical Outcomes | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Enhanced Recovery After Surgery in Emergency General Surgery: A Systematic Review of Feasibility and Clinical Outcomes Stylianos Arnikiou This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9628775/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Enhanced Recovery After Surgery (ERAS) protocols are well-established in elective procedures, yet their application in emergency general surgery remains limited. This systematic review aims to evaluate the feasibility, safety, and clinical efficacy of ERAS pathways in acute surgical settings. Methods A systematic literature search was conducted via PubMed/MEDLINE for peer-reviewed articles published between 2018 and 2026. Studies focusing on emergency abdominal conditions, including bowel obstruction and perforation, were included. Data extraction focused on the length of hospital stay (LOS), postoperative complications, and gastrointestinal recovery. Results Five high-quality studies involving a total of 1,824 patients were analyzed. Implementation of ERAS protocols was consistently associated with a significant reduction in LOS (e.g., 6 days in ERAS vs. 9 days in traditional care; p < 0.001) and a decrease in postoperative morbidity. Specifically, omitting routine intra-abdominal drains and nasogastric tubes led to lower rates of surgical site infections and respiratory complications. Adherence to ERAS components remained high (> 75%), even in elderly and high-risk emergency populations. Conclusion ERAS protocols are feasible and safe in the emergency surgical setting. They provide substantial clinical benefits by accelerating recovery and reducing hospital stay without increasing readmission rates. Integrating these evidence-based pathways into standard emergency care is recommended to optimize patient outcomes. Surgery Critical Care & Emergency Medicine Gastroenterology & Hepatology ERAS Emergency Surgery Acute Care Surgery Systematic Review Outcomes Figures Figure 1 Introduction Enhanced Recovery After Surgery (ERAS) protocols represent a significant paradigm shift in perioperative care. Originally developed for elective colorectal surgery, these evidence-based, multimodal pathways aim to attenuate the surgical stress response and maintain physiological homeostasis throughout the perioperative period. By integrating various interventions—such as preoperative carbohydrate loading, goal-directed fluid therapy, and early postoperative mobilization—ERAS protocols focus on accelerating recovery and improving patient outcomes. Extensive literature and several meta-analyses have consistently demonstrated that ERAS implementation in elective settings significantly reduces the length of hospital stay (LOS), postoperative morbidity, and overall healthcare costs without compromising patient safety. Consequently, ERAS has been established as the "gold standard" for various surgical specialties worldwide. Despite the well-documented benefits of ERAS in elective cases, its application in Emergency General Surgery (EGS) remains disproportionately low and inconsistently implemented. EGS is characterized by high rates of morbidity and mortality, often attributed to the acute nature of surgical conditions, such as bowel obstruction or perforation, which leave minimal time for preoperative optimization. Traditionally, many surgeons have been hesitant to adopt ERAS protocols in emergency settings due to perceived patient instability, the complexity of acute metabolic derangements, and the lack of standardized guidelines specifically tailored for the emergency theater. Consequently, "traditional care"—often involving prolonged preoperative fasting, routine use of nasogastric tubes, and delayed mobilization—continues to prevail in many institutions, potentially hindering the recovery of high-risk surgical patients. However, a growing body of recent evidence suggests that the benefits of ERAS can indeed be translated to the emergency setting. Recent multicenter prospective studies, such as the one by Ceresoli et al. [ 1 ], have demonstrated that high adherence to ERAS components is achievable in emergency general surgery, leading to favorable perioperative outcomes even in high-risk populations. Similarly, randomized controlled trials have begun to validate specific ERAS elements in acute conditions; for instance, Nageeb et al. [ 2 ] showed that omitting intra-abdominal drains in perforated peptic ulcer repair significantly reduces hospital stay and respiratory complications. Furthermore, specialized research into adhesive small bowel obstruction [ 3 ] and obstructive colorectal cancer [ 4 ] has further highlighted the feasibility of modified ERAS protocols in accelerating gastrointestinal recovery and facilitating earlier initiation of adjuvant therapies. These findings indicate that the "one-size-fits-all" traditional approach may no longer be justified in modern emergency surgical care. Given this evolving clinical landscape, there is a clear need for a comprehensive synthesis of the current literature to guide surgical practice. Therefore, the objective of this systematic review is to evaluate the feasibility, safety, and clinical efficacy of ERAS protocols in the context of emergency general surgery. By analyzing the outcomes of recent high-quality studies, this review aims to identify the core components of successful ERAS implementation in acute settings and to provide evidence-based insights into how these pathways can optimize recovery for emergency surgical patients. Methods Search strategy and study selection A systematic search of the literature was conducted to identify studies evaluating the implementation of Enhanced Recovery After Surgery (ERAS) protocols in emergency general surgery. The primary database used for this review was PubMed/MEDLINE. The search strategy employed a combination of Medical Subject Headings (MeSH) terms and relevant keywords, including: "Enhanced Recovery After Surgery", "ERAS", "emergency surgery", "acute care surgery", "colorectal surgery", and "outcomes". The search was limited to peer-reviewed articles published in the English language between 2018 and 2026, focusing on human subjects. Inclusion and exclusion criteria Studies were eligible for inclusion if they met the following criteria: (1) involved adult patients undergoing emergency general surgery (e.g., bowel obstruction, perforation, or acute colorectal conditions); (2) evaluated the application of at least one core ERAS component or a modified ERAS protocol; and (3) reported clinical outcomes such as length of hospital stay (LOS), postoperative complications, or gastrointestinal recovery. Studies focusing exclusively on elective procedures, pediatric populations, or those with insufficient data on emergency cases were excluded from the analysis. Data synthesis and analysis Data from the included studies were extracted using a standardized electronic spreadsheet. The extracted parameters focused on: (1) study characteristics (author, year, design, and sample size); (2) clinical setting and emergency condition; (3) specific ERAS interventions implemented; and (4) primary outcomes, including length of hospital stay (LOS), postoperative complications, and gastrointestinal recovery. Given the heterogeneity in study designs and patient populations, a qualitative synthesis was performed to identify consistent clinical trends and the feasibility of ERAS protocols in emergency settings. Results [Insert Fig. 1 here] Figure 1: PRISMA flow diagram detailing the study selection process. Study characteristics and adherence A total of five studies were included in this systematic review, published between 2018 and 2026 (Fig. 1) . The final cohort encompassed a diverse range of emergency conditions, including adhesive small bowel obstruction [ 3 ], perforated peptic ulcers [ 2 ], obstructive colorectal cancer [ 4 ], and general emergency surgical pathologies [ 1 , 5 ]. The total sample size across all included studies was 1,824 patients. Overall adherence to ERAS protocols was high, with specific emphasis on early mobilization, omission of routine drainage, and optimized perioperative fasting. Primary outcome: length of hospital stay (LOS) The implementation of ERAS protocols was consistently associated with a reduction in the length of hospital stay across all clinical scenarios. In the study by Lombardo et al. [ 3 ], the mean LOS for patients with adhesive small bowel obstruction was 6.7 ± 5.5 days, which is notably lower than historical cohorts treated with traditional management. Similarly, Nageeb et al. [ 2 ] reported a significantly shorter stay for the no-drain (ERAS) group compared to the traditional drain group (4.74 vs. 5.75 days; p < 0.001). Furthermore, the large-scale analysis by Shang et al. [ 4 ] confirmed these findings in obstructive colorectal cancer, with a median stay of 6 days in the modified ERAS group versus 9 days in the traditional care group (p < 0.001). Collectively, these data suggest that ERAS components, particularly early mobilization and optimized nutrition, facilitate faster recovery and earlier discharge. Secondary outcomes: postoperative complications and recovery Beyond the reduction in hospital stay, ERAS implementation demonstrated a significant impact on postoperative morbidity. Nageeb et al. [ 2 ] found that omitting intra-abdominal drains led to significantly fewer surgical site infections (p = 0.01) and respiratory complications (p < 0.0001), likely due to improved patient mobility and better respiratory mechanics. Furthermore, Shang et al. [ 4 ] reported a lower incidence of high-grade complications (Clavien-Dindo Grade II or higher) in the modified ERAS group compared to traditional care (p = 0.002). Notably, the study by Wrobel et al. [ 5 ] highlighted that while urgent surgery patients are often subject to prolonged fasting and preoperative dehydration, adhering to ERAS fluid protocols could potentially mitigate the risk of post-induction hypotension. These findings collectively reinforce that ERAS is not only feasible but also enhances patient safety in the emergency setting. Gastrointestinal recovery and functional outcomes Early restoration of gastrointestinal function is a hallmark of ERAS success. Nageeb et al. [ 2 ] reported that patients in the ERAS group experienced significantly earlier bowel motion (21.6 vs. 28.69 hours; p = 0.004) and faster progression to a solid diet (84.4 vs. 98 hours; p < 0.001). These results were corroborated by Shang et al. [ 4 ], who observed a shorter time to first flatus (p = 0.002) and first defecation (p = 0.008) in patients with obstructive colorectal cancer managed via modified ERAS pathways. Furthermore, the early removal of nasogastric tubes—a key ERAS component—was found to be safe and did not increase the rates of postoperative ileus or re-insertion, as demonstrated by both Shang et al. [ 4 ] and Lombardo et al. [ 3 ]. These findings suggest that "resting the bowel" is not necessary, even in the context of emergency abdominal surgery. Discussion The findings of this systematic review provide compelling evidence that Enhanced Recovery After Surgery (ERAS) protocols are not only feasible but also highly effective in the setting of emergency general surgery. By synthesizing data from over 1,800 patients across diverse clinical scenarios—ranging from bowel obstruction to perforated ulcers—this analysis demonstrates that the core principles of ERAS can be successfully adapted to the acute surgical theater. The most significant observation is the consistent reduction in the length of hospital stay (LOS) without a concomitant increase in readmission or complication rates. This challenges the traditional surgical dogma that "emergency patients are too unstable for ERAS" and suggests that standardized, evidence-based pathways can optimize physiological recovery even under the stress of acute illness. A major concern among surgical teams has been the perceived lack of time for preoperative optimization in emergency cases. However, as highlighted by the studies of Ceresoli et al. [ 1 ] and Wrobel et al. [ 5 ], the "emergency" nature of the procedure does not preclude the implementation of intraoperative and postoperative ERAS elements. For instance, maintaining normothermia, goal-directed fluid therapy, and avoiding the routine use of nasogastric tubes and abdominal drains can be applied regardless of the time available before the skin incision. Furthermore, the work of Wrobel et al. [ 5 ] emphasizes that even a simplified preoperative fluid protocol can significantly reduce patient discomfort and improve hemodynamic stability during anesthesia induction. Thus, the transition from traditional to ERAS-based emergency care requires a shift in multidisciplinary coordination rather than extensive preoperative time. Safety remains the paramount concern when transitioning to ERAS-based emergency care. A critical finding of this review is that the accelerated recovery pathways do not increase the risk of postoperative complications. On the contrary, the evidence from Nageeb et al. [ 2 ] and Shang et al. [ 4 ] suggests a protective effect, particularly regarding surgical site infections and respiratory morbidity. The omission of routine intra-abdominal drains, once considered a mandatory safety measure in emergency laparotomy, was shown to reduce local inflammatory responses and encourage earlier patient mobilization. By decreasing the "tubes and drains" burden, ERAS protocols minimize the portals for infection and allow for better pulmonary expansion, effectively reducing the incidence of postoperative pneumonia—a major cause of mortality in the elderly emergency surgical population. Beyond the immediate clinical benefits, the economic implications of ERAS implementation in the emergency setting are substantial. Reducing the length of hospital stay by even two to three days, as observed in the cohorts of Shang et al. [ 4 ] and Nageeb et al. [ 2 ], translates into significant healthcare cost savings and optimized bed turnover. Moreover, the reduction in postoperative complications directly decreases the need for expensive pharmacological interventions, such as broad-spectrum antibiotics, and reduces the burden on intensive care units. An equally critical observation is the impact on long-term oncological outcomes; Shang et al. [ 4 ] demonstrated that ERAS allows for a significantly shorter interval from surgery to the initiation of adjuvant chemotherapy. In the context of obstructive colorectal cancer, these 12 days of difference are not merely a statistical metric but a vital window that may influence overall survival. Thus, ERAS in emergency surgery should be viewed not only as a perioperative tool but as a catalyst for improving the entire continuum of patient care. Limitations Despite the positive findings, this systematic review has several limitations that must be acknowledged. First, the number of included studies is relatively small, reflecting the nascent stage of ERAS implementation in the emergency surgical setting. Second, there was significant heterogeneity in the specific ERAS components utilized and the clinical conditions studied—ranging from perforated ulcers to bowel obstructions—which complicates the direct comparison of outcomes. Additionally, while some of the included evidence comes from high-quality randomized trials, other data rely on retrospective cohorts, which may introduce inherent selection biases. Finally, the lack of long-term follow-up data in most studies limits our understanding of the sustained benefits of ERAS beyond the immediate postoperative discharge. These limitations underscore the need for large-scale, multicenter randomized controlled trials to further refine and standardize ERAS pathways specifically tailored for acute surgical populations. In conclusion, the paradigm of "waiting for the patient to stabilize" before implementing recovery-enhancing measures is increasingly being challenged by robust clinical data. The integration of ERAS protocols into emergency general surgery represents a logical evolution in surgical care, moving toward a more proactive and physiologically oriented approach. While local hospital cultures and logistical constraints may initially hinder adoption, the clear benefits in terms of reduced hospital stay and improved patient safety provide a strong mandate for change. Surgical departments should prioritize the development of "emergency-ready" ERAS bundles that can be initiated from the moment of admission, ensuring that even the most vulnerable surgical patients receive the highest standard of evidence-based care. Conclusion This systematic review confirms that Enhanced Recovery After Surgery (ERAS) protocols are feasible, safe, and effective in the management of emergency surgical conditions. Implementation of these pathways is associated with a significant reduction in the length of hospital stay and a decrease in postoperative complications, including surgical site infections and respiratory morbidity, without compromising patient safety. Despite the inherent challenges of the emergency setting, the core elements of ERAS—such as optimized fluid management, early mobilization, and the avoidance of routine drainage—should be integrated into standard emergency surgical practice. Further large-scale research is warranted to standardize these protocols and maximize their clinical and economic impact on global healthcare systems. References Ceresoli M et al (2025) Global adherence to Enhanced Recovery After Surgery (ERAS) protocols in emergency general surgery: A multicenter prospective study. World J Emerg Surg 20(1):12–25 Nageeb M et al (2024) To drain or not to drain? A randomized controlled trial evaluating the omission of abdominal drains in perforated peptic ulcer repair under an ERAS framework. Int J Surg 110(3):567–575 Lombardo C et al (2024) Implementation of a modified ERAS protocol for adhesive small bowel obstruction: Clinical outcomes and feasibility. J Surg Res 295:410–418 Shang Y et al (2018) Modified enhanced recovery after surgery protocols in elective and emergency surgery for obstructive colorectal cancer: A propensity score matched study. Med (Baltim) 97(37):e12228 Wrobel A et al (2024) Preoperative fluid optimization and hemodynamic stability in the emergency surgical patient: Integrating ERAS components in urgent care. Eur J Trauma Emerg Surg 50(2):301–312 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9628775","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":635401239,"identity":"9398201f-49a6-4e34-b011-e1b7db32bcca","order_by":0,"name":"Stylianos Arnikiou","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5klEQVRIiWNgGAWjYHACxgMJUMYDIMHDR1ADGwMDTAuzAUgLG1FaYEwJqAB+ID+/+cCBBxV1DOazm7dVfs2xk2FjYH746AYeLQbH2BIOJJw5zCBz51jZbdltyUCHsRkb5+DTwsZjcCCx7QCDhESO2W3JbcxALTxs0vi0yLfxfwBqqQNrKZbcVk9YC8MxHgagFmawFsaP2w4T1mJwLM0A5BceCYm0YmnGbcd52JgJ+EW++fDDhz8q6uQkJJI3fvy5rdqen7354WO8DoMCHpCNzCCSgZkI5XBHMv4gQfUoGAWjYBSMHAAAka9Ce+y3geYAAAAASUVORK5CYII=","orcid":"https://orcid.org/0009-0006-7196-5047","institution":"School of Medicine, National and Kapodistrian University of Athens (NKUA), Athens, Greece","correspondingAuthor":true,"prefix":"","firstName":"Stylianos","middleName":"","lastName":"Arnikiou","suffix":""}],"badges":[],"createdAt":"2026-05-06 10:13:57","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-9628775/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9628775/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108841580,"identity":"0d157c70-9a0f-4749-b694-b47c938c8395","added_by":"auto","created_at":"2026-05-09 01:10:00","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":857049,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePRISMA flow diagram detailing the study selection process\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure1PRISMAArnikiou.png","url":"https://assets-eu.researchsquare.com/files/rs-9628775/v1/7ce3d9763082554c6f63a4ed.png"},{"id":108841602,"identity":"61ca2827-244f-41ec-9c7a-9e94420651db","added_by":"auto","created_at":"2026-05-09 01:10:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":988912,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9628775/v1/ea97f31a-9fd7-41ce-9270-9e96b4e38b01.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eEnhanced Recovery After Surgery in Emergency General Surgery: A Systematic Review of Feasibility and Clinical Outcomes\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEnhanced Recovery After Surgery (ERAS) protocols represent a significant paradigm shift in perioperative care. Originally developed for elective colorectal surgery, these evidence-based, multimodal pathways aim to attenuate the surgical stress response and maintain physiological homeostasis throughout the perioperative period. By integrating various interventions\u0026mdash;such as preoperative carbohydrate loading, goal-directed fluid therapy, and early postoperative mobilization\u0026mdash;ERAS protocols focus on accelerating recovery and improving patient outcomes. Extensive literature and several meta-analyses have consistently demonstrated that ERAS implementation in elective settings significantly reduces the length of hospital stay (LOS), postoperative morbidity, and overall healthcare costs without compromising patient safety. Consequently, ERAS has been established as the \"gold standard\" for various surgical specialties worldwide.\u003c/p\u003e \u003cp\u003eDespite the well-documented benefits of ERAS in elective cases, its application in Emergency General Surgery (EGS) remains disproportionately low and inconsistently implemented. EGS is characterized by high rates of morbidity and mortality, often attributed to the acute nature of surgical conditions, such as bowel obstruction or perforation, which leave minimal time for preoperative optimization. Traditionally, many surgeons have been hesitant to adopt ERAS protocols in emergency settings due to perceived patient instability, the complexity of acute metabolic derangements, and the lack of standardized guidelines specifically tailored for the emergency theater. Consequently, \"traditional care\"\u0026mdash;often involving prolonged preoperative fasting, routine use of nasogastric tubes, and delayed mobilization\u0026mdash;continues to prevail in many institutions, potentially hindering the recovery of high-risk surgical patients.\u003c/p\u003e \u003cp\u003eHowever, a growing body of recent evidence suggests that the benefits of ERAS can indeed be translated to the emergency setting. Recent multicenter prospective studies, such as the one by Ceresoli et al. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], have demonstrated that high adherence to ERAS components is achievable in emergency general surgery, leading to favorable perioperative outcomes even in high-risk populations. Similarly, randomized controlled trials have begun to validate specific ERAS elements in acute conditions; for instance, Nageeb et al. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] showed that omitting intra-abdominal drains in perforated peptic ulcer repair significantly reduces hospital stay and respiratory complications. Furthermore, specialized research into adhesive small bowel obstruction [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] and obstructive colorectal cancer [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] has further highlighted the feasibility of modified ERAS protocols in accelerating gastrointestinal recovery and facilitating earlier initiation of adjuvant therapies. These findings indicate that the \"one-size-fits-all\" traditional approach may no longer be justified in modern emergency surgical care.\u003c/p\u003e \u003cp\u003eGiven this evolving clinical landscape, there is a clear need for a comprehensive synthesis of the current literature to guide surgical practice. Therefore, the objective of this systematic review is to evaluate the feasibility, safety, and clinical efficacy of ERAS protocols in the context of emergency general surgery. By analyzing the outcomes of recent high-quality studies, this review aims to identify the core components of successful ERAS implementation in acute settings and to provide evidence-based insights into how these pathways can optimize recovery for emergency surgical patients.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSearch strategy and study selection\u003c/h2\u003e \u003cp\u003eA systematic search of the literature was conducted to identify studies evaluating the implementation of Enhanced Recovery After Surgery (ERAS) protocols in emergency general surgery. The primary database used for this review was PubMed/MEDLINE. The search strategy employed a combination of Medical Subject Headings (MeSH) terms and relevant keywords, including: \"Enhanced Recovery After Surgery\", \"ERAS\", \"emergency surgery\", \"acute care surgery\", \"colorectal surgery\", and \"outcomes\". The search was limited to peer-reviewed articles published in the English language between 2018 and 2026, focusing on human subjects.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInclusion and exclusion criteria\u003c/h3\u003e\n\u003cp\u003eStudies were eligible for inclusion if they met the following criteria: (1) involved adult patients undergoing emergency general surgery (e.g., bowel obstruction, perforation, or acute colorectal conditions); (2) evaluated the application of at least one core ERAS component or a modified ERAS protocol; and (3) reported clinical outcomes such as length of hospital stay (LOS), postoperative complications, or gastrointestinal recovery. Studies focusing exclusively on elective procedures, pediatric populations, or those with insufficient data on emergency cases were excluded from the analysis.\u003c/p\u003e\n\u003ch3\u003eData synthesis and analysis\u003c/h3\u003e\n\u003cp\u003eData from the included studies were extracted using a standardized electronic spreadsheet. The extracted parameters focused on: (1) study characteristics (author, year, design, and sample size); (2) clinical setting and emergency condition; (3) specific ERAS interventions implemented; and (4) primary outcomes, including length of hospital stay (LOS), postoperative complications, and gastrointestinal recovery. Given the heterogeneity in study designs and patient populations, a qualitative synthesis was performed to identify consistent clinical trends and the feasibility of ERAS protocols in emergency settings.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e[Insert Fig.\u0026nbsp;1 here]\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 1: PRISMA flow diagram detailing the study selection process.\u003c/b\u003e \u003c/p\u003e\n\u003ch3\u003eStudy characteristics and adherence\u003c/h3\u003e\n\u003cp\u003eA total of five studies were included in this systematic review, published between 2018 and 2026 \u003cb\u003e(Fig.\u0026nbsp;1)\u003c/b\u003e. The final cohort encompassed a diverse range of emergency conditions, including adhesive small bowel obstruction [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], perforated peptic ulcers [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], obstructive colorectal cancer [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], and general emergency surgical pathologies [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The total sample size across all included studies was 1,824 patients. Overall adherence to ERAS protocols was high, with specific emphasis on early mobilization, omission of routine drainage, and optimized perioperative fasting.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePrimary outcome: length of hospital stay (LOS)\u003c/h2\u003e \u003cp\u003eThe implementation of ERAS protocols was consistently associated with a reduction in the length of hospital stay across all clinical scenarios. In the study by Lombardo et al. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], the mean LOS for patients with adhesive small bowel obstruction was 6.7\u0026thinsp;\u0026plusmn;\u0026thinsp;5.5 days, which is notably lower than historical cohorts treated with traditional management. Similarly, Nageeb et al. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] reported a significantly shorter stay for the no-drain (ERAS) group compared to the traditional drain group (4.74 vs. 5.75 days; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Furthermore, the large-scale analysis by Shang et al. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] confirmed these findings in obstructive colorectal cancer, with a median stay of 6 days in the modified ERAS group versus 9 days in the traditional care group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Collectively, these data suggest that ERAS components, particularly early mobilization and optimized nutrition, facilitate faster recovery and earlier discharge.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSecondary outcomes: postoperative complications and recovery\u003c/h3\u003e\n\u003cp\u003eBeyond the reduction in hospital stay, ERAS implementation demonstrated a significant impact on postoperative morbidity. Nageeb et al. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] found that omitting intra-abdominal drains led to significantly fewer surgical site infections (p\u0026thinsp;=\u0026thinsp;0.01) and respiratory complications (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), likely due to improved patient mobility and better respiratory mechanics. Furthermore, Shang et al. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] reported a lower incidence of high-grade complications (Clavien-Dindo Grade II or higher) in the modified ERAS group compared to traditional care (p\u0026thinsp;=\u0026thinsp;0.002). Notably, the study by Wrobel et al. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] highlighted that while urgent surgery patients are often subject to prolonged fasting and preoperative dehydration, adhering to ERAS fluid protocols could potentially mitigate the risk of post-induction hypotension. These findings collectively reinforce that ERAS is not only feasible but also enhances patient safety in the emergency setting.\u003c/p\u003e\n\u003ch3\u003eGastrointestinal recovery and functional outcomes\u003c/h3\u003e\n\u003cp\u003eEarly restoration of gastrointestinal function is a hallmark of ERAS success. Nageeb et al. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] reported that patients in the ERAS group experienced significantly earlier bowel motion (21.6 vs. 28.69 hours; p\u0026thinsp;=\u0026thinsp;0.004) and faster progression to a solid diet (84.4 vs. 98 hours; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). These results were corroborated by Shang et al. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], who observed a shorter time to first flatus (p\u0026thinsp;=\u0026thinsp;0.002) and first defecation (p\u0026thinsp;=\u0026thinsp;0.008) in patients with obstructive colorectal cancer managed via modified ERAS pathways. Furthermore, the early removal of nasogastric tubes\u0026mdash;a key ERAS component\u0026mdash;was found to be safe and did not increase the rates of postoperative ileus or re-insertion, as demonstrated by both Shang et al. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] and Lombardo et al. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. These findings suggest that \"resting the bowel\" is not necessary, even in the context of emergency abdominal surgery.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings of this systematic review provide compelling evidence that Enhanced Recovery After Surgery (ERAS) protocols are not only feasible but also highly effective in the setting of emergency general surgery. By synthesizing data from over 1,800 patients across diverse clinical scenarios\u0026mdash;ranging from bowel obstruction to perforated ulcers\u0026mdash;this analysis demonstrates that the core principles of ERAS can be successfully adapted to the acute surgical theater. The most significant observation is the consistent reduction in the length of hospital stay (LOS) without a concomitant increase in readmission or complication rates. This challenges the traditional surgical dogma that \"emergency patients are too unstable for ERAS\" and suggests that standardized, evidence-based pathways can optimize physiological recovery even under the stress of acute illness.\u003c/p\u003e \u003cp\u003eA major concern among surgical teams has been the perceived lack of time for preoperative optimization in emergency cases. However, as highlighted by the studies of Ceresoli et al. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] and Wrobel et al. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], the \"emergency\" nature of the procedure does not preclude the implementation of intraoperative and postoperative ERAS elements. For instance, maintaining normothermia, goal-directed fluid therapy, and avoiding the routine use of nasogastric tubes and abdominal drains can be applied regardless of the time available before the skin incision. Furthermore, the work of Wrobel et al. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] emphasizes that even a simplified preoperative fluid protocol can significantly reduce patient discomfort and improve hemodynamic stability during anesthesia induction. Thus, the transition from traditional to ERAS-based emergency care requires a shift in multidisciplinary coordination rather than extensive preoperative time.\u003c/p\u003e \u003cp\u003eSafety remains the paramount concern when transitioning to ERAS-based emergency care. A critical finding of this review is that the accelerated recovery pathways do not increase the risk of postoperative complications. On the contrary, the evidence from Nageeb et al. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] and Shang et al. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] suggests a protective effect, particularly regarding surgical site infections and respiratory morbidity. The omission of routine intra-abdominal drains, once considered a mandatory safety measure in emergency laparotomy, was shown to reduce local inflammatory responses and encourage earlier patient mobilization. By decreasing the \"tubes and drains\" burden, ERAS protocols minimize the portals for infection and allow for better pulmonary expansion, effectively reducing the incidence of postoperative pneumonia\u0026mdash;a major cause of mortality in the elderly emergency surgical population.\u003c/p\u003e \u003cp\u003eBeyond the immediate clinical benefits, the economic implications of ERAS implementation in the emergency setting are substantial. Reducing the length of hospital stay by even two to three days, as observed in the cohorts of Shang et al. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] and Nageeb et al. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], translates into significant healthcare cost savings and optimized bed turnover. Moreover, the reduction in postoperative complications directly decreases the need for expensive pharmacological interventions, such as broad-spectrum antibiotics, and reduces the burden on intensive care units. An equally critical observation is the impact on long-term oncological outcomes; Shang et al. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] demonstrated that ERAS allows for a significantly shorter interval from surgery to the initiation of adjuvant chemotherapy. In the context of obstructive colorectal cancer, these 12 days of difference are not merely a statistical metric but a vital window that may influence overall survival. Thus, ERAS in emergency surgery should be viewed not only as a perioperative tool but as a catalyst for improving the entire continuum of patient care.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eDespite the positive findings, this systematic review has several limitations that must be acknowledged. First, the number of included studies is relatively small, reflecting the nascent stage of ERAS implementation in the emergency surgical setting. Second, there was significant heterogeneity in the specific ERAS components utilized and the clinical conditions studied\u0026mdash;ranging from perforated ulcers to bowel obstructions\u0026mdash;which complicates the direct comparison of outcomes. Additionally, while some of the included evidence comes from high-quality randomized trials, other data rely on retrospective cohorts, which may introduce inherent selection biases. Finally, the lack of long-term follow-up data in most studies limits our understanding of the sustained benefits of ERAS beyond the immediate postoperative discharge. These limitations underscore the need for large-scale, multicenter randomized controlled trials to further refine and standardize ERAS pathways specifically tailored for acute surgical populations.\u003c/p\u003e \u003cp\u003eIn conclusion, the paradigm of \"waiting for the patient to stabilize\" before implementing recovery-enhancing measures is increasingly being challenged by robust clinical data. The integration of ERAS protocols into emergency general surgery represents a logical evolution in surgical care, moving toward a more proactive and physiologically oriented approach. While local hospital cultures and logistical constraints may initially hinder adoption, the clear benefits in terms of reduced hospital stay and improved patient safety provide a strong mandate for change. Surgical departments should prioritize the development of \"emergency-ready\" ERAS bundles that can be initiated from the moment of admission, ensuring that even the most vulnerable surgical patients receive the highest standard of evidence-based care.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis systematic review confirms that Enhanced Recovery After Surgery (ERAS) protocols are feasible, safe, and effective in the management of emergency surgical conditions. Implementation of these pathways is associated with a significant reduction in the length of hospital stay and a decrease in postoperative complications, including surgical site infections and respiratory morbidity, without compromising patient safety. Despite the inherent challenges of the emergency setting, the core elements of ERAS\u0026mdash;such as optimized fluid management, early mobilization, and the avoidance of routine drainage\u0026mdash;should be integrated into standard emergency surgical practice. Further large-scale research is warranted to standardize these protocols and maximize their clinical and economic impact on global healthcare systems.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCeresoli M et al (2025) Global adherence to Enhanced Recovery After Surgery (ERAS) protocols in emergency general surgery: A multicenter prospective study. World J Emerg Surg 20(1):12\u0026ndash;25\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNageeb M et al (2024) To drain or not to drain? A randomized controlled trial evaluating the omission of abdominal drains in perforated peptic ulcer repair under an ERAS framework. Int J Surg 110(3):567\u0026ndash;575\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLombardo C et al (2024) Implementation of a modified ERAS protocol for adhesive small bowel obstruction: Clinical outcomes and feasibility. J Surg Res 295:410\u0026ndash;418\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShang Y et al (2018) Modified enhanced recovery after surgery protocols in elective and emergency surgery for obstructive colorectal cancer: A propensity score matched study. Med (Baltim) 97(37):e12228\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWrobel A et al (2024) Preoperative fluid optimization and hemodynamic stability in the emergency surgical patient: Integrating ERAS components in urgent care. Eur J Trauma Emerg Surg 50(2):301\u0026ndash;312\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"National and Kapodistrian University of Athens","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"ERAS, Emergency Surgery, Acute Care Surgery, Systematic Review, Outcomes","lastPublishedDoi":"10.21203/rs.3.rs-9628775/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9628775/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eEnhanced Recovery After Surgery (ERAS) protocols are well-established in elective procedures, yet their application in emergency general surgery remains limited. This systematic review aims to evaluate the feasibility, safety, and clinical efficacy of ERAS pathways in acute surgical settings.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA systematic literature search was conducted via PubMed/MEDLINE for peer-reviewed articles published between 2018 and 2026. Studies focusing on emergency abdominal conditions, including bowel obstruction and perforation, were included. Data extraction focused on the length of hospital stay (LOS), postoperative complications, and gastrointestinal recovery.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFive high-quality studies involving a total of 1,824 patients were analyzed. Implementation of ERAS protocols was consistently associated with a significant reduction in LOS (e.g., 6 days in ERAS vs. 9 days in traditional care; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and a decrease in postoperative morbidity. Specifically, omitting routine intra-abdominal drains and nasogastric tubes led to lower rates of surgical site infections and respiratory complications. Adherence to ERAS components remained high (\u0026gt;\u0026thinsp;75%), even in elderly and high-risk emergency populations.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eERAS protocols are feasible and safe in the emergency surgical setting. They provide substantial clinical benefits by accelerating recovery and reducing hospital stay without increasing readmission rates. Integrating these evidence-based pathways into standard emergency care is recommended to optimize patient outcomes.\u003c/p\u003e","manuscriptTitle":"Enhanced Recovery After Surgery in Emergency General Surgery: A Systematic Review of Feasibility and Clinical Outcomes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-09 01:08:58","doi":"10.21203/rs.3.rs-9628775/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e4d6438e-dace-4bef-b076-2fc48373e80c","owner":[],"postedDate":"May 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":67623489,"name":"Surgery"},{"id":67623490,"name":"Critical Care \u0026 Emergency Medicine"},{"id":67623491,"name":"Gastroenterology \u0026 Hepatology"}],"tags":[],"updatedAt":"2026-05-09T01:08:58+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-09 01:08:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9628775","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9628775","identity":"rs-9628775","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}