Assessing Awareness and Attitudes Toward Enhanced Recovery After Surgery (ERAS) Protocols Among Surgeons in Palestinian Hospitals: A Cross-Sectional Study

Assessing Awareness and Attitudes Toward Enhanced Recovery After Surgery (ERAS) Protocols Among Surgeons in Palestinian Hospitals: A Cross-Sectional Study | 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 Research Article Assessing Awareness and Attitudes Toward Enhanced Recovery After Surgery (ERAS) Protocols Among Surgeons in Palestinian Hospitals: A Cross-Sectional Study Sema Mohammed Taher, Mohammed M. H. Hajhamad¹, Anhar Al Assali², and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8990946/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Enhanced Recovery After Surgery (ERAS) is a multidisciplinary, evidence-based set of perioperative care protocols designed to reduce surgical stress, optimize recovery, and improve patient outcomes. It integrates practices such as early mobilization, optimized pain control, reduced fasting, and goal-directed fluid therapy, requiring collaboration among surgeons, anesthesiologists, nurses, and allied health professionals. This study aimed to assess surgeons’ awareness, attitudes, and acceptance of ERAS protocols and to identify factors influencing their adoption in Palestinian hospitals. Methods A cross-sectional study was conducted among 143 surgeons working in governmental, private, and teaching hospitals. Data were collected using a structured, self-administered questionnaire developed through a literature review and validated by an expert panel. Reliability testing demonstrated strong internal consistency (Cronbach’s α = 0.88 overall). Descriptive statistics summarized demographic characteristics, awareness, and attitudes, while ordinal logistic regression analysis was used to identify predictors of ERAS acceptance. Results Surgeons demonstrated high awareness of core ERAS principles, particularly early mobilization (84.6%), early urinary catheter removal (82.5%), and intraoperative thermoregulation (80.4%). Awareness of preoperative carbohydrate loading (67.1%) and goal-directed fluid therapy (72.7%) was comparatively lower. Attitudes toward ERAS were generally positive, with most surgeons recognizing its potential to improve patient outcomes, reduce complications, and enhance satisfaction. Regression analysis showed that concern about increased team workload was the only significant predictor of lower ERAS acceptance (β = −1.12, p = 0.011). Conclusions Surgeons in Palestinian hospitals conceptually support ERAS and acknowledge its benefits; however, practical barriers, particularly concerns related to team workload, limit its broader adoption. Addressing these challenges requires institutional support, adequate staffing, and strengthened multidisciplinary collaboration. Enhanced Recovery After Surgery ERAS Surgeons Awareness Attitudes Acceptance Perioperative Care Palestine Introduction Surgical care is a cornerstone of modern healthcare systems, playing a vital role in reducing morbidity, mortality, and long-term disability worldwide [1, 2]. Despite remarkable advances in surgical techniques and perioperative management, recovery after surgery remains a complex and resource-intensive process [3–5]. Patients often experience prolonged hospital stays, delayed mobilization, persistent postoperative pain, and preventable complications, all of which place a considerable burden on healthcare systems [6, 7]. Traditional perioperative practices, such as extended fasting before surgery, liberal fluid administration, routine use of drains, delayed oral feeding, and prolonged bed rest, were once considered standard but are now recognized as contributing to surgical stress, slower recovery, and adverse outcomes [8–10]. In response to these challenges, the concept of Enhanced Recovery After Surgery (ERAS) emerged in the late 1990s as a multidisciplinary, evidence-based approach designed to optimize perioperative care, minimize surgical stress, and accelerate patient recovery [11, 12]. The strength of ERAS protocols lies in their multidisciplinary and standardized approach, requiring close collaboration among surgeons, anesthesiologists, nurses, physiotherapists, and nutritionists [11–14]. Surgeons, in particular, play a decisive role in shaping perioperative practices, from surgical technique to postoperative feeding and mobilization. Although international evidence consistently demonstrates that ERAS shortens recovery time, reduces complications, and improves patient satisfaction, its adoption remains uneven, especially in low- and middle-income countries where limited resources, staffing shortages, and resistance to change often hinder implementation [15, 16]. In Palestine, where hospitals face a high surgical burden under constrained conditions, structured ERAS programs are not routinely applied, and little is known about surgeons’ awareness, attitudes, and acceptance of these protocols. This gap in knowledge raises important questions about the feasibility of ERAS integration into local practice and highlights the need to understand the perceptions of surgeons who are central to its success. The primary aim of this study was to assess surgeons’ awarenes, attitudes, and acceptance of ERAS protocols in the Palestinian healthcare context. To achieve this, the study was conducted to achieve several specific objectives: 1) to evaluate surgeons’ knowledge of the fundamental principles of ERAS, 2) to examine their awareness of the clinical benefits and outcomes associated with its implementation, 3) to determine their self-reported familiarity with ERAS concepts, and 4) to explore their attitudes toward integrating ERAS into routine surgical practice. In addition, the study seeks to identify factors influencing surgeons’ acceptance or reluctance, including perceived barriers such as workload concerns, and to analyze how demographic, professional, and institutional characteristics may shape levels of acceptance. By pursuing these objectives, the study aims to generate evidence that can inform targeted educational programs, guide institutional policies, and support the development of context-appropriate strategies for ERAS adoption in Palestine. Methodology Study design This study employed a descriptive cross-sectional design to assess surgeons’ awareness, attitudes, and acceptance of Enhanced Recovery After Surgery (ERAS) protocols in Palestinian hospitals. A cross-sectional approach was selected as it allows the evaluation of perceptions and knowledge within a defined population at a single point in time, without manipulation of study variables. Study setting The study was conducted in governmental, private, and non-governmental (NGO/charity) hospitals across the West Bank, Palestine. These institutions represent the primary providers of surgical care in the region and encompass a wide range of surgical specialties. Including different hospital types aimed to capture variation in institutional structure, resource availability, and perioperative practices. Study period Data collection was carried out over a 12-month period, from November 2024 to November 2025, allowing adequate time for participant recruitment across multiple hospitals and ensuring representation of surgeons with diverse clinical backgrounds and experience levels. Study population The study population consisted of surgeons actively practicing in hospitals in the West Bank during the study period. Surgeons from various specialties involved in perioperative patient care were included to ensure comprehensive assessment of ERAS awareness and attitudes across disciplines. Inclusion and exclusion criteria Inclusion criteria Surgeons practicing in governmental, private, or NGO hospitals in the West Bank Surgeons from any surgical specialty Willingness to participate and provide informed consent Exclusion criteria Surgeons not actively involved in clinical practice during the study period Interns, medical students, and non-surgical physicians Incomplete or improperly completed questionnaires Sample size and sampling technique Sample size was calculated using the Raosoft online sample size calculator. The target population was estimated at approximately 220 surgeons practicing in the West Bank. Using a 95% confidence level, 5% margin of error, and a response distribution of 50%, the minimum required sample size was 140 participants. A total of 143 surgeons were recruited, exceeding the minimum requirement and providing sufficient statistical power. A convenience sampling technique was used due to logistical constraints and variability in surgeon availability. While this approach may limit generalizability, it enabled inclusion of surgeons from diverse institutions and specialties. Data collection instrument Data were collected using a structured, self-administered questionnaire developed specifically for this study following an extensive review of the literature on ERAS protocols and perioperative care. The English version of the questionnaire is provided as a supplementary file. The questionnaire assessed demographic and professional characteristics, awareness of ERAS principles and benefits, attitudes toward ERAS implementation, perceived barriers, and overall acceptance. Responses to awareness and attitude items were recorded using a 5-point Likert scale ranging from strongly disagree (1) to strongly agree (5). Demographic variables were collected using fixed-choice responses. Validity and reliability Face validity was established through expert review by a panel of senior surgeons, academic researchers, and healthcare quality specialists, who evaluated clarity, relevance, and contextual suitability. Minor linguistic and structural modifications were made based on their feedback. Internal consistency was assessed using Cronbach’s alpha. Reliability coefficients demonstrated good to excellent consistency across domains: awareness of ERAS principles (α = 0.81), attitudes toward ERAS implementation (α = 0.84), perceived barriers (α = 0.86), and the overall questionnaire (α = 0.88). Data collection procedure Questionnaires were distributed in person during working hours to maximize response rates. Participants completed the questionnaires anonymously and returned them immediately after completion. Confidentiality was assured, and no identifying personal information was collected. Data management and statistical analysis Data were entered, coded, and analyzed using SPSS version 26. Descriptive statistics were used to summarize participant characteristics. Frequencies and percentages were calculated for categorical variables, while means and standard deviations were computed for Likert-scale items. Overall ERAS acceptance was categorized into low, moderate, and high levels based on composite scores. Ordinal logistic regression analysis was performed to identify predictors of ERAS acceptance. Independent variables included workload concerns, ERAS knowledge and training, nursing staff availability, age, years of experience, and hospital type. Results were reported as regression coefficients (β), standard errors, Wald χ² statistics, and p-values. Statistical significance was set at p < 0.05. The proportional odds assumption was tested and met. Results Response rate and participant characteristics Out of 220 surgeons invited to participate in the study, 143 responded, yielding a response rate of 65%, which is considered good for survey-based research. The final sample included surgeons actively practicing in governmental, private, and NGO hospitals in the West Bank, representing various surgical specialties. Demographic and professional characteristics The demographic and professional characteristics of participants are summarized in Table 1 . Among the respondents, 57 (39.9%) were older than 45 years, 52 (36.4%) were aged 36–45 years, and 34 (23.8%) were 35 years or younger. Most participants were male (124, 86.7%), while 19 (13.3%) were female. More than half of the surgeons had over 10 years of experience (79, 55.2%), followed by 38 (26.6%) with 6–10 years and 26 (18.2%) with ≤ 5 years. Only 29 surgeons (20.3%) reported having received formal ERAS training. Additional characteristics are presented in Table 1 . Table 1 Distribution of demographic and professional characteristics among participating surgeons (n = 143) Variable n (%) Age group (years) ≤ 35 34 (23.8) 36–45 52 (36.4) > 45 57 (39.9) Gender Male 124 (86.7) Female 19 (13.3) Years of experience ≤ 5 26 (18.2) 6–10 38 (26.6) > 10 79 (55.2) Hospital type Governmental hospital 61 (42.7) Private hospital 46 (32.2) NGO/Charity hospital 36 (25.2) Specialty General surgery 59 (41.3) Orthopedic surgery 24 (16.8) Obstetrics/Gynecology 21 (14.7) Urology 14 (9.8) Neurosurgery 10 (7.0) Other surgical specialties 15 (10.5) Received ERAS training Yes 29 (20.3) No 114 (79.7) ERAS: Enhanced recovery after surgery, NGO: nongovernmental organization Surgeons’ awareness of key ERAS principles Surgeons demonstrated high awareness of key ERAS principles (Table 2 ). The highest awareness was observed for early mobilization (121, 84.6%) and early urinary catheter removal (118, 82.5%). Awareness of preoperative carbohydrate loading was comparatively lower (96, 67.1%). Table 2 Surgeons’ awareness of key ERAS principles # Agree or strongly agree Neutral Disagree or strongly disagree ERAS principle n (%) n (%) n (%) 1 ERAS starts preoperatively and continues postoperatively 112 (78.3) 18 (12.6) 13 (9.1) 2 Preoperative carbohydrate loading is part of ERAS 96 (67.1) 27 (18.9) 20 (14.0) 3 Goal-directed fluid therapy is a key ERAS component 104 (72.7) 22 (15.4) 17 (11.9) 4 Early urinary catheter removal is recommended 118 (82.5) 15 (10.5) 10 (7.0) 5 Early oral feeding is allowed in ERAS 109 (76.2) 21 (14.7) 13 (9.1) 6 Early mobilization is a core ERAS principle 121 (84.6) 14 (9.8) 8 (5.6) 7 Intraoperative thermoregulation is essential in ERAS 115 (80.4) 17 (11.9) 11 (7.7) ERAS: Enhanced recovery after surgery Surgeons’ awareness of advantages and clinical outcomes of ERAS protocols Surgeons demonstrated high awareness of the clinical benefits of ERAS (Table 3 ). A total of 116 surgeons (81.1%) agreed or strongly agreed that ERAS reduces hospital length of stay, while 110 (76.9%) recognized its role in lowering postoperative complications. Similarly, 113 surgeons (79.0%) acknowledged that ERAS improves overall patient outcomes, and 108 (75.5%) considered ERAS safe for most routine surgical patients. The highest agreement was observed for multimodal analgesia and opioid reduction (119, 83.2%) Table 3 Surgeons’ awareness of advantages and clinical outcomes of ERAS protocols # Agree or strongly agree Neutral Disagree or strongly disagree ERAS advantage n (%) n (%) n (%) 1 ERAS reduces postoperative complications 110 (76.9) 20 (14.0) 13 (9.1) 2 ERAS reduces length of hospital stay 116 (81.1) 16 (11.2) 11 (7.7) 3 ERAS improves overall patient outcomes 113 (79.0) 18 (12.6) 12 (8.4) 4 ERAS is safe for most routine surgical patients 108 (75.5) 21 (14.7) 14 (9.8) 5 Multimodal analgesia and opioid reduction are key ERAS elements 119 (83.2) 15 (10.5) 9 (6.3) ERAS: Enhanced recovery after surgery Self-reported familiarity with ERAS protocols Levels of familiarity with ERAS protocols varied among surgeons (Table 4 ). High familiarity was reported by 68 surgeons (47.5%), while 54 (37.8%) reported moderate familiarity. Table 4 Distribution of surgeons’ self-reported familiarity with ERAS protocols Familiarity level n (%) Low familiarity 21 (14.7) Moderate familiarity 54 (37.8) High familiarity 68 (47.5) Attitudes toward ERAS implementation Overall attitudes toward ERAS implementation were positive (Table 5 ). A total of 98 surgeons (68.5%) agreed or strongly agreed that ERAS should be routinely implemented in surgical practice, with a mean score of 3.82 ± 0.89. Similarly, 103 surgeons (72.0%) believed ERAS improves the quality of surgical care (mean = 3.88 ± 0.83), while 97 (67.8%) agreed that ERAS enhances patient satisfaction (mean = 3.79 ± 0.87). The highest level of agreement was observed for the statement that ERAS requires strong multidisciplinary collaboration, endorsed by 113 surgeons (79.0%), with the highest mean score of 4.01 ± 0.79. Additionally, 92 surgeons (64.3%) expressed personal willingness to adopt ERAS protocols in their own practice (mean = 3.71 ± 0.91). Lower agreement was observed for the statement that ERAS reduces postoperative workload. Only 74 surgeons (51.7%) agreed that ERAS reduces postoperative workload, while 38 (26.6%) remained neutral and 31 (21.7%) disagreed. This item yielded the lowest mean score (3.43 ± 0.98), suggesting that concerns about workload may represent a barrier to broader acceptance of ERAS protocols. Table 5 Distribution of surgeons’ attitudes toward ERAS implementation in surgical practice # Agree or strongly agree Neutral Disagree or strongly disagree Attitude statement n (%) n (%) n (%) Mean ± SD 1 ERAS should be routinely implemented in surgical practice 98 (68.5) 27 (18.9) 18 (12.6) 3.82 ± 0.89 2 ERAS protocols are practical and applicable in daily work 85 (59.4) 34 (23.8) 24 (16.8) 3.64 ± 0.94 3 ERAS improves quality of surgical care 103 (72.0) 25 (17.5) 15 (10.5) 3.88 ± 0.83 4 ERAS implementation enhances patient satisfaction 97 (67.8) 29 (20.3) 17 (11.9) 3.79 ± 0.87 5 ERAS implementation reduces postoperative workload 74 (51.7) 38 (26.6) 31 (21.7) 3.43 ± 0.98 6 ERAS protocols require strong multidisciplinary collaboration 113 (79.0) 19 (13.3) 11 (7.7) 4.01 ± 0.79 7 I am personally willing to adopt ERAS in my practice 92 (64.3) 31 (21.7) 20 (14.0) 3.71 ± 0.91 ERAS: Enhanced recovery after surgery, SD: standard deviation Overall attitude toward ERAS implementation Overall, 88 surgeons (61.5%) demonstrated a positive attitude toward ERAS implementation ( Table 6 ). Table 6 Distribution of overall attitude scores toward ERAS implementation among surgeons Attitude level Mean score range n (%) Negative attitude ≤ 2.9 19 (13.3) Neutral attitude 3.0–3.4 36 (25.2) Positive attitude ≥ 3.5 88 (61.5) Factors affecting surgeons’ acceptance or reluctance toward ERAS protocols, including perceived advantages, challenges faced, and associated concerns Ordinal logistic regression analysis was performed to identify predictors of ERAS acceptance, categorized as low, moderate, or high (Table 7 ).Concern about increased team workload was the only significant predictor of ERAS acceptance (β = −1.12, p = 0.011). Surgeons who perceived ERAS as increasing team workload were significantly less likely to report higher levels of acceptance. No other variables showed a statistically significant association with ERAS acceptance. (β = -0.51, p = 0.191), absence of formal ERAS training (β = -0.47, p = 0.250), nursing staff shortage (β = -0.58, p = 0.107), age (β = -0.29, p = 0.348), years of surgical experience (β = -0.34, p = 0.303), and hospital type (β = -0.22, p = 0.432), were not significantly associated with ERAS acceptance. Table 7 Ordinal logistic regression predicting surgeons’ acceptance of ERAS protocols Predictor Estimate (β) S.E. Wald χ 2 p-value Concern about increased team workload -1.12 0.44 6.48 0.011 Lack of ERAS knowledge -0.51 0.39 1.71 0.191 Lack of ERAS training -0.47 0.41 1.32 0.250 Nursing staff shortage -0.58 0.36 2.60 0.107 Age -0.29 0.31 0.88 0.348 Years of experience -0.34 0.33 1.06 0.303 Hospital type -0.22 0.28 0.62 0.432 Relationship between surgical specialty and awareness and acceptance of ERAS protocols Significant associations were observed between surgical specialty and several ERAS- related components(Table 8 ). Awareness of early mobilization differed significantly across specialties (χ² = 9.84, p = 0.043), with general surgeons and obstetrics/ gynecology surgeons demonstrating higher recognition compared with other specialties. Similarly, awareness of early oral feeding was significantly associated with specialty (χ² = 11.27, p = 0.024). Significant variation was also observed in knowledge of preoperative carbohydrate loading (χ² = 13.62, p = 0.009) and goal-directed fluid therapy (χ² = 10.95, p = 0.027), with surgeons from general surgery reporting higher awareness than subspecialties such as neurosurgery and orthopedics. Attitudes toward ERAS implementation differed significantly by specialty (χ² = 8.71, p = 0.048), and overall acceptance levels were also significantly associated with surgical discipline (χ² = 12.33, p = 0.015). General surgeons demonstrated the highest proportion of positive attitudes and high acceptance, whereas subspecialty surgeons exhibited relatively greater neutrality or reluctance. Table 8 Association between surgical specialty and key ERAS components ERAS element χ² p-value Significance Early mobilization awareness 9.84 0.043 Significant Early oral feeding awareness 11.27 0.024 Significant Preoperative carbohydrate loading awareness 13.62 0.009 Significant Goal-directed fluid therapy awareness 10.95 0.027 Significant Positive attitude toward ERAS implementation 8.71 0.048 Significant Overall ERAS acceptance level 12.33 0.015 Significant Association between surgical specialty and ERAS awareness, attitudes, and workload perception Chi-square analysis revealed significant differences in ERAS awareness across surgical specialties (Table 9 ). General surgeons and obstetrics/gynecology surgeons consistently demonstrated higher recognition of core ERAS principles, including early mobilization, early oral feeding, carbohydrate loading, and goal-directed fluid therapy (p < 0.05). In contrast, lower awareness was observed among orthopedic and neurosurgical surgeons, particularly for metabolic optimization components. Table 9 ERAS awareness by surgical specialty (% agreeing/strongly agreeing) ERAS Component General surgery Orthopedic Ob/Gyn Urology Neurosurgery p-value Early mobilization 91.5 79.2 90.5 78.6 70.0 0.043 Early oral feeding 88.1 70.8 85.7 71.4 60.0 0.024 Carbohydrate loading 76.3 54.2 71.4 57.1 40.0 0.009 Goal-directed fluids 83.1 66.7 81.0 64.3 50.0 0.027 Overall acceptance of ERAS protocols also varied significantly by specialty (p = 0.015). General surgeons reported the highest proportion of high acceptance, whereas neurosurgeons and orthopedic surgeons demonstrated greater levels of moderate or low acceptance (Table 10 ). Table 10 Overall ERAS acceptance level by specialty Specialty High acceptance Moderate Low p-value General surgery 72.9% 20.3% 6.8% 0.015 Orthopedic 54.2% 33.3% 12.5% Ob/Gyn 66.7% 23.8% 9.5% Urology 50.0% 35.7% 14.3% Neurosurgery 40.0% 40.0% 20.0% Importantly, perception of increased team workload differed significantly across specialties (p = 0.008). Neurosurgeons and orthopedic surgeons were most likely to perceive ERAS as increasing workload, while general surgeons reported the lowest workload concern (Table 11 ). Table 11 Perception of increased team workload by specialty (% agreeing ERAS increases workload) Specialty Agree (%) General surgery 38.9 Orthopedic 58.3 Ob/Gyn 42.9 Urology 57.1 Neurosurgery 70.0 p-value 0.008 Discussion This study provides the first systematic assessment of surgeons’ awareness, attitudes, and acceptance of Enhanced Recovery After Surgery (ERAS) protocols in Palestinian hospitals. Overall, surgeons demonstrated good awareness of core ERAS principles, particularly early mobilization, early oral feeding, and urinary catheter removal, while awareness of preoperative carbohydrate loading and goal-directed fluid therapy was lower. These findings align with international reports, where low- and middle-income countries often show limited implementation of metabolic optimization components due to resource constraints and concerns about aspiration risk [15, 18, 19]. Attitudes toward ERAS were generally positive, with most surgeons recognizing its potential to improve patient outcomes, reduce complications, and enhance satisfaction. Similar trends have been reported in high-income countries, where surgeons view ERAS as a framework to enhance recovery and care quality [13, 14]. However, practical barriers, particularly perceived increases in team workload, were the main limitation to broader adoption. This is consistent with studies from the Middle East, Asia, and Eastern Europe, where staffing shortages and high patient volumes hinder ERAS implementation [15, 16]. The variation in awareness and acceptance across surgical specialties underscores the need for tailored interventions. General surgeons reported higher familiarity and acceptance compared with orthopedic and neurosurgical surgeons, reflecting greater exposure to ERAS protocols in general and colorectal surgery pathways [13, 21]. This pattern is consistent with findings from Europe and North America, where specialty-specific familiarity strongly influences implementation [21, 22]. Evidence from high-resource healthcare settings suggests that ERAS can ultimately reduce workload by shortening hospital stays and minimizing complications [22, 23]. The discrepancy between perceived and actual workload highlights the importance of institutional support, adequate staffing, and structured multidisciplinary collaboration to realize the benefits of ERAS. In conclusion, Palestinian surgeons are conceptually aligned with ERAS principles, but adoption is constrained by perceived workload challenges. Targeted education, policy integration, and resource allocation are essential to facilitate sustainable ERAS implementation, improve surgical outcomes, and enhance patient recovery. Limitations This study has several limitations that should be acknowledged. First, the use of a convenience sampling technique may limit the generalizability of the findings, as surgeons who were more available or interested in ERAS may have been overrepresented. Second, the reliance on self-administered questionnaires introduces the possibility of response bias, particularly social desirability bias, as participants may have provided answers they perceived as favorable rather than reflecting their actual practices. Third, the study was conducted exclusively in hospitals within the West Bank, which may not fully capture the perspectives of surgeons working in other Palestinian regions or in different healthcare systems. Finally, while the questionnaire demonstrated strong reliability, it primarily assessed awareness and attitudes rather than actual implementation practices, meaning the results reflect perceptions rather than observed behavior. These limitations suggest that future research should employ probability sampling, include observational components, and expand to broader geographic contexts to strengthen the external validity of the findings Conclusion This study highlights that surgeons in Palestinian hospitals possess strong awareness of core ERAS principles and generally positive attitudes toward their implementation, yet practical barriers, particularly concerns about increased team workload, remain the primary obstacle to widespread adoption. While knowledge gaps in components such as carbohydrate loading and goal-directed fluid therapy mirror challenges reported internationally, the overall acceptance of ERAS demonstrates readiness for integration if institutional support, multidisciplinary collaboration, and targeted training are prioritized. By addressing workload concerns and reinforcing under-recognized elements through structured education and policy frameworks, Palestinian healthcare systems can move toward comprehensive ERAS implementation, ultimately improving surgical outcomes, reducing complications, and enhancing patient recovery Abbreviations ERAS Enhanced Recovery After Surgery NGO Non–governmental Organization SD Standard Deviation SPSS Statistical Package for the Social Sciences Declarations Ethics approval and consent to participate Ethical approval for this study was obtained from the Institutional Review Board (IRB) of An-Najah National University (IRB Protocol Number: Med. Jan. 2025/5; approval date: 5 January 2025). Participation was voluntary, and informed consent was obtained from all participants prior to data collection. All procedures were conducted in accordance with relevant ethical guidelines and regulations and the principles of the Declaration of Helsinki. Consent for publication Not applicable, as the manuscript does not contain any individual person’s data in any form. Competing interests The authors declare that they have no competing interests. Funding This research received no external funding. Author Contribution ST, BN, DA, and NK contributed to the study conception and design. Data collection was performed by ST, BN, DA, and NK. Data analysis and interpretation were conducted by all authors. The manuscript was drafted by ST, BN, DA, and NK and critically revised for important intellectual content by MHH, AA, and AD. All authors read and approved the final manuscript. Acknowledgement The authors would like to thank the supervisors and faculty members who provided guidance and support during the development of this research. The authors also express their appreciation to all surgeons who participated in this study and contributed their time and insights. Data Availability The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Trial registration Clinical trial number: not applicable. References Maswime S, Jayaraman S, Alaba O, Robalo M. Universal access to surgical care—A global public health priority. PLOS Glob Public Health. 2025;5(4):e0004326. Anandalwar S, Sifri Z, Hopkins MA, Whitley D, Harfouche M, Narayan M. Evolution of global surgery: lessons learned and a look toward the future. Trauma Surg Acute Care Open. 2025;10(Suppl 3):e001541. Harvie DA, Levett DZH, Grocott MPW. Understanding outcomes after major surgery. Anesth Analg. 2023;136(4):655–664. Papautsky EL. Patient decision making in recovering from surgery. Front Psychol. 2023;14:1170658. Cunha MF, Pellino G. Environmental effects of surgical procedures and strategies for sustainable surgery. Nat Rev Gastroenterol Hepatol. 2023;20(6):399–410. Le HD, Wolinska JM, Baertschiger RM, Himidan SA. Complication is inevitable, but suffering is optional: psychological aspects of dealing with complications in surgery. Eur J Pediatr Surg. 2023;33(3):181–190. Stokes SM, Scaife CL, Brooke BS, Glasgow RE, Mulvihill SJ, Finlayson SRG, et al. Hospital costs following surgical complications: a value-driven outcomes analysis. Ann Surg. 2022;275(2):e375–e381. He Y, Wang R, Wang F, Chen L, Shang T, Zheng L. Clinical effect and safety of new preoperative fasting guidelines for elective surgery: a systematic review and meta-analysis. Gland Surg. 2022;11(3):563–575. Silva Júnior RER, Soriano CA, Lima PAS, de Oliveira Santos BF, Pereira WGN, de Brito Filho MT, et al. Beyond guidelines: the persistent challenge of preoperative fasting times. Surgeries. 2023;4(4):611–622. Sharma V, Prasad J, Choudhary K, Choudhary D. Traditional prolonged fasting: time to change practice. Eur J Mol Clin Med. 2022;9(3):2245–2255. Stenberg E, dos Reis Falcão LF, O’Kane M, Liem R, Pournaras DJ, Salminen P, et al. Guidelines for perioperative care in bariatric surgery: ERAS Society recommendations—2021 update. World J Surg. 2022;46(4):729–751. Mithany RH, Daniel N, Shahid MH, Aslam S, Abdelmaseeh M, Gerges F, et al. Revolutionizing surgical care: the power of enhanced recovery after surgery (ERAS). Cureus. 2023;15(11):e48976. Smith TW, Wang X, Singer MA, Godellas CV, Vaince FT. Enhanced recovery after surgery: implementation across surgical subspecialties. Am J Surg. 2020;219(3):530–534. Kamal U, Issa Y, Beta E. Enhanced recovery after surgery protocols: transforming perioperative care. ASA Monitor. 2025;89(4):18–20. Kifle F, Kenna P, Daniel S, Maswime S, Biccard B. ERAS protocol implementation and impact in Africa: a scoping review. Perioper Med (Lond). 2024;13:86. Hong M, Ghajar M, Allen W, Jasti S, Alvarez-Downing MM. Implementation costs of ERAS in colorectal surgery: a systematic review. World J Surg. 2023;47(7):1589–1596. Wright RM, Nelson G. Applying principles of enhanced recovery after surgery. Br J Surg. 2025;112(9):znaf194. Haselton SD, Chadayammuri VP, Emerson RH. Preoperative carbohydrate loading in ERAS for elective total hip arthroplasty. Clin Nutr ESPEN. 2025;68:602–607. Lu J, Khamar J, McKechnie T, Lee Y, Amin N, Hong D, et al. Preoperative carbohydrate loading before colorectal surgery: systematic review and meta-analysis. Int J Colorectal Dis. 2022;37(12):2431–2450. Pogatschnik C, Steiger E. Review of preoperative carbohydrate loading. Nutr Clin Pract. 2015;30(5):660–664. Gómez-Hidalgo NR, Pletnev A, Razumova Z, Bizzarri N, Selcuk I, Theofanakis C, et al. ERAS implementation in gynecologic oncology across Europe. Int J Gynecol Obstet. 2023;160(1):306–312. Barajas-Gamboa JS, Zhan K, Khan MSI, Lopez Meyer JC, Pantoja JP, Abril C, et al. ERAS reduces complications and length of stay in bariatric surgery. Obes Surg. 2025;35(10):4171–4182. Balachandran S, Alharrasi M, Al Dhabbari F, Al Masroori F. Knowledge of perioperative guidelines and barriers among cardiac nurses. J Educ Health Promot. 2025;14:447. Özçelik M. Implementation of ERAS protocols: in theory and practice. Turk J Anaesthesiol Reanim. 2024;52(5):163–168. Zhang Q, Sun Q, Li J, Fu X, Wu Y, Zhang J, et al. Impact of ERAS and multidisciplinary teams in colorectal cancer. Pain Ther. 2024;14(1):201–215. Additional Declarations No competing interests reported. Supplementary Files Supplementaryfile1Questionnairenew22.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 06 May, 2026 Reviews received at journal 23 Mar, 2026 Reviewers agreed at journal 21 Mar, 2026 Reviewers invited by journal 20 Mar, 2026 Editor assigned by journal 10 Mar, 2026 Submission checks completed at journal 09 Mar, 2026 First submitted to journal 09 Mar, 2026 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-8990946","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":610845595,"identity":"bdff352d-aa9e-4b79-be82-eaa7daa71935","order_by":0,"name":"Sema Mohammed Taher","email":"","orcid":"","institution":"An-Najah National University","correspondingAuthor":false,"prefix":"","firstName":"Sema","middleName":"Mohammed","lastName":"Taher","suffix":""},{"id":610845596,"identity":"6c171882-ade6-4c82-b245-03c46febd568","order_by":1,"name":"Mohammed M. H. Hajhamad¹","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA20lEQVRIiWNgGAWjYBACAwYGNhDNOJ+9AcS1IEHLxp4DIK4ECVoabiSAaCK0mLMfv/bgZ46dbOPM51c3/CiQYOBv707Aq8WyJ6fcsHdbsnG7dE7ZzR6gwyTOnN2A32EHctIkeLcxJzbOzkm7wQPUYiCRS0DL+Tdpkn+31Sc23DyTdvMPUVpupB+T5t12OLHhBvux28TZcuMNm7TstuPGG3ty2G7LGEjwEPbL+fRnkm+3VcvOZz/+7OabPzZy/O29+LUwMPAYoDB4CCgHAfYH6IxRMApGwSgYBagAAClCTXmqP5Q5AAAAAElFTkSuQmCC","orcid":"","institution":"Rafidia Hospital, Ministry of Health","correspondingAuthor":true,"prefix":"","firstName":"Mohammed","middleName":"M. H.","lastName":"Hajhamad¹","suffix":""},{"id":610845598,"identity":"6fdca083-0d30-495f-93ea-dc7f139dec08","order_by":2,"name":"Anhar Al Assali²","email":"","orcid":"","institution":"An-Najah National University","correspondingAuthor":false,"prefix":"","firstName":"Anhar","middleName":"Al","lastName":"Assali²","suffix":""},{"id":610845601,"identity":"14538341-1ebf-410c-a5f8-a5d4e039edb2","order_by":3,"name":"Ahmed Dalbah³","email":"","orcid":"","institution":"Najah National University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"","lastName":"Dalbah³","suffix":""},{"id":610845605,"identity":"2d79871d-202c-444a-9803-8833a2562b31","order_by":4,"name":"Bayan Khalid Nassar","email":"","orcid":"","institution":"An-Najah National University","correspondingAuthor":false,"prefix":"","firstName":"Bayan","middleName":"Khalid","lastName":"Nassar","suffix":""},{"id":610845607,"identity":"9b00afda-99d0-4db9-824b-69e155b0264b","order_by":5,"name":"Donia Tarek Abedalkhalek","email":"","orcid":"","institution":"An-Najah National University","correspondingAuthor":false,"prefix":"","firstName":"Donia","middleName":"Tarek","lastName":"Abedalkhalek","suffix":""},{"id":610845608,"identity":"3095482f-ff0c-4ab7-89fb-ecfee9c59e39","order_by":6,"name":"Nancy Ali Kabiya","email":"","orcid":"","institution":"An-Najah National University","correspondingAuthor":false,"prefix":"","firstName":"Nancy","middleName":"Ali","lastName":"Kabiya","suffix":""}],"badges":[],"createdAt":"2026-02-27 18:39:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8990946/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8990946/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105381884,"identity":"c7866033-cbea-4e0a-aac9-3d24cde23264","added_by":"auto","created_at":"2026-03-25 11:27:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1531734,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8990946/v1/782abe29-37e9-4087-8568-e89ec5ccdaee.pdf"},{"id":105381807,"identity":"da2e3f4e-a538-4530-a8c5-f3757471bcf7","added_by":"auto","created_at":"2026-03-25 11:27:16","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":31353,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile1Questionnairenew22.docx","url":"https://assets-eu.researchsquare.com/files/rs-8990946/v1/5376aa1c08e93ba5869971ec.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Assessing Awareness and Attitudes Toward Enhanced Recovery After Surgery (ERAS) Protocols Among Surgeons in Palestinian Hospitals: A Cross-Sectional Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSurgical care is a cornerstone of modern healthcare systems, playing a vital role in reducing morbidity, mortality, and long-term disability worldwide [1, 2]. Despite remarkable advances in surgical techniques and perioperative management, recovery after surgery remains a complex and resource-intensive process [3\u0026ndash;5]. Patients often experience prolonged hospital stays, delayed mobilization, persistent postoperative pain, and preventable complications, all of which place a considerable burden on healthcare systems [6, 7]. Traditional perioperative practices, such as extended fasting before surgery, liberal fluid administration, routine use of drains, delayed oral feeding, and prolonged bed rest, were once considered standard but are now recognized as contributing to surgical stress, slower recovery, and adverse outcomes [8\u0026ndash;10]. In response to these challenges, the concept of Enhanced Recovery After Surgery (ERAS) emerged in the late 1990s as a multidisciplinary, evidence-based approach designed to optimize perioperative care, minimize surgical stress, and accelerate patient recovery [11, 12].\u003c/p\u003e \u003cp\u003eThe strength of ERAS protocols lies in their multidisciplinary and standardized approach, requiring close collaboration among surgeons, anesthesiologists, nurses, physiotherapists, and nutritionists [11\u0026ndash;14]. Surgeons, in particular, play a decisive role in shaping perioperative practices, from surgical technique to postoperative feeding and mobilization. Although international evidence consistently demonstrates that ERAS shortens recovery time, reduces complications, and improves patient satisfaction, its adoption remains uneven, especially in low- and middle-income countries where limited resources, staffing shortages, and resistance to change often hinder implementation [15, 16]. In Palestine, where hospitals face a high surgical burden under constrained conditions, structured ERAS programs are not routinely applied, and little is known about surgeons\u0026rsquo; awareness, attitudes, and acceptance of these protocols. This gap in knowledge raises important questions about the feasibility of ERAS integration into local practice and highlights the need to understand the perceptions of surgeons who are central to its success.\u003c/p\u003e \u003cp\u003eThe primary aim of this study was to assess surgeons\u0026rsquo; awarenes, attitudes, and acceptance of ERAS protocols in the Palestinian healthcare context. To achieve this, the study was conducted to achieve several specific objectives: 1) to evaluate surgeons\u0026rsquo; knowledge of the fundamental principles of ERAS, 2) to examine their awareness of the clinical benefits and outcomes associated with its implementation, 3) to determine their self-reported familiarity with ERAS concepts, and 4) to explore their attitudes toward integrating ERAS into routine surgical practice. In addition, the study seeks to identify factors influencing surgeons\u0026rsquo; acceptance or reluctance, including perceived barriers such as workload concerns, and to analyze how demographic, professional, and institutional characteristics may shape levels of acceptance. By pursuing these objectives, the study aims to generate evidence that can inform targeted educational programs, guide institutional policies, and support the development of context-appropriate strategies for ERAS adoption in Palestine.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis study employed a descriptive cross-sectional design to assess surgeons\u0026rsquo; awareness, attitudes, and acceptance of Enhanced Recovery After Surgery (ERAS) protocols in Palestinian hospitals. A cross-sectional approach was selected as it allows the evaluation of perceptions and knowledge within a defined population at a single point in time, without manipulation of study variables.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy setting\u003c/h3\u003e\n\u003cp\u003eThe study was conducted in governmental, private, and non-governmental (NGO/charity) hospitals across the West Bank, Palestine. These institutions represent the primary providers of surgical care in the region and encompass a wide range of surgical specialties. Including different hospital types aimed to capture variation in institutional structure, resource availability, and perioperative practices.\u003c/p\u003e\n\u003ch3\u003eStudy period\u003c/h3\u003e\n\u003cp\u003eData collection was carried out over a 12-month period, from November 2024 to November 2025, allowing adequate time for participant recruitment across multiple hospitals and ensuring representation of surgeons with diverse clinical backgrounds and experience levels.\u003c/p\u003e\n\u003ch3\u003eStudy population\u003c/h3\u003e\n\u003cp\u003eThe study population consisted of surgeons actively practicing in hospitals in the West Bank during the study period. Surgeons from various specialties involved in perioperative patient care were included to ensure comprehensive assessment of ERAS awareness and attitudes across disciplines.\u003c/p\u003e\n\u003ch3\u003eInclusion and exclusion criteria\u003c/h3\u003e\n\u003cp\u003eInclusion criteria\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eSurgeons practicing in governmental, private, or NGO hospitals in the West Bank\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSurgeons from any surgical specialty\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eWillingness to participate and provide informed consent\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eExclusion criteria\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eSurgeons not actively involved in clinical practice during the study period\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eInterns, medical students, and non-surgical physicians\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eIncomplete or improperly completed questionnaires\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSample size and sampling technique\u003c/h2\u003e \u003cp\u003eSample size was calculated using the Raosoft online sample size calculator. The target population was estimated at approximately 220 surgeons practicing in the West Bank. Using a 95% confidence level, 5% margin of error, and a response distribution of 50%, the minimum required sample size was 140 participants.\u003c/p\u003e \u003cp\u003eA total of 143 surgeons were recruited, exceeding the minimum requirement and providing sufficient statistical power. A convenience sampling technique was used due to logistical constraints and variability in surgeon availability. While this approach may limit generalizability, it enabled inclusion of surgeons from diverse institutions and specialties.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData collection instrument\u003c/h3\u003e\n\u003cp\u003eData were collected using a structured, self-administered questionnaire developed specifically for this study following an extensive review of the literature on ERAS protocols and perioperative care. The English version of the questionnaire is provided as a supplementary file. The questionnaire assessed demographic and professional characteristics, awareness of ERAS principles and benefits, attitudes toward ERAS implementation, perceived barriers, and overall acceptance.\u003c/p\u003e \u003cp\u003eResponses to awareness and attitude items were recorded using a 5-point Likert scale ranging from strongly disagree (1) to strongly agree (5). Demographic variables were collected using fixed-choice responses.\u003c/p\u003e\n\u003ch3\u003eValidity and reliability\u003c/h3\u003e\n\u003cp\u003eFace validity was established through expert review by a panel of senior surgeons, academic researchers, and healthcare quality specialists, who evaluated clarity, relevance, and contextual suitability. Minor linguistic and structural modifications were made based on their feedback.\u003c/p\u003e \u003cp\u003eInternal consistency was assessed using Cronbach\u0026rsquo;s alpha. Reliability coefficients demonstrated good to excellent consistency across domains: awareness of ERAS principles (α\u0026thinsp;=\u0026thinsp;0.81), attitudes toward ERAS implementation (α\u0026thinsp;=\u0026thinsp;0.84), perceived barriers (α\u0026thinsp;=\u0026thinsp;0.86), and the overall questionnaire (α\u0026thinsp;=\u0026thinsp;0.88).\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eData collection procedure\u003c/h2\u003e \u003cp\u003eQuestionnaires were distributed in person during working hours to maximize response rates. Participants completed the questionnaires anonymously and returned them immediately after completion. Confidentiality was assured, and no identifying personal information was collected.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eData management and statistical analysis\u003c/h2\u003e \u003cp\u003eData were entered, coded, and analyzed using SPSS version 26. Descriptive statistics were used to summarize participant characteristics. Frequencies and percentages were calculated for categorical variables, while means and standard deviations were computed for Likert-scale items.\u003c/p\u003e \u003cp\u003eOverall ERAS acceptance was categorized into low, moderate, and high levels based on composite scores. Ordinal logistic regression analysis was performed to identify predictors of ERAS acceptance. Independent variables included workload concerns, ERAS knowledge and training, nursing staff availability, age, years of experience, and hospital type. Results were reported as regression coefficients (β), standard errors, Wald χ\u0026sup2; statistics, and p-values. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. The proportional odds assumption was tested and met.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003ch2\u003eResponse rate and participant characteristics\u003c/h2\u003e \u003cp\u003eOut of 220 surgeons invited to participate in the study, 143 responded, yielding a response rate of 65%, which is considered good for survey-based research. The final sample included surgeons actively practicing in governmental, private, and NGO hospitals in the West Bank, representing various surgical specialties.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eDemographic and professional characteristics\u003c/h2\u003e \u003cp\u003eThe demographic and professional characteristics of participants are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Among the respondents, 57 (39.9%) were older than 45 years, 52 (36.4%) were aged 36\u0026ndash;45 years, and 34 (23.8%) were 35 years or younger. Most participants were male (124, 86.7%), while 19 (13.3%) were female. More than half of the surgeons had over 10 years of experience (79, 55.2%), followed by 38 (26.6%) with 6\u0026ndash;10 years and 26 (18.2%) with \u0026le;\u0026thinsp;5 years. Only 29 surgeons (20.3%) reported having received formal ERAS training.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eAdditional characteristics are \u003cb\u003epresented in\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of demographic and professional characteristics among participating surgeons (n\u0026thinsp;=\u0026thinsp;143)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge group (years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34 (23.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e36\u0026ndash;45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e52 (36.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e57 (39.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e124 (86.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19 (13.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eYears of experience\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26 (18.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38 (26.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e79 (55.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHospital type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGovernmental hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e61 (42.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivate hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46 (32.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNGO/Charity hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e36 (25.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSpecialty\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e59 (41.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrthopedic surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24 (16.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObstetrics/Gynecology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21 (14.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14 (9.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeurosurgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10 (7.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther surgical specialties\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15 (10.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReceived ERAS training\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29 (20.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e114 (79.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eERAS: Enhanced recovery after surgery, NGO: nongovernmental organization\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eSurgeons\u0026rsquo; awareness of key ERAS principles\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eSurgeons demonstrated high awareness of key ERAS principles (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The highest\u003c/p\u003e \u003cp\u003eawareness was observed for early mobilization (121, 84.6%) and early urinary catheter\u003c/p\u003e \u003cp\u003eremoval (118, 82.5%). Awareness of preoperative carbohydrate loading was\u003c/p\u003e \u003cp\u003ecomparatively lower (96, 67.1%).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSurgeons\u0026rsquo; awareness of key ERAS principles\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e#\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAgree or strongly agree\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNeutral\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDisagree or strongly disagree\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eERAS principle\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eERAS starts preoperatively and continues postoperatively\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e112 (78.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18 (12.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13 (9.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreoperative carbohydrate loading is part of ERAS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e96 (67.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e27 (18.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20 (14.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGoal-directed fluid therapy is a key ERAS component\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e104 (72.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22 (15.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e17 (11.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEarly urinary catheter removal is recommended\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e118 (82.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15 (10.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10 (7.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEarly oral feeding is allowed in ERAS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e109 (76.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21 (14.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13 (9.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEarly mobilization is a core ERAS principle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e121 (84.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14 (9.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8 (5.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntraoperative thermoregulation is essential in ERAS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e115 (80.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17 (11.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e11 (7.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eERAS: Enhanced recovery after surgery\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eSurgeons\u0026rsquo; awareness of advantages and clinical outcomes of ERAS protocols\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eSurgeons demonstrated high awareness of the clinical benefits of ERAS (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). A\u003c/p\u003e \u003cp\u003etotal of 116 surgeons (81.1%) agreed or strongly agreed that ERAS reduces hospital\u003c/p\u003e \u003cp\u003elength of stay, while 110 (76.9%) recognized its role in lowering postoperative\u003c/p\u003e \u003cp\u003ecomplications. Similarly, 113 surgeons (79.0%) acknowledged that ERAS improves\u003c/p\u003e \u003cp\u003eoverall patient outcomes, and 108 (75.5%) considered ERAS safe for most routine\u003c/p\u003e \u003cp\u003esurgical patients.\u003c/p\u003e \u003cp\u003eThe highest agreement was observed for multimodal analgesia and opioid reduction\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e(119, 83.2%)\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSurgeons\u0026rsquo; awareness of advantages and clinical outcomes of ERAS protocols\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e#\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAgree or strongly agree\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNeutral\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDisagree or strongly disagree\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eERAS advantage\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eERAS reduces postoperative complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e110 (76.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20 (14.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13 (9.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eERAS reduces length of hospital stay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e116 (81.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16 (11.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e11 (7.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eERAS improves overall patient outcomes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e113 (79.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18 (12.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12 (8.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eERAS is safe for most routine surgical patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e108 (75.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21 (14.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14 (9.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMultimodal analgesia and opioid reduction are key ERAS elements\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e119 (83.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15 (10.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9 (6.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eERAS: Enhanced recovery after surgery\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eSelf-reported familiarity with ERAS protocols\u003c/h2\u003e \u003cp\u003eLevels of familiarity with ERAS protocols varied among surgeons (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). High\u003c/p\u003e \u003cp\u003efamiliarity was reported by 68 surgeons (47.5%), while 54 (37.8%) reported moderate\u003c/p\u003e \u003cp\u003efamiliarity.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of surgeons\u0026rsquo; self-reported familiarity with ERAS protocols\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamiliarity level\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow familiarity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21 (14.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate familiarity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e54 (37.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh familiarity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e68 (47.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eAttitudes toward ERAS implementation\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eOverall attitudes toward ERAS implementation were positive (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). A total of 98\u003c/p\u003e \u003cp\u003esurgeons (68.5%) agreed or strongly agreed that ERAS should be routinely\u003c/p\u003e \u003cp\u003eimplemented in surgical practice, with a mean score of 3.82\u0026thinsp;\u0026plusmn;\u0026thinsp;0.89. Similarly, 103\u003c/p\u003e \u003cp\u003esurgeons (72.0%) believed ERAS improves the quality of surgical care (mean\u0026thinsp;=\u0026thinsp;3.88 \u0026plusmn;\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e0.83), while 97 (67.8%) agreed that ERAS enhances patient satisfaction (mean\u0026thinsp;=\u0026thinsp;3.79 \u0026plusmn;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e0.87).\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe highest level of agreement was observed for the statement that ERAS requires\u003c/p\u003e \u003cp\u003estrong multidisciplinary collaboration, endorsed by 113 surgeons (79.0%), with the\u003c/p\u003e \u003cp\u003ehighest mean score of 4.01\u0026thinsp;\u0026plusmn;\u0026thinsp;0.79. Additionally, 92 surgeons (64.3%) expressed\u003c/p\u003e \u003cp\u003epersonal willingness to adopt ERAS protocols in their own practice (mean\u0026thinsp;=\u0026thinsp;3.71 \u0026plusmn;\u003c/p\u003e \u003cp\u003e0.91).\u003c/p\u003e \u003cp\u003eLower agreement was observed for the statement that ERAS reduces postoperative\u003c/p\u003e \u003cp\u003eworkload. Only 74 surgeons (51.7%) agreed that ERAS reduces postoperative\u003c/p\u003e \u003cp\u003eworkload, while 38 (26.6%) remained neutral and 31 (21.7%) disagreed. This item\u003c/p\u003e \u003cp\u003eyielded the lowest mean score (3.43\u0026thinsp;\u0026plusmn;\u0026thinsp;0.98), suggesting that concerns about workload\u003c/p\u003e \u003cp\u003emay represent a barrier to broader acceptance of ERAS protocols.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of surgeons\u0026rsquo; attitudes toward ERAS implementation in surgical practice\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e#\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAgree or strongly agree\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNeutral\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDisagree or strongly disagree\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAttitude statement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eERAS should be routinely implemented in surgical practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e98 (68.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e27 (18.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e18 (12.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e3.82\u0026thinsp;\u0026plusmn;\u0026thinsp;0.89\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eERAS protocols are practical and applicable in daily work\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e85 (59.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e34 (23.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e24 (16.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e3.64\u0026thinsp;\u0026plusmn;\u0026thinsp;0.94\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eERAS improves quality of surgical care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e103 (72.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25 (17.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e15 (10.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e3.88\u0026thinsp;\u0026plusmn;\u0026thinsp;0.83\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eERAS implementation enhances patient satisfaction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e97 (67.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29 (20.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e17 (11.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e3.79\u0026thinsp;\u0026plusmn;\u0026thinsp;0.87\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eERAS implementation reduces postoperative workload\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e74 (51.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e38 (26.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e31 (21.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e3.43\u0026thinsp;\u0026plusmn;\u0026thinsp;0.98\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eERAS protocols require strong multidisciplinary collaboration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e113 (79.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19 (13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e11 (7.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e4.01\u0026thinsp;\u0026plusmn;\u0026thinsp;0.79\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI am personally willing to adopt ERAS in my practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e92 (64.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e31 (21.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20 (14.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e3.71\u0026thinsp;\u0026plusmn;\u0026thinsp;0.91\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eERAS: Enhanced recovery after surgery, SD: standard deviation\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eOverall attitude toward ERAS implementation\u003c/h2\u003e \u003cdiv id=\"Sec21\" class=\"Section3\"\u003e \u003ch2\u003eOverall, 88 surgeons (61.5%) demonstrated a\u003c/h2\u003e \u003cdiv id=\"Sec22\" class=\"Section4\"\u003e \u003ch2\u003epositive attitude toward ERAS implementation\u003c/h2\u003e \u003cp\u003e \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of overall attitude scores toward ERAS implementation among surgeons\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttitude level\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean score range\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNegative attitude\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19 (13.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeutral attitude\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.0\u0026ndash;3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36 (25.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive attitude\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e88 (61.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eFactors affecting surgeons\u0026rsquo; acceptance or reluctance toward ERAS protocols, including perceived advantages, challenges faced, and associated concerns\u003c/b\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eOrdinal logistic regression analysis was performed to identify predictors of ERAS acceptance, categorized as low, moderate, or high (Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e).Concern about\u003c/p\u003e \u003cp\u003eincreased team workload was the only significant predictor of ERAS acceptance (β =\u003c/p\u003e \u003cp\u003e\u0026minus;1.12, p\u0026thinsp;=\u0026thinsp;0.011). Surgeons who perceived ERAS as increasing team workload were\u003c/p\u003e \u003cp\u003esignificantly less likely to report higher levels of acceptance.\u003c/p\u003e \u003cp\u003eNo other variables showed a statistically significant association with ERAS acceptance.\u003c/p\u003e \u003cp\u003e(β = -0.51, p\u0026thinsp;=\u0026thinsp;0.191), absence of formal ERAS training (β = -0.47, p\u0026thinsp;=\u0026thinsp;0.250), nursing\u003c/p\u003e \u003cp\u003estaff shortage (β = -0.58, p\u0026thinsp;=\u0026thinsp;0.107), age (β = -0.29, p\u0026thinsp;=\u0026thinsp;0.348), years of surgical\u003c/p\u003e \u003cp\u003eexperience (β = -0.34, p\u0026thinsp;=\u0026thinsp;0.303), and hospital type (β = -0.22, p\u0026thinsp;=\u0026thinsp;0.432), were not\u003c/p\u003e \u003cp\u003esignificantly associated with ERAS acceptance.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOrdinal logistic regression predicting surgeons\u0026rsquo; acceptance of ERAS protocols\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePredictor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEstimate (β)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eS.E.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eWald χ\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConcern about increased team workload\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-1.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e6.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.011\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLack of ERAS knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e1.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e0.191\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLack of ERAS training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e1.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e0.250\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNursing staff shortage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e2.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e0.107\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e0.348\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears of experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e1.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e0.303\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eHospital type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e-0.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.432\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eRelationship between surgical specialty and awareness and acceptance of ERAS protocols\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eSignificant associations were observed between surgical specialty and several ERAS-\u003c/p\u003e \u003cp\u003erelated components(Table\u0026nbsp;\u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e8\u003c/span\u003e). Awareness of early mobilization differed significantly\u003c/p\u003e \u003cp\u003eacross specialties (χ\u0026sup2; = 9.84, p\u0026thinsp;=\u0026thinsp;0.043), with general surgeons and obstetrics/\u003c/p\u003e \u003cp\u003egynecology surgeons demonstrating higher recognition compared with other specialties.\u003c/p\u003e \u003cp\u003eSimilarly, awareness of early oral feeding was significantly associated with specialty (χ\u0026sup2;\u003c/p\u003e \u003cp\u003e=\u0026thinsp;11.27, p\u0026thinsp;=\u0026thinsp;0.024).\u003c/p\u003e \u003cp\u003eSignificant variation was also observed in knowledge of preoperative carbohydrate\u003c/p\u003e \u003cp\u003eloading (χ\u0026sup2; = 13.62, p\u0026thinsp;=\u0026thinsp;0.009) and goal-directed fluid therapy (χ\u0026sup2; = 10.95, p\u0026thinsp;=\u0026thinsp;0.027),\u003c/p\u003e \u003cp\u003ewith surgeons from general surgery reporting higher awareness than subspecialties\u003c/p\u003e \u003cp\u003esuch as neurosurgery and orthopedics.\u003c/p\u003e \u003cp\u003eAttitudes toward ERAS implementation differed significantly by specialty (χ\u0026sup2; = 8.71, p =\u003c/p\u003e \u003cp\u003e0.048), and overall acceptance levels were also significantly associated with surgical\u003c/p\u003e \u003cp\u003ediscipline (χ\u0026sup2; = 12.33, p\u0026thinsp;=\u0026thinsp;0.015). General surgeons demonstrated the highest\u003c/p\u003e \u003cp\u003eproportion of positive attitudes and high acceptance, whereas subspecialty surgeons\u003c/p\u003e \u003cp\u003eexhibited relatively greater neutrality or reluctance.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab8\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 8\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociation between surgical specialty and key ERAS components\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eERAS element\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eχ\u0026sup2;\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSignificance\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEarly mobilization awareness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.043\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSignificant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEarly oral feeding awareness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.024\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSignificant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative carbohydrate loading awareness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.009\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSignificant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGoal-directed fluid therapy awareness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.027\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSignificant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive attitude toward ERAS implementation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.048\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSignificant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall ERAS acceptance level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.015\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSignificant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eAssociation between surgical specialty and ERAS awareness, attitudes, and workload perception\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eChi-square analysis revealed significant differences in ERAS awareness across surgical specialties (Table\u0026nbsp;\u003cspan refid=\"Tab9\" class=\"InternalRef\"\u003e9\u003c/span\u003e). General surgeons and obstetrics/gynecology surgeons consistently demonstrated higher recognition of core ERAS principles, including early mobilization, early oral feeding, carbohydrate loading, and goal-directed fluid therapy (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). In contrast, lower awareness was observed among orthopedic and neurosurgical surgeons, particularly for metabolic optimization components.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab9\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 9\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eERAS awareness by surgical specialty (% agreeing/strongly agreeing)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eERAS Component\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGeneral surgery\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOrthopedic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOb/Gyn\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUrology\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNeurosurgery\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEarly mobilization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e91.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e90.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e78.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e70.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.043\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEarly oral feeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e71.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e60.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.024\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCarbohydrate loading\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e71.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e57.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e40.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.009\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGoal-directed fluids\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e81.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e64.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e50.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.027\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eOverall acceptance of ERAS protocols also varied significantly by specialty (p\u0026thinsp;=\u0026thinsp;0.015). General surgeons reported the highest proportion of high acceptance, whereas neurosurgeons and orthopedic surgeons demonstrated greater levels of moderate or low acceptance (Table\u0026nbsp;\u003cspan refid=\"Tab10\" class=\"InternalRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab10\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 10\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOverall ERAS acceptance level by specialty\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecialty\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh acceptance\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003e0.015\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrthopedic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOb/Gyn\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeurosurgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eImportantly, perception of increased team workload differed significantly across specialties (p\u0026thinsp;=\u0026thinsp;0.008). Neurosurgeons and orthopedic surgeons were most likely to perceive ERAS as increasing workload, while general surgeons reported the lowest workload concern (Table\u0026nbsp;\u003cspan refid=\"Tab11\" class=\"InternalRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab11\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 11\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePerception of increased team workload by specialty (% agreeing ERAS increases workload)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecialty\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrthopedic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOb/Gyn\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeurosurgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ep-value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0.008\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provides the first systematic assessment of surgeons\u0026rsquo; awareness, attitudes, and acceptance of Enhanced Recovery After Surgery (ERAS) protocols in Palestinian hospitals. Overall, surgeons demonstrated good awareness of core ERAS principles, particularly early mobilization, early oral feeding, and urinary catheter removal, while awareness of preoperative carbohydrate loading and goal-directed fluid therapy was lower. These findings align with international reports, where low- and middle-income countries often show limited implementation of metabolic optimization components due to resource constraints and concerns about aspiration risk [15, 18, 19].\u003c/p\u003e \u003cp\u003eAttitudes toward ERAS were generally positive, with most surgeons recognizing its potential to improve patient outcomes, reduce complications, and enhance satisfaction. Similar trends have been reported in high-income countries, where surgeons view ERAS as a framework to enhance recovery and care quality [13, 14]. However, practical barriers, particularly perceived increases in team workload, were the main limitation to broader adoption. This is consistent with studies from the Middle East, Asia, and Eastern Europe, where staffing shortages and high patient volumes hinder ERAS implementation [15, 16].\u003c/p\u003e \u003cp\u003eThe variation in awareness and acceptance across surgical specialties underscores the need for tailored interventions. General surgeons reported higher familiarity and acceptance compared with orthopedic and neurosurgical surgeons, reflecting greater exposure to ERAS protocols in general and colorectal surgery pathways [13, 21]. This pattern is consistent with findings from Europe and North America, where specialty-specific familiarity strongly influences implementation [21, 22].\u003c/p\u003e \u003cp\u003eEvidence from high-resource healthcare settings suggests that ERAS can ultimately reduce workload by shortening hospital stays and minimizing complications [22, 23]. The discrepancy between perceived and actual workload highlights the importance of institutional support, adequate staffing, and structured multidisciplinary collaboration to realize the benefits of ERAS.\u003c/p\u003e \u003cp\u003eIn conclusion, Palestinian surgeons are conceptually aligned with ERAS principles, but adoption is constrained by perceived workload challenges. Targeted education, policy integration, and resource allocation are essential to facilitate sustainable ERAS implementation, improve surgical outcomes, and enhance patient recovery.\u003c/p\u003e \u003cdiv id=\"Sec26\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThis study has several limitations that should be acknowledged. First, the use of a convenience sampling technique may limit the generalizability of the findings, as surgeons who were more available or interested in ERAS may have been overrepresented. Second, the reliance on self-administered questionnaires introduces the possibility of response bias, particularly social desirability bias, as participants may have provided answers they perceived as favorable rather than reflecting their actual practices. Third, the study was conducted exclusively in hospitals within the West Bank, which may not fully capture the perspectives of surgeons working in other Palestinian regions or in different healthcare systems. Finally, while the questionnaire demonstrated strong reliability, it primarily assessed awareness and attitudes rather than actual implementation practices, meaning the results reflect perceptions rather than observed behavior. These limitations suggest that future research should employ probability sampling, include observational components, and expand to broader geographic contexts to strengthen the external validity of the findings\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThis study highlights that surgeons in Palestinian hospitals possess strong awareness of core ERAS principles and generally positive attitudes toward their implementation, yet practical barriers, particularly concerns about increased team workload, remain the primary obstacle to widespread adoption. While knowledge gaps in components such as carbohydrate loading and goal-directed fluid therapy mirror challenges reported internationally, the overall acceptance of ERAS demonstrates readiness for integration if institutional support, multidisciplinary collaboration, and targeted training are prioritized. By addressing workload concerns and reinforcing under-recognized elements through structured education and policy frameworks, Palestinian healthcare systems can move toward comprehensive ERAS implementation, ultimately improving surgical outcomes, reducing complications, and enhancing patient recovery\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eERAS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEnhanced Recovery After Surgery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNGO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNon\u0026ndash;governmental Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStandard Deviation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSPSS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStatistical Package for the Social Sciences\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003eEthical approval for this study was obtained from the Institutional Review Board (IRB) of An-Najah National University (IRB Protocol Number: Med. Jan. 2025/5; approval date: 5 January 2025). Participation was voluntary, and informed consent was obtained from all participants prior to data collection. All procedures were conducted in accordance with relevant ethical guidelines and regulations and the principles of the Declaration of Helsinki.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable, as the manuscript does not contain any individual person\u0026rsquo;s data in any form.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis research received no external funding.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eST, BN, DA, and NK contributed to the study conception and design. Data collection was performed by ST, BN, DA, and NK. Data analysis and interpretation were conducted by all authors. The manuscript was drafted by ST, BN, DA, and NK and critically revised for important intellectual content by MHH, AA, and AD. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors would like to thank the supervisors and faculty members who provided guidance and support during the development of this research. The authors also express their appreciation to all surgeons who participated in this study and contributed their time and insights.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClinical trial number: not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMaswime S, Jayaraman S, Alaba O, Robalo M. Universal access to surgical care\u0026mdash;A global public health priority. PLOS Glob Public Health. 2025;5(4):e0004326.\u003c/li\u003e\n\u003cli\u003eAnandalwar S, Sifri Z, Hopkins MA, Whitley D, Harfouche M, Narayan M. Evolution of global surgery: lessons learned and a look toward the future. Trauma Surg Acute Care Open. 2025;10(Suppl 3):e001541.\u003c/li\u003e\n\u003cli\u003eHarvie DA, Levett DZH, Grocott MPW. Understanding outcomes after major surgery. Anesth Analg. 2023;136(4):655\u0026ndash;664.\u003c/li\u003e\n\u003cli\u003ePapautsky EL. Patient decision making in recovering from surgery. Front Psychol. 2023;14:1170658.\u003c/li\u003e\n\u003cli\u003eCunha MF, Pellino G. Environmental effects of surgical procedures and strategies for sustainable surgery. Nat Rev Gastroenterol Hepatol. 2023;20(6):399\u0026ndash;410.\u003c/li\u003e\n\u003cli\u003eLe HD, Wolinska JM, Baertschiger RM, Himidan SA. Complication is inevitable, but suffering is optional: psychological aspects of dealing with complications in surgery. Eur J Pediatr Surg. 2023;33(3):181\u0026ndash;190.\u003c/li\u003e\n\u003cli\u003eStokes SM, Scaife CL, Brooke BS, Glasgow RE, Mulvihill SJ, Finlayson SRG, et al. Hospital costs following surgical complications: a value-driven outcomes analysis. Ann Surg. 2022;275(2):e375\u0026ndash;e381.\u003c/li\u003e\n\u003cli\u003eHe Y, Wang R, Wang F, Chen L, Shang T, Zheng L. Clinical effect and safety of new preoperative fasting guidelines for elective surgery: a systematic review and meta-analysis. Gland Surg. 2022;11(3):563\u0026ndash;575.\u003c/li\u003e\n\u003cli\u003eSilva J\u0026uacute;nior RER, Soriano CA, Lima PAS, de Oliveira Santos BF, Pereira WGN, de Brito Filho MT, et al. Beyond guidelines: the persistent challenge of preoperative fasting times. Surgeries. 2023;4(4):611\u0026ndash;622.\u003c/li\u003e\n\u003cli\u003eSharma V, Prasad J, Choudhary K, Choudhary D. Traditional prolonged fasting: time to change practice. Eur J Mol Clin Med. 2022;9(3):2245\u0026ndash;2255.\u003c/li\u003e\n\u003cli\u003eStenberg E, dos Reis Falc\u0026atilde;o LF, O\u0026rsquo;Kane M, Liem R, Pournaras DJ, Salminen P, et al. Guidelines for perioperative care in bariatric surgery: ERAS Society recommendations\u0026mdash;2021 update. World J Surg. 2022;46(4):729\u0026ndash;751.\u003c/li\u003e\n\u003cli\u003eMithany RH, Daniel N, Shahid MH, Aslam S, Abdelmaseeh M, Gerges F, et al. Revolutionizing surgical care: the power of enhanced recovery after surgery (ERAS). Cureus. 2023;15(11):e48976.\u003c/li\u003e\n\u003cli\u003eSmith TW, Wang X, Singer MA, Godellas CV, Vaince FT. Enhanced recovery after surgery: implementation across surgical subspecialties. Am J Surg. 2020;219(3):530\u0026ndash;534.\u003c/li\u003e\n\u003cli\u003eKamal U, Issa Y, Beta E. Enhanced recovery after surgery protocols: transforming perioperative care. ASA Monitor. 2025;89(4):18\u0026ndash;20.\u003c/li\u003e\n\u003cli\u003eKifle F, Kenna P, Daniel S, Maswime S, Biccard B. ERAS protocol implementation and impact in Africa: a scoping review. Perioper Med (Lond). 2024;13:86.\u003c/li\u003e\n\u003cli\u003eHong M, Ghajar M, Allen W, Jasti S, Alvarez-Downing MM. Implementation costs of ERAS in colorectal surgery: a systematic review. World J Surg. 2023;47(7):1589\u0026ndash;1596.\u003c/li\u003e\n\u003cli\u003eWright RM, Nelson G. Applying principles of enhanced recovery after surgery. Br J Surg. 2025;112(9):znaf194.\u003c/li\u003e\n\u003cli\u003eHaselton SD, Chadayammuri VP, Emerson RH. Preoperative carbohydrate loading in ERAS for elective total hip arthroplasty. Clin Nutr ESPEN. 2025;68:602\u0026ndash;607.\u003c/li\u003e\n\u003cli\u003eLu J, Khamar J, McKechnie T, Lee Y, Amin N, Hong D, et al. Preoperative carbohydrate loading before colorectal surgery: systematic review and meta-analysis. Int J Colorectal Dis. 2022;37(12):2431\u0026ndash;2450.\u003c/li\u003e\n\u003cli\u003ePogatschnik C, Steiger E. Review of preoperative carbohydrate loading. Nutr Clin Pract. 2015;30(5):660\u0026ndash;664.\u003c/li\u003e\n\u003cli\u003eG\u0026oacute;mez-Hidalgo NR, Pletnev A, Razumova Z, Bizzarri N, Selcuk I, Theofanakis C, et al. ERAS implementation in gynecologic oncology across Europe. Int J Gynecol Obstet. 2023;160(1):306\u0026ndash;312.\u003c/li\u003e\n\u003cli\u003eBarajas-Gamboa JS, Zhan K, Khan MSI, Lopez Meyer JC, Pantoja JP, Abril C, et al. ERAS reduces complications and length of stay in bariatric surgery. Obes Surg. 2025;35(10):4171\u0026ndash;4182.\u003c/li\u003e\n\u003cli\u003eBalachandran S, Alharrasi M, Al Dhabbari F, Al Masroori F. Knowledge of perioperative guidelines and barriers among cardiac nurses. J Educ Health Promot. 2025;14:447.\u003c/li\u003e\n\u003cli\u003e\u0026Ouml;z\u0026ccedil;elik M. Implementation of ERAS protocols: in theory and practice. Turk J Anaesthesiol Reanim. 2024;52(5):163\u0026ndash;168.\u003c/li\u003e\n\u003cli\u003eZhang Q, Sun Q, Li J, Fu X, Wu Y, Zhang J, et al. Impact of ERAS and multidisciplinary teams in colorectal cancer. Pain Ther. 2024;14(1):201\u0026ndash;215.\u003c/li\u003e\n\u003c/ol\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Enhanced Recovery After Surgery, ERAS, Surgeons, Awareness, Attitudes, Acceptance, Perioperative Care, Palestine","lastPublishedDoi":"10.21203/rs.3.rs-8990946/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8990946/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEnhanced Recovery After Surgery (ERAS) is a multidisciplinary, evidence-based set of perioperative care protocols designed to reduce surgical stress, optimize recovery, and improve patient outcomes. It integrates practices such as early mobilization, optimized pain control, reduced fasting, and goal-directed fluid therapy, requiring collaboration among surgeons, anesthesiologists, nurses, and allied health professionals. This study aimed to assess surgeons’ awareness, attitudes, and acceptance of ERAS protocols and to identify factors influencing their adoption in Palestinian hospitals.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA cross-sectional study was conducted among 143 surgeons working in governmental, private, and teaching hospitals. Data were collected using a structured, self-administered questionnaire developed through a literature review and validated by an expert panel. Reliability testing demonstrated strong internal consistency (Cronbach’s α = 0.88 overall). Descriptive statistics summarized demographic characteristics, awareness, and attitudes, while ordinal logistic regression analysis was used to identify predictors of ERAS acceptance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSurgeons demonstrated high awareness of core ERAS principles, particularly early mobilization (84.6%), early urinary catheter removal (82.5%), and intraoperative thermoregulation (80.4%). Awareness of preoperative carbohydrate loading (67.1%) and goal-directed fluid therapy (72.7%) was comparatively lower. Attitudes toward ERAS were generally positive, with most surgeons recognizing its potential to improve patient outcomes, reduce complications, and enhance satisfaction. Regression analysis showed that concern about increased team workload was the only significant predictor of lower ERAS acceptance (β = −1.12, p = 0.011).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSurgeons in Palestinian hospitals conceptually support ERAS and acknowledge its benefits; however, practical barriers, particularly concerns related to team workload, limit its broader adoption. Addressing these challenges requires institutional support, adequate staffing, and strengthened multidisciplinary collaboration.\u003c/p\u003e","manuscriptTitle":"Assessing Awareness and Attitudes Toward Enhanced Recovery After Surgery (ERAS) Protocols Among Surgeons in Palestinian Hospitals: A Cross-Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-25 11:23:08","doi":"10.21203/rs.3.rs-8990946/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"155048019150155201582967680508417127402","date":"2026-05-06T12:09:05+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-23T15:09:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"99133621874652473175055190990482655996","date":"2026-03-21T13:48:18+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-20T14:15:33+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-10T13:16:33+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-09T17:56:30+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2026-03-09T14:06:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b17bd090-4e75-40a1-9d3b-5b467f2139ce","owner":[],"postedDate":"March 25th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"155048019150155201582967680508417127402","date":"2026-05-06T12:09:05+00:00","index":30,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-25T11:23:08+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-25 11:23:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8990946","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8990946","identity":"rs-8990946","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}