A Scoping review of Enhanced Recovery After Surgery (ERAS), protocol implementation, and its impact on surgical outcomes and healthcare systems in Africa

A Scoping review of Enhanced Recovery After Surgery (ERAS), protocol implementation, and its impact on surgical outcomes and healthcare systems in Africa | 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 A Scoping review of Enhanced Recovery After Surgery (ERAS), protocol implementation, and its impact on surgical outcomes and healthcare systems in Africa Fitsum Kifle, Peniel Kenna, Selam Daniel, Salome Maswime, Bruce Biccard This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4488858/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 Aug, 2024 Read the published version in Perioperative Medicine → Version 1 posted 9 You are reading this latest preprint version Abstract Background Enhanced Recovery After Surgery (ERAS) is a patient-centered approach to surgery designed to reduce stress responses and facilitate faster recovery. ERAS protocols have been widely adopted in high-income countries, supported by robust research demonstrating improved patient outcomes. However, in Africa, there is limited evidence regarding its implementation. This review aims to identify the existing literature on the implementation of ERAS principles in Africa, the reported clinical outcomes, and the challenges and recommendations for successful implementation. Methods We conducted a librarian-assisted literature search of electronic research databases between October and November 2023. Titles and abstracts were screened for eligibility, duplicates were then removed, followed by full-text assessment of potentially eligible studies. We utilized the summative content analysis method to synthesize and group the data into fewer categories based on agreed-upon criteria. Descriptive statistics were used to describe the results. Results The search identified 342 potential studies resulting in 15 eligible studies for inclusion in the review. The publication years ranged from 2016 to 2023. The studies originated from three countries: Egypt (n = 10), South Africa (n = 4), and Uganda (n = 1). Successful implementation was associated with reduced hospital length of stay (n = 12), lower mortality rates (n = 3), and improved pain outcomes (n = 7). Challenges included protocol adherence (n = 5) and limitations in research design to generate strong evidence (n = 3). Recommendations included formal adoption of ERAS principles (n = 5), the need for a sustained research commitment, and exploration of the applicability of ERAS in diverse surgical contexts (n = 8). Large-scale implementation beyond individual institutions was encouraged for further validation of its impact on patient outcomes and healthcare costs (n = 1). Conclusions Despite the limited number of studies on ERAS implementation in Africa, the available evidence suggests that it reduces the length of hospital stays and mortality rates. This is crucial for the region, given its higher mortality rates, necessitating more collaborative, methodically well-designed studies to establish stronger evidence for ERAS in lower resource environments. ERAS Africa outcomes review Figures Figure 1 Background The Enhanced Recovery After Surgery (ERAS) concept was introduced in the early 1990s based on improved understanding of the pathophysiology of postoperative recovery ( 1 – 3 ). ERAS is a comprehensive approach to perioperative care that aims to reduce the stress response to surgery, enabling a faster recovery and return to baseline function ( 3 – 5 ). Implementing ERAS protocols has shown significant benefits in various surgical specialties, leading to improved patient satisfaction and reduced healthcare costs ( 6 ). Over the past three decades, ERAS has gained popularity and widespread adoption in hospitals worldwide ( 1 , 3 ). Its holistic approach to patient management is not only improving patient outcomes but also fostering collaboration between healthcare disciplines, resulting in a more efficient and patient-centered surgical experience. In high-income countries, ERAS has become the standard of care for various surgical procedures, supported by specialty-specific guidelines and protocols ( 3 , 5 , 7 , 8 ). The adoption of ERAS practices is supported by a strong ERAS societal establishment and evidence-based research ( 5 , 9 ). The ERAS society provides continuous education and support to healthcare professionals, ensuring they remain current with ERAS protocols ( 9 , 10 ). The society helps validate the effectiveness of ERAS practices, further encouraging their widespread adoption in surgical settings. Currently, the society is active in over 20 countries, and evidence from these member states demonstrates that ERAS protocols have significantly improved patient outcomes, including reduced complications and shorter hospital stays ( 3 , 9 ). This evidence supports the global expansion of ERAS implementation. However, the evidence on the implementation of ERAS practice in Africa is very limited ( 11 ), and most reports from the region are from small-scale studies or anecdotal reports. Additionally, resource constraints may further hinder the widespread implementation of ERAS in this region. In this scoping review, we aimed to identify and analyze the existing literature on the implementation of ERAS practice in Africa. By examining the current evidence, we hope to gain insights into the challenges and opportunities for implementing ERAS in this region, as well as identify potential strategies for overcoming barriers and promoting successful adoption of ERAS protocols. Aim The primary objective of this scoping review is to assess the literature on implementing ERAS protocols in African healthcare. The secondary objectives are to identify clinical outcomes, and the challenges related to the adoption of ERAS across African surgical settings. Method This scoping review followed Joanna Briggs Institute (JBI's) guidelines for scoping reviews ( 12 ). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) was used for reporting ( 13 ). This review was conducted in accordance with an a priori protocol registered in the open science framework https://doi.org/10.17605/OSF.IO/D4N52 Review questions What is the extent of literature available on the implementation of Enhanced Recovery After Surgery (ERAS) protocols in African healthcare settings? What are the common reported practices and clinical outcomes associated with the adoption of ERAS protocols in various surgical specialties in Africa? What are the challenges in the implementation of ERAS protocols within the African context? What are the recommendations for the successful implementation of ERAS protocols in African surgical practice? Are there gaps in the current research, and what areas require further investigation to understand the impact of ERAS protocols on surgical outcomes in African populations? Search strategy An independent librarian assisted systematic search of electronic databases, including PubMed, Scopus, Embase, Cochrane, and Web of Sciences was conducted between October and November 2023. The search strategy included keywords related to Africa, names of African countries, Enhanced Recovery After Surgery (ERAS), and Fast-Track Surgery, as shown in Appendix 1. Inclusion and exclusion criteria Inclusion criteria: The inclusion criteria for the study were defined using the updated methodological guidance for the conduct of scoping reviews using the ‘Population, Context, and Concept’ (PCCs) framework ( 14 ). The population included patients and healthcare providers in African healthcare settings. The context included healthcare settings providing surgery across Africa. The central concept investigated was the implementation and impact of Enhanced Recovery After Surgery (ERAS) protocols across various surgical specialties within African healthcare settings. The inclusion criteria were therefore defined as: Publication type: peer-reviewed journal articles. Geographic focus: studies conducted in any African country or healthcare setting. Time period: time filter was not applied to include all relevant studies. Language: studies published in English or, if available, with English translations or abstract. Topic relevance: studies exploring the implementation and impact of ERAS protocols in surgical practice within the African context. The exclusion criteria were: Publication type: conference abstracts, letters, editorials, and commentaries. Geographic focus: studies conducted outside of Africa. Time period: date and time filters were not applied. Language: studies published in languages other than English, with no available translations. Topic irrelevance: studies that do not focus on the implementation and impact of ERAS protocols on surgical practice within the African context. Data screening and analysis All studies were imported into the Mendeley software, and duplicates were removed. All studies were assessed in duplicate for eligibility by FK, PK, and SD, who also performed full-text assessments of potentially eligible studies following the screening of titles and abstracts for eligibility. The agreement on the full-text assessments was based on the pre-established inclusion and exclusion criteria of the study, listed above. In cases of disagreement, the matter was referred to SM and BB for comprehensive evaluation to ensure the inclusion of relevant research. We extracted data on ERAS implementation and the reported outcomes, challenges encountered, and recommendations on ERAS implementation data for our study, as shown in Appendix 2. Data analysis was conducted using Google Spreadsheet to organize and summarize the relevant studies based on the specified criteria. The variables from included publications were extracted to the spreadsheet, which included titles, authors, publication year, journal name, country of study, study design, language of study, and topic of relevance. Data synthesis was performed on the topic of relevance, geographic focus, reported clinical outcomes, challenges in adopting, and recommendations associated with the implementation of ERAS practice in African settings. We utilized the summative content analysis method to synthesize and group these data into fewer categories based on agreed-upon and predefined criteria ( 15 ). Descriptive statistics were used to present the characteristics of the included studies, and tables were used to present the findings. The following are the predefined criteria: Clinical outcomes after implementation refer to the observable effects and results of implementing ERAS protocols, as reported by the investigators. Challenges encountered in implementing the ERAS protocol refer to obstacles or difficulties faced during the adoption and execution of ERAS guidelines, as described by the investigators. Recommendations proposed refer to suggested actions or strategies proposed to address the challenges identified in implementing ERAS protocols. Results The database search identified 342 potential studies. After removal of duplicates, title and abstract review, citation search, and full-text review, 12 eligible studies were identified. A search of the reference lists of the eligible studies identified an additional three studies, with a total of 15 studies included in the analysis. The search results and inclusion and exclusion processes are shown in Fig. 1 . Characteristics of included studies Fifteen articles were included which evaluated the implementation of ERAS protocols across various surgical specialties in African healthcare settings. The surgical procedures included gastrointestinal ( 16 ), bariatric ( 17 ), colorectal ( 18 ), radical cystectomy ( 19 ), total hip and knee arthroplasty ( 20 , 21 ), emergency cesarean deliveries ( 22 ), kidney transplantation ( 23 ), abdominal hysterectomy (n = 3) ( 24 – 26 ), spinal surgery ( 27 ), gynecologic ( 28 ) and, gynecologic oncology (n = 2) ( 29 , 30 ). The publications were from three African countries: Egypt (n = 10) ( 16 , 19 , 23 – 30 ), South Africa (n = 4) ( 17 , 18 , 20 , 21 ), and Uganda (n = 1) ( 22 ) published between 2016 and 2023. The research methodologies included prospective cohorts (n = 6) ( 16 – 20 , 29 ), randomized controlled trials (RCT) (n = 4) ( 22 , 24 , 27 , 28 ), retrospective cohorts (n = 2) ( 21 , 23 ), non-randomized clinical trials (n = 1) ( 30 ), and quasi-experimental designs (n = 2) ( 25 , 26 ). A further description of the characteristics of the included studies are shown Table 1 . Table 1 Characteristics of the included studies Title Year of publication Journal Country Surgical specialty Sample size Type of Research Enhanced recovery protocols versus traditional methods after resection and re-anastomosis in gastrointestinal surgery in pediatric patients( 15 ) 2018 Annals of Pediatric Surgery Egypt Gastrointestinal Surgery 60 prospective cohort The Successful Implementation of a Modified Enhanced Recovery After Surgery (ERAS) Program for Bariatric Surgery in a South African Teaching Hospital ( 16 ) 2018 Surgical Laparoscopy Endoscopy & Percutaneous Techniques South Africa Bariatric Surgery 62 Prospective Cohort Implementation of enhanced recovery after surgery for endometrial carcinoma: a non-randomized controlled trial ( 29 ) 2019 BMJ Egypt Endometrial Carcinoma 58 Non-randomized clinical trail Quality of recovery after total hip and knee arthroplasty in South Africa: a national prospective observational cohort study ( 19 ) 2020 BMC Musculoskeletal Disorders South Africa Total Hip and Knee Arthroplasty 186 Prospective Cohort Implementation of enhanced recovery after surgery in gynecological operations: a randomized controlled trial ( 27 ) 2020 Ain-Shams Journal of Anesthesiology Egypt Gynecological Operations 216 RCT Implementation of Enhanced Recovery After Surgery as a Protocol Versus Routine Care on Women Undergoing Hysterectomy.( 23 ) 2020 Assiut Scientific Nursing Journal Egypt Abdominal Hysterectomy 140 RCT Improvement of Outcome by Implementation of Enhanced Recovery Pathway in Gynecologic/ Oncology Surgery ( 28 ) 2021 EJHM- Egypt Gynecological Oncologic Surgeries 54 Prospective cohort Colorectal surgical outcomes following implementation of an enhanced recovery after surgery programme in Cape Town ( 17 ) 2021 South African Journal of Surgery South Africa Colorectal 457 Prospective cohort The efficacy of enhanced recovery protocol from anesthesia in diabetic patients undergoing radical cystectomy ( 18 ) 2021 Alexandria Journal of Medicine Egypt Radical Cystectomy 54 prospective cohort A Randomized Controlled Trial of Enhanced Recovery After Surgery Versus Standard of Care Recovery for Emergency Cesarean Deliveries at Mbarara Hospital, Uganda ( 21 ) 2022 anesthesia-analgesia Uganda Emergency Cesarean Deliveries 160 RCT Comparing outcomes between enhanced recovery after surgery and traditional protocols in total knee arthroplasty: a retrospective cohort study ( 20 ) 2022 South African Orthopaedic Journal South Africa Total Knee Arthroplasty 119 Retrospective cohort Enhanced Recovery After Surgery Pathway in Kidney Transplantation: The Road Less Traveled ( 22 ) 2022 Transplantation direct Egypt Kidney Transplantation 20 Retrospective cohort Effect of Enhanced Recovery After Surgery Protocol on Postoperative Outcomes of Women Undergoing Abdominal Hysterectomy ( 24 ) 2023 SAGE Open Nurs Egypt Abdominal Hysterectomy 118 Quasi-experimental design Enhanced recovery after spinal surgery protocol versus conventional care in non- insulin diabetic patients: A prospective randomized trial ( 26 ) 2023 Egypt Spinal Surgery 72 RCT Effect of Enhanced Recovery nursing program on recovery process of women after hysterectomy operation in Suez Canal University Hospital and General Hospital at Ismailia City ( 25 ) 2023 IJNRHN Egypt Abdominal Hysterectomy 132 quasi-experimental study Keys; BMC- Biomed Central BMJ- British Medical Journal EJHM- Egyptian Journal of Hospital Medicine IJNRHN- International Journal of Novel Research in Healthcare and Nursing RCT – Randomized Control Trial SAMJ- South African Medical Journal Findings of the Review A. Reported clinical outcomes The reported clinical outcomes of ERAS implementation include a reduction in hospital length of stay (n = 12) ( 16 , 17 , 19 – 22 , 24 , 25 , 28 – 31 ), lower mortality rates (n = 3) ( 17 , 19 , 26 ), lower pain scores and improved pain management (n = 7) ( 20 – 22 , 26 – 29 ), and a decrease in hospital re-admissions (n = 2) ( 19 , 28 ). Implementation was also associated with a decrease in morbidity (n = 6) ( 17 , 20 , 26 , 28 , 30 , 31 ), and an increase in early mobility (n = 4)( 22 , 26 – 28 ). Improvement in the functional scores (n = 1) ( 26 ), patient satisfaction (n = 1) ( 26 ), early rehabilitation (n = 1) ( 26 ), and the prompt initiation of oral feeding (n = 3) ( 18 , 27 , 28 ), were also reported following the implementation of ERAS. ERAS was associated with cost savings (n = 4) ( 20 , 26 , 29 , 30 ), optimizing antibiotic use (n = 1) ( 18 ), refining fluid management (n = 2) ( 21 , 24 ), and improved overall quality of recovery (n = 2) ( 21 , 29 ). Table 2 further describes the reported clinical outcomes of ERAS implementations. Table 2 Reported clinical outcomes. Clinical Outcome of ERAS Protocol Number of articles Reduced Hospital Length Of Stay ( 14 , 15 , 16 , 17 , 18 , 19 , 20 , 22 , 23 , 26 , 27 , 28 ) 12 Reduced Pain Score and Improved Management ( 18 – 20 , 24 – 27 ) 7 Reduced Morbidity ( 15 , 18 , 23 , 26 , 29 , 28 ) 6 Early Mobility ( 20 , 24 , 25 , 26 ) 4 Lowered Overall Costs ( 18 , 24 , 27 , 28 ) 4 Reduced Mortality ( 15 , 17 , 24 ) 3 Early Initiation of Oral Feeding ( 16 , 25 , 26 ) 3 Reduced Re-Admission ( 17 , 26 ) 2 Decrease In IV Fluid Requirement ( 19 , 22 ) 2 Improved Quality of Recovery ( 19 , 27 ) 2 Improvement In Functional Scores ( 24 ) 1 Reduced Catheterization Duration ( 20 ) 1 Improved Patient Satisfaction( 24 ) 1 Early Rehabilitation ( 24 ) 1 Better Postoperative Follow-Up ( 15 ) 1 Reduced Postoperative Fever and Chest Infection ( 14 ) 1 Shorter Duration of Antibiotic Use ( 16 ) 1 B. Reported challenges ERAS protocols presented numerous challenges. There was a lack of standardization of practice (n = 2) ( 18 , 19 ), hindering uniform implementation. There were challenges in adhering to the recommended protocols (n = 5) ( 19 , 21 , 27 , 28 , 30 ). Limitations in research design and methodologies compromising the ability to generate strong evidence were acknowledged (n = 3) ( 27 – 29 ). A lack of trained staff (n = 2) ( 21 , 23 ), patient education (n = 1) ( 28 ), and multidisciplinary collaboration (n = 3) ( 22 , 28 , 30 ), were also reported as challenges to optimize ERAS effectiveness. Resistance to change (n = 3) ( 20 – 22 ), posed a barrier to widespread acceptance, while difficulty conducting preoperative optimization (n = 1) ( 26 ), and resource limitations (n = 1) ( 26 ), were additional challenges. Table 3 shows the reported challenges. Table 3 Reported Challenges Challenges in Adopting the Protocol Number of articles Adherence to protocols ( 17 , 19 , 25 , 26 , 28 ) 5 Multidisciplinary collaboration ( 26 )( 28 )( 20 ) 3 Resistance to change ( 18 )( 19 )( 20 ) 3 Research design limitation ( 25 – 27 ) 3 Lacked standardization ( 16 , 17 ) 2 Lack of trained staff and awareness ( 19 , 20 ) 2 Patient education ( 26 ) 1 Difficulty of conducting preoperative optimization( 23 ) 1 Resource limitation ( 23 ) 1 C. Recommendations Several recommendations were made in the reviewed publications to aid adoption and implementation of ERAS protocols in Africa. Firstly, there was a call for the practical implementation of ERAS principles within surgical practices (n = 5) ( 16 , 19 , 24 – 26 ). Additionally, it was recommended that ERAS should not merely remain a set of principles but should be formally adopted and established as a standard of care in medical practices, with four studies supporting this proposition (n = 4) ( 20 – 22 , 28 ). Furthermore, studies advocated for a sustained commitment to research efforts, encompassing the evaluation of ERAS effectiveness, potential modifications for improved outcomes, and exploration of its applicability in different surgical contexts (n = 8) ( 17 – 19 , 22 , 25 , 26 , 28 , 29 ). The feasibility and effectiveness of ERAS in Low- and Middle-Income Countries (LMICs) was emphasized (n = 1) ( 17 ). There was also a recommendation to extend ERAS implementation to various surgical disciplines across the African continent (n = 1)( 17 ). The recognition of perioperative care as a distinct sub-specialty was recommended (n = 1) ( 20 ). There was a call for the undertaking of cost-effectiveness analyses related to ERAS implementation (n = 2) ( 22 , 25 ), aiming to assess the economic implications and benefits associated with adopting these protocols in low resource environments. Table 4 shows the recommendations made by the authors for the future implementation and expansion of ERAS programs in African health care settings. Table 4 Reported recommendations. Recommendations Number of articles Further Research ( 15 – 17 , 20 , 23 , 24 , 26 )( 27 ) 8 To implement the protocol ( 14 , 17 , 22 , 23 , 24 ) 5 Protocol be adopted as a standard of care( 18 – 20 , 26 ) 4 Education and training ( 19 , 28 ) 2 Continuous evaluation ( 19 , 28 ) 2 To conduct a cost-effectiveness analysis( 20 , 23 ) 2 Team collaboration ( 28 ) 1 ERAS is feasible and effective in a LMICs ( 15 ) 1 ERAS could be implemented for other forms of surgery In South Africa and across the African context ( 15 ) 1 Recognition of perioperative care as a sub-specialty ( 18 ) 1 Specialty specific tailored protocol ( 20 ) 1 Discussion The principal findings of this review are that ERAS protocols can improve patient recovery and postoperative outcomes in African healthcare settings. Although the number of studies is limited (n = 15), the studies included in this review showed positive impacts of ERAS implementation, including reduced hospital length of stay (n = 12), lower mortality rates (n = 3), and improved pain management of patients (n = 7). However, challenges such as lack of adherence to protocols (n = 5), standardization (n = 2) and trained staff (n = 2) were identified, and the need for further research (n = 8) was recommended to fully understand the potential benefits and barriers of implementing ERAS protocols in African healthcare settings. Despite using an inclusive and comprehensive search strategy the number of existing studies on the implementation of ERAS protocols in Africa is very low, as we were only able to find a few studies (n = 15) and they were limited to certain geographical locations, as most of these studies were conducted in Egypt (n = 10) and South Africa (n = 4). This finding is also consistent with a study of the global distribution of ERAS research, which found that most studies have been conducted in high-income countries ( 11 ). Furthermore, the implementation efforts were mostly in obstetric and gynecological procedures (n = 7). While this is a positive step, as most surgical procedures are obstetric in Africa ( 32 , 33 ), it is important to increase these studies towards other Bellwether surgeries as well, i.e. emergency laparotomy and treatment of open fractures ( 34 ). As the capacity to perform these Bellwether procedures are related with performing all obstetric, general, basic, emergency, and orthopedic procedures, and the findings to be gained from the implementation of ERAS practices might also then, easily extend to the broader group of surgical procedures ( 34 ). The findings presented in this review highlight the multifaceted benefits of ERAS protocols in improving various aspects of patient outcomes and healthcare resource utilization. One notable improvement is the consistent reduction in hospital length of stay across the studies (n = 12), suggesting a more efficient recovery process facilitated by ERAS. This not only contributes to cost savings but also aligns with the broader healthcare priority of minimizing waste and optimizing resource utilization ( 35 ), especially in Africa's health care system, where resources are often limited and in high demand ( 36 – 38 ). The decrease in mortality rates, lower morbidity, and reduced need for re-admission highlight the positive impact of implementing ERAS on a large scale in Africa, where high mortality and morbidity rates exist ( 33 ). ERAS protocols can help address these challenges by improving patient outcomes and reducing the burden on healthcare systems. There were several challenges identified in ERAS protocol implementation that highlight the difficulties of optimizing ERAS practices in African clinical settings. The lack of standardization, presents a significant hurdle, impeding consistent application across diverse healthcare contexts. A proposed guideline for ERAS implementation in LMICs could assist in addressing some of these challenges ( 39 ). Other challenges related to resistance to change and adherence to ERAS protocol are inevitable challenges of change management ( 40 ), also reported globally ( 1 ). However, overcoming resistance to change and ensuring adherence to protocols will require multidisciplinary collaboration, leadership, and evidence-based strategies ( 41 , 42 ). Even though these are mentioned as some of the challenges, they are also considered recommendations and hence should be part of the solution. In addition, providing adequate training and education to healthcare providers and providing continuous patient education can help in effectively implementing ERAS protocols and ensuring their long-term success. The limitations in research design emphasizes the need for robust studies to inform high-level evidence-based practices for ERAS in Africa. This review suggests that the practical integration (n = 5) and formal adoption of ERAS principles within surgical practices is crucial to improving patient outcomes, which is also supported by another review conducted to assess the feasibility of LMICs, which suggests the utilization of implementation sciences ( 43 ). This formal adoption would ensure consistent implementation of ERAS principles across different surgical practices, leading to improved patient outcomes and reduced variability in care. This review suggests that this needs to be supported by ongoing education and training of healthcare professionals to effectively implement and sustain ERAS protocols in clinical settings. There is a general recommendation for the need for further research to gather more evidence to support ERAS in Africa (n = 8). This was also highlighted as one of the national perioperative research priorities in South Africa where a stepped-wedge trial of an ERAS program for surgical, obstetric, and trauma procedures was recommended ( 44 ). The authors of this article also stress the importance of conducting well-designed studies with larger sample sizes to provide more robust evidence on the effectiveness and safety of ERAS protocols in diverse clinical settings and surgical procedures. They also recommend that future research focus on evaluating the cost-effectiveness and long-term outcomes associated with implementing these protocols, either fully or partially. The limitation of this review is as it is scoping review, and it did not include a comprehensive analysis of all available literature on ERAS programs. Additionally, the studies primarily focused on short-term outcomes and did not thoroughly examine potential complications or adverse events associated with ERAS protocols. Further research is needed to address these gaps in knowledge and provide a more comprehensive understanding of the benefits and limitations of implementing ERAS programs in various healthcare settings. Declarations Ethics The University of Cape Town Human Research Ethics Committee has waived the need for ethics in the study, as it does not involve human or animal participants. This decision was communicated in letter Ref number 220/2024. Conflicts of interest The authors/reviewers declare that they have no conflict of interest. Competing interests None to declare. Funding This study is partially supported by the University of Cape Town Department of Anaesthesia and Perioperative Medicine through a grant secured from the National Institute for Health and Care Research (NIHR) Global Health Group on Perioperative and Critical Care. Author Contribution FK, PK, and SD conducted the literature search, screened articles, and extracted data. FK analyzed data and drafted the initial manuscript, while SD and BB provided critical revisions and feedback to improve the final version and supervise the project. All authors approved the final manuscript for submission. Acknowledgement The authors would like to thank Ms. Dilshaad Brey (UCT librarian) for her assistance during the database searches and in organising the search results. References Kehlet H. Enhanced postoperative recovery: good from afar, but far from good? Anaesthesia [Internet]. 2020 Jan 1 [cited 2023 Oct 29];75 Suppl 1(S1):e54–61. 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Ahmed H, Atia G, Keshk EA, Abd-Allah IM. Effect of Enhanced Recovery nursing program on recovery process of women after hysterectomy operation in Suez Canal University Hospital and General Hospital at Ismailia City. International Journal of Novel Research in Healthcare and Nursing [Internet]. [cited 2023 Dec 10];7:165–77. Available from: www.noveltyjournals.com Elgamal SM, Abdelhalim AA, Arida EA, Elhabashy AM, Sabra RAE. Enhanced recovery after spinal surgery protocol versus conventional care in non- insulin diabetic patients: A prospective randomized trial. Egypt J Anaesth [Internet]. 2023 Dec 31 [cited 2023 Nov 30];39(1):313–21. Available from: https://www.tandfonline.com/doi/abs/10.1080/11101849.2023.2196113 Abdelrazik AN, Sanad AS. Implementation of enhanced recovery after surgery in gynecological operations: a randomized controlled trial. Ain-Shams Journal of Anesthesiology 2020 12:1 [Internet]. 2020 Dec 11 [cited 2023 Nov 30];12(1):1–9. Available from: https://asja.springeropen.com/articles/10.1186/s42077-020-00116-4 Sarhan AMM, Dayem HMA, Abdelrahman HMF, Elnaem RAA. Improvement of Outcome by Implementation of Enhanced Recovery Pathway in Gynecologic/ Oncology Surgery. Egypt J Hosp Med [Internet]. 2021 Apr 1 [cited 2023 Dec 10];83(1):856–61. Available from: https://ejhm.journals.ekb.eg/article_156458.html Sameer A, El-Gindi E, El-Khateeb R, Abdelrazik A, Moussa A, Hafiz A. EP615 Implementation of enhanced recovery after surgery for endometrial carcinoma: a non-randomized controlled trial. International Journal of Gynecologic Cancer [Internet]. 2019 Nov 1 [cited 2023 Nov 30];29(Suppl 4):A361.1-A361. Available from: https://ijgc.bmj.com/content/29/Suppl_4/A361.1 Oodit RL, Ljungqvist O, Moodley J. Can an Enhanced Recovery After Surgery (ERAS) programme improve colorectal cancer outcomes in South Africa? South African Journal of Surgery [Internet]. 2018 Nov;56(1):8–11. Available from: http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612018000100002&lng=en&nrm=iso&tlng=en Bentounsi Z, Sheik-Ali S, Drury G, Lavy C. Surgical care in district hospitals in sub-Saharan Africa: a scoping review. BMJ Open [Internet]. 2021 Mar 1 [cited 2023 Dec 7];11(3):e042862. Available from: https://bmjopen.bmj.com/content/11/3/e042862 Biccard BM, Madiba TE, Kluyts HL, Munlemvo DM, Madzimbamuto FD, Basenero A, et al. Perioperative patient outcomes in the African Surgical Outcomes Study: a 7-day prospective observational cohort study. Lancet [Internet]. 2018 Apr 21 [cited 2023 Dec 7];391(10130):1589–98. Available from: https://pubmed.ncbi.nlm.nih.gov/29306587/ O’Neill KM, Greenberg SLM, Cherian M, Gillies RD, Daniels KM, Roy N, et al. Bellwether Procedures for Monitoring and Planning Essential Surgical Care in Low- and Middle-Income Countries: Caesarean Delivery, Laparotomy, and Treatment of Open Fractures. World J Surg [Internet]. 2016 Nov 1 [cited 2023 Apr 19];40(11):2611–9. Available from: https://link.springer.com/article/10.1007/s00268-016-3614-y Zlaugotne B, Pubule J, Gusca J, Kalnins SN. Quantitative and Qualitative Assessment of Healthcare Waste and Resource Potential Assessment. Environmental and Climate Technologies. 2022 Jan 1;26(1):64–74. Lavy C, Sauven K, Mkandawire N, Charian M, Gosselin R, Ndihokubwayo JB, et al. State of surgery in tropical Africa: A review. World J Surg [Internet]. 2011 Feb 14 [cited 2023 Dec 7];35(2):262–71. Available from: https://link.springer.com/article/10.1007/s00268-010-0885-6 Mehta A, Andrew Awuah W, Tunde Aborode A, Cheng Ng J, Candelario K, Vieira IMP, et al. Telesurgery’s potential role in improving surgical access in Africa. Annals of Medicine and Surgery [Internet]. 2022 Oct 1 [cited 2023 Dec 7];82:104511. Available from: /pmc/articles/PMC9577435/ Frimpong-Boateng K, Edwin F. Surgical leadership in Africa - Challenges and opportunities. Innov Surg Sci [Internet]. 2020 Jun 1 [cited 2023 Dec 7];4(2):59–64. Available from: https://www.degruyter.com/document/doi/10.1515/iss-2018-0036/html?lang=en Oodit R, Biccard BM, Panieri E, Alvarez AO, Sioson MRS, Maswime S, et al. Guidelines for Perioperative Care in Elective Abdominal and Pelvic Surgery at Primary and Secondary Hospitals in Low–Middle-Income Countries (LMIC’s): Enhanced Recovery After Surgery (ERAS) Society Recommendation. World Journal of Surgery 2022 46:8 [Internet]. 2022 May 31 [cited 2023 Apr 19];46(8):1826–43. Available from: https://link.springer.com/article/10.1007/s00268-022-06587-w MacPhee M. Strategies and tools for managing change. Journal of Nursing Administration. 2007 Sep;37(9):405–13. Tippireddy S, Ghatol D. Anesthetic Management for Enhanced Recovery After Major Surgery (ERAS). StatPearls [Internet]. 2023 Jan 29 [cited 2024 May 16]; Available from: https://www.ncbi.nlm.nih.gov/books/NBK574567/ Gramlich LM, Sheppard CE, Wasylak T, Gilmour LE, Ljungqvist O, Basualdo-Hammond C, et al. Implementation of Enhanced Recovery After Surgery: A strategy to transform surgical care across a health system. Implementation Science [Internet]. 2017 May 19 [cited 2024 May 16];12(1):1–17. Available from: https://implementationscience.biomedcentral.com/articles/10.1186/s13012-017-0597-5 Riad AM, Barry A, Knight SR, Arbaugh CJ, Haque PD, Weiser TG, et al. Perioperative optimisation in low- and middle-income countries (LMICs): A systematic review and meta-analysis of enhanced recovery after surgery (ERAS). J Glob Health [Internet]. 2023 [cited 2023 Dec 7];13:4114. Available from: /pmc/articles/PMC10546475/ Biccard BM, Alphonsus CS, Bishop DG, Cronje L, Kluyts HL, Kusel B, et al. National priorities for perioperative research in South Africa. S Afr Med J [Internet]. 2016 May 1 [cited 2023 Dec 7];106(5):485–8. Available from: https://pubmed.ncbi.nlm.nih.gov/27138668/ Appendix Appendices 1 and 2 are not available with this version. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 02 Aug, 2024 Read the published version in Perioperative Medicine → Version 1 posted Editorial decision: Revision requested 22 Jun, 2024 Reviews received at journal 22 Jun, 2024 Reviewers agreed at journal 14 Jun, 2024 Reviews received at journal 02 Jun, 2024 Reviewers agreed at journal 01 Jun, 2024 Reviewers invited by journal 30 May, 2024 Editor assigned by journal 29 May, 2024 Submission checks completed at journal 29 May, 2024 First submitted to journal 28 May, 2024 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. 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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-4488858","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":313194010,"identity":"df50274b-c103-4ce3-90a1-36f06205934e","order_by":0,"name":"Fitsum Kifle","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAArklEQVRIiWNgGAWjYBAC9mYwZcPA2ECsFp7DzCAqjYGZeC0HwFoOM7ATr4Wd//Bn3pzzebyzmx9+YKixiSashZmZTZp32+1iyTnHjCUYjqXlErTNHqiFGaglceOMHDZgGBwmrAVoC/Nn3m3nEvffIEELA9BhBxIbSbHFTHLutuTERpBfEojxCw//wccf3m6zS2wEhdiHGhvCWhBAAogTiFcO0zIKRsEoGAWjABsAAP0EOLubcT2NAAAAAElFTkSuQmCC","orcid":"","institution":"University of Cape Town","correspondingAuthor":true,"prefix":"","firstName":"Fitsum","middleName":"","lastName":"Kifle","suffix":""},{"id":313194011,"identity":"e376250c-eed2-4ea1-a724-ce50a9ba2888","order_by":1,"name":"Peniel Kenna","email":"","orcid":"","institution":"Debre Berhan University Asrat Woldyes Health Sciences Campus","correspondingAuthor":false,"prefix":"","firstName":"Peniel","middleName":"","lastName":"Kenna","suffix":""},{"id":313194012,"identity":"6b397511-c840-40d7-8c9f-6d8cff20ec65","order_by":2,"name":"Selam Daniel","email":"","orcid":"","institution":"Kidus Petros Hospital","correspondingAuthor":false,"prefix":"","firstName":"Selam","middleName":"","lastName":"Daniel","suffix":""},{"id":313194013,"identity":"65d95b00-50bd-463b-8c49-18e28347b02d","order_by":3,"name":"Salome Maswime","email":"","orcid":"","institution":"University of Cape Town","correspondingAuthor":false,"prefix":"","firstName":"Salome","middleName":"","lastName":"Maswime","suffix":""},{"id":313194014,"identity":"c16904c5-ed31-485f-b915-abaecd71aef2","order_by":4,"name":"Bruce Biccard","email":"","orcid":"","institution":"University of Cape Town","correspondingAuthor":false,"prefix":"","firstName":"Bruce","middleName":"","lastName":"Biccard","suffix":""}],"badges":[],"createdAt":"2024-05-28 07:21:56","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4488858/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4488858/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13741-024-00435-2","type":"published","date":"2024-08-02T15:57:43+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":58314715,"identity":"3405870b-d716-49f6-8728-bedd07933267","added_by":"auto","created_at":"2024-06-13 20:51:14","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":64276,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA workflow diagram\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4488858/v1/855cc4bc42bc0909ba678847.png"},{"id":61793961,"identity":"e9c9b2e1-ee80-418c-a27e-5d68d2511ab6","added_by":"auto","created_at":"2024-08-05 16:17:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":816932,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4488858/v1/740f85ca-5efa-4b07-af15-c02629f5699a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Scoping review of Enhanced Recovery After Surgery (ERAS), protocol implementation, and its impact on surgical outcomes and healthcare systems in Africa","fulltext":[{"header":"Background","content":"\u003cp\u003eThe Enhanced Recovery After Surgery (ERAS) concept was introduced in the early 1990s based on improved understanding of the pathophysiology of postoperative recovery (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). ERAS is a comprehensive approach to perioperative care that aims to reduce the stress response to surgery, enabling a faster recovery and return to baseline function (\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Implementing ERAS protocols has shown significant benefits in various surgical specialties, leading to improved patient satisfaction and reduced healthcare costs (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Over the past three decades, ERAS has gained popularity and widespread adoption in hospitals worldwide (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Its holistic approach to patient management is not only improving patient outcomes but also fostering collaboration between healthcare disciplines, resulting in a more efficient and patient-centered surgical experience.\u003c/p\u003e \u003cp\u003eIn high-income countries, ERAS has become the standard of care for various surgical procedures, supported by specialty-specific guidelines and protocols (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The adoption of ERAS practices is supported by a strong ERAS societal establishment and evidence-based research (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). The ERAS society provides continuous education and support to healthcare professionals, ensuring they remain current with ERAS protocols (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The society helps validate the effectiveness of ERAS practices, further encouraging their widespread adoption in surgical settings. Currently, the society is active in over 20 countries, and evidence from these member states demonstrates that ERAS protocols have significantly improved patient outcomes, including reduced complications and shorter hospital stays (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). This evidence supports the global expansion of ERAS implementation.\u003c/p\u003e \u003cp\u003eHowever, the evidence on the implementation of ERAS practice in Africa is very limited (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), and most reports from the region are from small-scale studies or anecdotal reports. Additionally, resource constraints may further hinder the widespread implementation of ERAS in this region. In this scoping review, we aimed to identify and analyze the existing literature on the implementation of ERAS practice in Africa. By examining the current evidence, we hope to gain insights into the challenges and opportunities for implementing ERAS in this region, as well as identify potential strategies for overcoming barriers and promoting successful adoption of ERAS protocols.\u003c/p\u003e \u003cp\u003eAim\u003c/p\u003e \u003cp\u003eThe primary objective of this scoping review is to assess the literature on implementing ERAS protocols in African healthcare. The secondary objectives are to identify clinical outcomes, and the challenges related to the adoption of ERAS across African surgical settings.\u003c/p\u003e "},{"header":"Method","content":"\u003cp\u003eThis scoping review followed Joanna Briggs Institute (JBI's) guidelines for scoping reviews (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) was used for reporting (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). This review was conducted in accordance with an a priori protocol registered in the open science framework \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.17605/OSF.IO/D4N52\u003c/span\u003e\u003cspan address=\"10.17605/OSF.IO/D4N52\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eReview questions\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat is the extent of literature available on the implementation of Enhanced Recovery After Surgery (ERAS) protocols in African healthcare settings?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat are the common reported practices and clinical outcomes associated with the adoption of ERAS protocols in various surgical specialties in Africa?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat are the challenges in the implementation of ERAS protocols within the African context?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat are the recommendations for the successful implementation of ERAS protocols in African surgical practice?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAre there gaps in the current research, and what areas require further investigation to understand the impact of ERAS protocols on surgical outcomes in African populations?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e\n\u003ch3\u003eSearch strategy\u003c/h3\u003e\n\u003cp\u003eAn independent librarian assisted systematic search of electronic databases, including PubMed, Scopus, Embase, Cochrane, and Web of Sciences was conducted between October and November 2023. The search strategy included keywords related to Africa, names of African countries, Enhanced Recovery After Surgery (ERAS), and Fast-Track Surgery, as shown in Appendix 1.\u003c/p\u003e \u003cp\u003eInclusion and exclusion criteria\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eInclusion criteria:\u003c/h2\u003e \u003cp\u003eThe inclusion criteria for the study were defined using the updated methodological guidance for the conduct of scoping reviews using the \u0026lsquo;Population, Context, and Concept\u0026rsquo; (PCCs) framework (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The population included patients and healthcare providers in African healthcare settings. The context included healthcare settings providing surgery across Africa. The central concept investigated was the implementation and impact of Enhanced Recovery After Surgery (ERAS) protocols across various surgical specialties within African healthcare settings.\u003c/p\u003e \u003cp\u003eThe inclusion criteria were therefore defined as:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePublication type: peer-reviewed journal articles.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eGeographic focus: studies conducted in any African country or healthcare setting.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTime period: time filter was not applied to include all relevant studies.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eLanguage: studies published in English or, if available, with English translations or abstract.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTopic relevance: studies exploring the implementation and impact of ERAS protocols in surgical practice within the African context.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eThe exclusion criteria were:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePublication type: conference abstracts, letters, editorials, and commentaries.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eGeographic focus: studies conducted outside of Africa.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTime period: date and time filters were not applied.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eLanguage: studies published in languages other than English, with no available translations.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTopic irrelevance: studies that do not focus on the implementation and impact of ERAS protocols on surgical practice within the African context.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData screening and analysis\u003c/h2\u003e \u003cp\u003eAll studies were imported into the Mendeley software, and duplicates were removed. All studies were assessed in duplicate for eligibility by FK, PK, and SD, who also performed full-text assessments of potentially eligible studies following the screening of titles and abstracts for eligibility. The agreement on the full-text assessments was based on the pre-established inclusion and exclusion criteria of the study, listed above. In cases of disagreement, the matter was referred to SM and BB for comprehensive evaluation to ensure the inclusion of relevant research. We extracted data on ERAS implementation and the reported outcomes, challenges encountered, and recommendations on ERAS implementation data for our study, as shown in Appendix 2.\u003c/p\u003e \u003cp\u003eData analysis was conducted using Google Spreadsheet to organize and summarize the relevant studies based on the specified criteria. The variables from included publications were extracted to the spreadsheet, which included titles, authors, publication year, journal name, country of study, study design, language of study, and topic of relevance. Data synthesis was performed on the topic of relevance, geographic focus, reported clinical outcomes, challenges in adopting, and recommendations associated with the implementation of ERAS practice in African settings. We utilized the summative content analysis method to synthesize and group these data into fewer categories based on agreed-upon and predefined criteria (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Descriptive statistics were used to present the characteristics of the included studies, and tables were used to present the findings.\u003c/p\u003e \u003cp\u003eThe following are the predefined criteria:\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eClinical outcomes after implementation\u003c/strong\u003e \u003cp\u003erefer to the observable effects and results of implementing ERAS protocols, as reported by the investigators.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eChallenges encountered in implementing the ERAS protocol\u003c/strong\u003e \u003cp\u003erefer to obstacles or difficulties faced during the adoption and execution of ERAS guidelines, as described by the investigators.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eRecommendations proposed\u003c/strong\u003e \u003cp\u003erefer to suggested actions or strategies proposed to address the challenges identified in implementing ERAS protocols.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe database search identified 342 potential studies. After removal of duplicates, title and abstract review, citation search, and full-text review, 12 eligible studies were identified. A search of the reference lists of the eligible studies identified an additional three studies, with a total of 15 studies included in the analysis. The search results and inclusion and exclusion processes are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eCharacteristics of included studies\u003c/p\u003e \u003cp\u003eFifteen articles were included which evaluated the implementation of ERAS protocols across various surgical specialties in African healthcare settings. The surgical procedures included gastrointestinal (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), bariatric (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), colorectal (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), radical cystectomy (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), total hip and knee arthroplasty (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), emergency cesarean deliveries (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), kidney transplantation (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e), abdominal hysterectomy (n\u0026thinsp;=\u0026thinsp;3) (\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), spinal surgery (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), gynecologic (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) and, gynecologic oncology (n\u0026thinsp;=\u0026thinsp;2) (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe publications were from three African countries: Egypt (n\u0026thinsp;=\u0026thinsp;10) (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan additionalcitationids=\"CR24 CR25 CR26 CR27 CR28 CR29\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), South Africa (n\u0026thinsp;=\u0026thinsp;4) (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), and Uganda (n\u0026thinsp;=\u0026thinsp;1) (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) published between 2016 and 2023. The research methodologies included prospective cohorts (n\u0026thinsp;=\u0026thinsp;6) (\u003cspan additionalcitationids=\"CR17 CR18 CR19\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), randomized controlled trials (RCT) (n\u0026thinsp;=\u0026thinsp;4) (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), retrospective cohorts (n\u0026thinsp;=\u0026thinsp;2) (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e), non-randomized clinical trials (n\u0026thinsp;=\u0026thinsp;1) (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), and quasi-experimental designs (n\u0026thinsp;=\u0026thinsp;2) (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). A further description of the characteristics of the included studies are shown Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\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\u003eCharacteristics of the included studies\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=\"char\" char=\".\" 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=\"char\" char=\".\" 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\u003eTitle\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYear of publication\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eJournal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCountry\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSurgical specialty\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSample size\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eType of Research\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnhanced recovery protocols versus traditional methods after resection and re-anastomosis in gastrointestinal surgery in pediatric patients(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAnnals of Pediatric Surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEgypt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGastrointestinal Surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eprospective cohort\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe Successful Implementation of a Modified Enhanced Recovery After Surgery (ERAS) Program for Bariatric Surgery in a South African Teaching Hospital (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eSurgical Laparoscopy Endoscopy \u0026amp; Percutaneous Techniques\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSouth Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBariatric Surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eProspective Cohort\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImplementation of enhanced recovery after surgery for endometrial carcinoma: a non-randomized controlled trial (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBMJ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEgypt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEndometrial Carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNon-randomized clinical trail\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuality of recovery after total hip and knee arthroplasty in South Africa: a national prospective observational cohort study (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBMC Musculoskeletal Disorders\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSouth Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal Hip and Knee Arthroplasty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e186\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eProspective Cohort\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImplementation of enhanced recovery after surgery in gynecological operations: a randomized controlled trial (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAin-Shams Journal of Anesthesiology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEgypt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGynecological Operations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e216\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRCT\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImplementation of Enhanced Recovery After Surgery as a Protocol Versus Routine Care on Women Undergoing Hysterectomy.(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eAssiut Scientific Nursing Journal\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEgypt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAbdominal Hysterectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e140\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRCT\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImprovement of Outcome by Implementation of Enhanced Recovery Pathway in Gynecologic/ Oncology Surgery (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEJHM-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEgypt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGynecological Oncologic Surgeries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eProspective cohort\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eColorectal surgical outcomes following implementation of an enhanced recovery after surgery programme in Cape Town (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSouth African Journal of Surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSouth Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eColorectal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e457\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eProspective cohort\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe efficacy of enhanced recovery protocol from anesthesia in diabetic patients undergoing radical cystectomy (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAlexandria Journal of Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEgypt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRadical Cystectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eprospective cohort\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA Randomized Controlled Trial of Enhanced Recovery After Surgery Versus Standard of Care Recovery for Emergency Cesarean Deliveries at Mbarara Hospital, Uganda (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eanesthesia-analgesia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUganda\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEmergency Cesarean Deliveries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e160\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRCT\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComparing outcomes between enhanced recovery after surgery and traditional protocols in total knee arthroplasty: a retrospective cohort study (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSouth African Orthopaedic Journal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSouth Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal Knee Arthroplasty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e119\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnhanced Recovery After Surgery Pathway in Kidney Transplantation: The Road Less Traveled (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTransplantation direct\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEgypt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eKidney Transplantation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEffect of Enhanced Recovery After Surgery Protocol on Postoperative Outcomes of Women Undergoing Abdominal Hysterectomy (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSAGE Open Nurs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEgypt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAbdominal Hysterectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e118\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eQuasi-experimental design\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnhanced recovery after spinal surgery protocol versus conventional care in non- insulin diabetic patients: A prospective randomized trial (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEgypt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSpinal Surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRCT\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEffect of Enhanced Recovery nursing program on recovery process of women after hysterectomy operation in Suez Canal University Hospital and General Hospital at Ismailia City (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIJNRHN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEgypt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAbdominal Hysterectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e132\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003equasi-experimental study\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eKeys;\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eBMC- Biomed Central\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eBMJ- British Medical Journal\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eEJHM- Egyptian Journal of Hospital Medicine\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eIJNRHN- International Journal of Novel Research in Healthcare and Nursing\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eRCT \u0026ndash; Randomized Control Trial\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eSAMJ- South African Medical Journal\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFindings of the Review\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eA. Reported clinical outcomes\u003c/h2\u003e \u003cp\u003eThe reported clinical outcomes of ERAS implementation include a reduction in hospital length of stay (n\u0026thinsp;=\u0026thinsp;12) (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan additionalcitationids=\"CR20 CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan additionalcitationids=\"CR29 CR30\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e), lower mortality rates (n\u0026thinsp;=\u0026thinsp;3) (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), lower pain scores and improved pain management (n\u0026thinsp;=\u0026thinsp;7) (\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan additionalcitationids=\"CR27 CR28\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), and a decrease in hospital re-admissions (n\u0026thinsp;=\u0026thinsp;2) (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Implementation was also associated with a decrease in morbidity (n\u0026thinsp;=\u0026thinsp;6) (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e), and an increase in early mobility (n\u0026thinsp;=\u0026thinsp;4)(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eImprovement in the functional scores (n\u0026thinsp;=\u0026thinsp;1) (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), patient satisfaction (n\u0026thinsp;=\u0026thinsp;1) (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), early rehabilitation (n\u0026thinsp;=\u0026thinsp;1) (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), and the prompt initiation of oral feeding (n\u0026thinsp;=\u0026thinsp;3) (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), were also reported following the implementation of ERAS. ERAS was associated with cost savings (n\u0026thinsp;=\u0026thinsp;4) (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), optimizing antibiotic use (n\u0026thinsp;=\u0026thinsp;1) (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), refining fluid management (n\u0026thinsp;=\u0026thinsp;2) (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), and improved overall quality of recovery (n\u0026thinsp;=\u0026thinsp;2) (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e further describes the reported clinical outcomes of ERAS implementations.\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\u003eReported clinical outcomes.\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\u003eClinical Outcome of ERAS Protocol\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of articles\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReduced Hospital Length Of Stay (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReduced Pain Score and Improved Management (\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan additionalcitationids=\"CR25 CR26\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReduced Morbidity (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEarly Mobility (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLowered Overall Costs (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReduced Mortality (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEarly Initiation of Oral Feeding (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReduced Re-Admission (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDecrease In IV Fluid Requirement (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImproved Quality of Recovery (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImprovement In Functional Scores (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReduced Catheterization Duration (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImproved Patient Satisfaction(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEarly Rehabilitation (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBetter Postoperative Follow-Up (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReduced Postoperative Fever and Chest Infection (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShorter Duration of Antibiotic Use (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\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=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eB. Reported challenges\u003c/h2\u003e \u003cp\u003eERAS protocols presented numerous challenges. There was a lack of standardization of practice (n\u0026thinsp;=\u0026thinsp;2) (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), hindering uniform implementation. There were challenges in adhering to the recommended protocols (n\u0026thinsp;=\u0026thinsp;5) (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Limitations in research design and methodologies compromising the ability to generate strong evidence were acknowledged (n\u0026thinsp;=\u0026thinsp;3) (\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). A lack of trained staff (n\u0026thinsp;=\u0026thinsp;2) (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e), patient education (n\u0026thinsp;=\u0026thinsp;1) (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), and multidisciplinary collaboration (n\u0026thinsp;=\u0026thinsp;3) (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), were also reported as challenges to optimize ERAS effectiveness. Resistance to change (n\u0026thinsp;=\u0026thinsp;3) (\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), posed a barrier to widespread acceptance, while difficulty conducting preoperative optimization (n\u0026thinsp;=\u0026thinsp;1) (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), and resource limitations (n\u0026thinsp;=\u0026thinsp;1) (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), were additional challenges. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the reported challenges.\u003c/p\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\u003eReported Challenges\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\u003eChallenges in Adopting the Protocol\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of articles\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdherence to protocols (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMultidisciplinary collaboration (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResistance to change (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResearch design limitation (\u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLacked standardization (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLack of trained staff and awareness (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient education (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDifficulty of conducting preoperative optimization(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResource limitation (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\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=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eC. Recommendations\u003c/h2\u003e \u003cp\u003eSeveral recommendations were made in the reviewed publications to aid adoption and implementation of ERAS protocols in Africa. Firstly, there was a call for the practical implementation of ERAS principles within surgical practices (n\u0026thinsp;=\u0026thinsp;5) (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Additionally, it was recommended that ERAS should not merely remain a set of principles but should be formally adopted and established as a standard of care in medical practices, with four studies supporting this proposition (n\u0026thinsp;=\u0026thinsp;4) (\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Furthermore, studies advocated for a sustained commitment to research efforts, encompassing the evaluation of ERAS effectiveness, potential modifications for improved outcomes, and exploration of its applicability in different surgical contexts (n\u0026thinsp;=\u0026thinsp;8) (\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). The feasibility and effectiveness of ERAS in Low- and Middle-Income Countries (LMICs) was emphasized (n\u0026thinsp;=\u0026thinsp;1) (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). There was also a recommendation to extend ERAS implementation to various surgical disciplines across the African continent (n\u0026thinsp;=\u0026thinsp;1)(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). The recognition of perioperative care as a distinct sub-specialty was recommended (n\u0026thinsp;=\u0026thinsp;1) (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). There was a call for the undertaking of cost-effectiveness analyses related to ERAS implementation (n\u0026thinsp;=\u0026thinsp;2) (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e), aiming to assess the economic implications and benefits associated with adopting these protocols in low resource environments. Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows the recommendations made by the authors for the future implementation and expansion of ERAS programs in African health care settings.\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\u003eReported recommendations.\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\u003eRecommendations\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of articles\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFurther Research (\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTo implement the protocol (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProtocol be adopted as a standard of care(\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation and training (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContinuous evaluation (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTo conduct a cost-effectiveness analysis(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTeam collaboration (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eERAS is feasible and effective in a LMICs (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eERAS could be implemented for other forms of surgery In South Africa and across the African context (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecognition of perioperative care as a sub-specialty (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecialty specific tailored protocol (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\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\u003eThe principal findings of this review are that ERAS protocols can improve patient recovery and postoperative outcomes in African healthcare settings. Although the number of studies is limited (n\u0026thinsp;=\u0026thinsp;15), the studies included in this review showed positive impacts of ERAS implementation, including reduced hospital length of stay (n\u0026thinsp;=\u0026thinsp;12), lower mortality rates (n\u0026thinsp;=\u0026thinsp;3), and improved pain management of patients (n\u0026thinsp;=\u0026thinsp;7). However, challenges such as lack of adherence to protocols (n\u0026thinsp;=\u0026thinsp;5), standardization (n\u0026thinsp;=\u0026thinsp;2) and trained staff (n\u0026thinsp;=\u0026thinsp;2) were identified, and the need for further research (n\u0026thinsp;=\u0026thinsp;8) was recommended to fully understand the potential benefits and barriers of implementing ERAS protocols in African healthcare settings.\u003c/p\u003e \u003cp\u003eDespite using an inclusive and comprehensive search strategy the number of existing studies on the implementation of ERAS protocols in Africa is very low, as we were only able to find a few studies (n\u0026thinsp;=\u0026thinsp;15) and they were limited to certain geographical locations, as most of these studies were conducted in Egypt (n\u0026thinsp;=\u0026thinsp;10) and South Africa (n\u0026thinsp;=\u0026thinsp;4). This finding is also consistent with a study of the global distribution of ERAS research, which found that most studies have been conducted in high-income countries (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Furthermore, the implementation efforts were mostly in obstetric and gynecological procedures (n\u0026thinsp;=\u0026thinsp;7). While this is a positive step, as most surgical procedures are obstetric in Africa (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e), it is important to increase these studies towards other Bellwether surgeries as well, i.e. emergency laparotomy and treatment of open fractures (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). As the capacity to perform these Bellwether procedures are related with performing all obstetric, general, basic, emergency, and orthopedic procedures, and the findings to be gained from the implementation of ERAS practices might also then, easily extend to the broader group of surgical procedures (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe findings presented in this review highlight the multifaceted benefits of ERAS protocols in improving various aspects of patient outcomes and healthcare resource utilization. One notable improvement is the consistent reduction in hospital length of stay across the studies (n\u0026thinsp;=\u0026thinsp;12), suggesting a more efficient recovery process facilitated by ERAS. This not only contributes to cost savings but also aligns with the broader healthcare priority of minimizing waste and optimizing resource utilization (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e), especially in Africa's health care system, where resources are often limited and in high demand (\u003cspan additionalcitationids=\"CR37\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). The decrease in mortality rates, lower morbidity, and reduced need for re-admission highlight the positive impact of implementing ERAS on a large scale in Africa, where high mortality and morbidity rates exist (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). ERAS protocols can help address these challenges by improving patient outcomes and reducing the burden on healthcare systems.\u003c/p\u003e \u003cp\u003eThere were several challenges identified in ERAS protocol implementation that highlight the difficulties of optimizing ERAS practices in African clinical settings. The lack of standardization, presents a significant hurdle, impeding consistent application across diverse healthcare contexts. A proposed guideline for ERAS implementation in LMICs could assist in addressing some of these challenges (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Other challenges related to resistance to change and adherence to ERAS protocol are inevitable challenges of change management (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e), also reported globally (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). However, overcoming resistance to change and ensuring adherence to protocols will require multidisciplinary collaboration, leadership, and evidence-based strategies (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). Even though these are mentioned as some of the challenges, they are also considered recommendations and hence should be part of the solution. In addition, providing adequate training and education to healthcare providers and providing continuous patient education can help in effectively implementing ERAS protocols and ensuring their long-term success. The limitations in research design emphasizes the need for robust studies to inform high-level evidence-based practices for ERAS in Africa.\u003c/p\u003e \u003cp\u003eThis review suggests that the practical integration (n\u0026thinsp;=\u0026thinsp;5) and formal adoption of ERAS principles within surgical practices is crucial to improving patient outcomes, which is also supported by another review conducted to assess the feasibility of LMICs, which suggests the utilization of implementation sciences (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). This formal adoption would ensure consistent implementation of ERAS principles across different surgical practices, leading to improved patient outcomes and reduced variability in care. This review suggests that this needs to be supported by ongoing education and training of healthcare professionals to effectively implement and sustain ERAS protocols in clinical settings.\u003c/p\u003e \u003cp\u003eThere is a general recommendation for the need for further research to gather more evidence to support ERAS in Africa (n\u0026thinsp;=\u0026thinsp;8). This was also highlighted as one of the national perioperative research priorities in South Africa where a stepped-wedge trial of an ERAS program for surgical, obstetric, and trauma procedures was recommended (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). The authors of this article also stress the importance of conducting well-designed studies with larger sample sizes to provide more robust evidence on the effectiveness and safety of ERAS protocols in diverse clinical settings and surgical procedures. They also recommend that future research focus on evaluating the cost-effectiveness and long-term outcomes associated with implementing these protocols, either fully or partially.\u003c/p\u003e \u003cp\u003eThe limitation of this review is as it is scoping review, and it did not include a comprehensive analysis of all available literature on ERAS programs. Additionally, the studies primarily focused on short-term outcomes and did not thoroughly examine potential complications or adverse events associated with ERAS protocols. Further research is needed to address these gaps in knowledge and provide a more comprehensive understanding of the benefits and limitations of implementing ERAS programs in various healthcare settings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics \u003c/h2\u003e\n\u003cp\u003eThe University of Cape Town Human Research Ethics Committee has waived the need for ethics in the study, as it does not involve human or animal participants. This decision was communicated in letter Ref number 220/2024.\u003c/p\u003e\n\u003ch2\u003eConflicts of interest\u003c/h2\u003e \u003cp\u003eThe authors/reviewers declare that they have no conflict of interest.\u003c/p\u003e\u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eNone to declare.\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis study is partially supported by the University of Cape Town Department of Anaesthesia and Perioperative Medicine through a grant secured from the National Institute for Health and Care Research (NIHR) Global Health Group on Perioperative and Critical Care.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eFK, PK, and SD conducted the literature search, screened articles, and extracted data. FK analyzed data and drafted the initial manuscript, while SD and BB provided critical revisions and feedback to improve the final version and supervise the project. All authors approved the final manuscript for submission.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors would like to thank Ms. Dilshaad Brey (UCT librarian) for her assistance during the database searches and in organising the search results.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKehlet H. Enhanced postoperative recovery: good from afar, but far from good? Anaesthesia [Internet]. 2020 Jan 1 [cited 2023 Oct 29];75 Suppl 1(S1):e54\u0026ndash;61. Available from: https://pubmed.ncbi.nlm.nih.gov/31903577/\u003c/li\u003e\n\u003cli\u003eSubramaniam D, Horgan AF. Enhanced recovery after colorectal surgery: an update on current practice. Surgery (United Kingdom) [Internet]. 2017 Feb 1 [cited 2023 Oct 29];35(2):98\u0026ndash;101. Available from: http://www.surgeryjournal.co.uk/article/S026393191630182X/fulltext\u003c/li\u003e\n\u003cli\u003eLjungqvist O, Scott M, Fearon KC. Enhanced Recovery After Surgery: A Review. 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South African Journal of Surgery [Internet]. 2021 Nov;59(4):157\u0026ndash;63. Available from: http://www.scielo.org.za/scielo.php?script=sci_arttext\u0026amp;pid=S0038-23612021000400007\u0026amp;lng=en\u0026amp;nrm=iso\u0026amp;tlng=en\u003c/li\u003e\n\u003cli\u003eAmmar RAEA, Areda EEDAEM, Abbady AAEA El, Halim MW. The efficacy of enhanced recovery protocol from anesthesia in diabetic patients undergoing radical cystectomy. Alexandria Journal of Medicine [Internet]. 2021 Jan 1 [cited 2023 Nov 30];57(1):38\u0026ndash;43. Available from: https://www.tandfonline.com/doi/abs/10.1080/20905068.2020.1842086\u003c/li\u003e\n\u003cli\u003ePlenge U, Parker R, Davids S, Davies GL, Fullerton Z, Gray L, et al. Quality of recovery after total hip and knee arthroplasty in South Africa: a national prospective observational cohort study. BMC Musculoskelet Disord [Internet]. 2020 Dec 1 [cited 2023 Nov 30];21(1). 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Available from: https://pubmed.ncbi.nlm.nih.gov/29306587/\u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Neill KM, Greenberg SLM, Cherian M, Gillies RD, Daniels KM, Roy N, et al. Bellwether Procedures for Monitoring and Planning Essential Surgical Care in Low- and Middle-Income Countries: Caesarean Delivery, Laparotomy, and Treatment of Open Fractures. World J Surg [Internet]. 2016 Nov 1 [cited 2023 Apr 19];40(11):2611\u0026ndash;9. Available from: https://link.springer.com/article/10.1007/s00268-016-3614-y\u003c/li\u003e\n\u003cli\u003eZlaugotne B, Pubule J, Gusca J, Kalnins SN. Quantitative and Qualitative Assessment of Healthcare Waste and Resource Potential Assessment. Environmental and Climate Technologies. 2022 Jan 1;26(1):64\u0026ndash;74. \u003c/li\u003e\n\u003cli\u003eLavy C, Sauven K, Mkandawire N, Charian M, Gosselin R, Ndihokubwayo JB, et al. State of surgery in tropical Africa: A review. World J Surg [Internet]. 2011 Feb 14 [cited 2023 Dec 7];35(2):262\u0026ndash;71. 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Guidelines for Perioperative Care in Elective Abdominal and Pelvic Surgery at Primary and Secondary Hospitals in Low\u0026ndash;Middle-Income Countries (LMIC\u0026rsquo;s): Enhanced Recovery After Surgery (ERAS) Society Recommendation. World Journal of Surgery 2022 46:8 [Internet]. 2022 May 31 [cited 2023 Apr 19];46(8):1826\u0026ndash;43. Available from: https://link.springer.com/article/10.1007/s00268-022-06587-w\u003c/li\u003e\n\u003cli\u003eMacPhee M. Strategies and tools for managing change. Journal of Nursing Administration. 2007 Sep;37(9):405\u0026ndash;13. \u003c/li\u003e\n\u003cli\u003eTippireddy S, Ghatol D. Anesthetic Management for Enhanced Recovery After Major Surgery (ERAS). StatPearls [Internet]. 2023 Jan 29 [cited 2024 May 16]; Available from: https://www.ncbi.nlm.nih.gov/books/NBK574567/\u003c/li\u003e\n\u003cli\u003eGramlich LM, Sheppard CE, Wasylak T, Gilmour LE, Ljungqvist O, Basualdo-Hammond C, et al. Implementation of Enhanced Recovery After Surgery: A strategy to transform surgical care across a health system. Implementation Science [Internet]. 2017 May 19 [cited 2024 May 16];12(1):1\u0026ndash;17. Available from: https://implementationscience.biomedcentral.com/articles/10.1186/s13012-017-0597-5\u003c/li\u003e\n\u003cli\u003eRiad AM, Barry A, Knight SR, Arbaugh CJ, Haque PD, Weiser TG, et al. Perioperative optimisation in low- and middle-income countries (LMICs): A systematic review and meta-analysis of enhanced recovery after surgery (ERAS). J Glob Health [Internet]. 2023 [cited 2023 Dec 7];13:4114. Available from: /pmc/articles/PMC10546475/\u003c/li\u003e\n\u003cli\u003eBiccard BM, Alphonsus CS, Bishop DG, Cronje L, Kluyts HL, Kusel B, et al. National priorities for perioperative research in South Africa. S Afr Med J [Internet]. 2016 May 1 [cited 2023 Dec 7];106(5):485\u0026ndash;8. Available from: https://pubmed.ncbi.nlm.nih.gov/27138668/\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Appendix","content":"\u003cp\u003eAppendices 1 and 2 are not available with this version.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"perioperative-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"peri","sideBox":"Learn more about [Perioperative Medicine](http://perioperativemedicinejournal.biomedcentral.com)","snPcode":"13741","submissionUrl":"https://submission.nature.com/new-submission/13741/3","title":"Perioperative Medicine","twitterHandle":"@EMSurgeryBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"ERAS, Africa, outcomes, review","lastPublishedDoi":"10.21203/rs.3.rs-4488858/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4488858/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eEnhanced Recovery After Surgery (ERAS) is a patient-centered approach to surgery designed to reduce stress responses and facilitate faster recovery. ERAS protocols have been widely adopted in high-income countries, supported by robust research demonstrating improved patient outcomes. However, in Africa, there is limited evidence regarding its implementation. This review aims to identify the existing literature on the implementation of ERAS principles in Africa, the reported clinical outcomes, and the challenges and recommendations for successful implementation.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a librarian-assisted literature search of electronic research databases between October and November 2023. Titles and abstracts were screened for eligibility, duplicates were then removed, followed by full-text assessment of potentially eligible studies. We utilized the summative content analysis method to synthesize and group the data into fewer categories based on agreed-upon criteria. Descriptive statistics were used to describe the results.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe search identified 342 potential studies resulting in 15 eligible studies for inclusion in the review. The publication years ranged from 2016 to 2023. The studies originated from three countries: Egypt (n\u0026thinsp;=\u0026thinsp;10), South Africa (n\u0026thinsp;=\u0026thinsp;4), and Uganda (n\u0026thinsp;=\u0026thinsp;1). Successful implementation was associated with reduced hospital length of stay (n\u0026thinsp;=\u0026thinsp;12), lower mortality rates (n\u0026thinsp;=\u0026thinsp;3), and improved pain outcomes (n\u0026thinsp;=\u0026thinsp;7). Challenges included protocol adherence (n\u0026thinsp;=\u0026thinsp;5) and limitations in research design to generate strong evidence (n\u0026thinsp;=\u0026thinsp;3). Recommendations included formal adoption of ERAS principles (n\u0026thinsp;=\u0026thinsp;5), the need for a sustained research commitment, and exploration of the applicability of ERAS in diverse surgical contexts (n\u0026thinsp;=\u0026thinsp;8). Large-scale implementation beyond individual institutions was encouraged for further validation of its impact on patient outcomes and healthcare costs (n\u0026thinsp;=\u0026thinsp;1).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eDespite the limited number of studies on ERAS implementation in Africa, the available evidence suggests that it reduces the length of hospital stays and mortality rates. This is crucial for the region, given its higher mortality rates, necessitating more collaborative, methodically well-designed studies to establish stronger evidence for ERAS in lower resource environments.\u003c/p\u003e","manuscriptTitle":"A Scoping review of Enhanced Recovery After Surgery (ERAS), protocol implementation, and its impact on surgical outcomes and healthcare systems in Africa","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-13 20:51:09","doi":"10.21203/rs.3.rs-4488858/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-06-22T14:04:26+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-22T08:10:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"73625327059472441651875770996050075568","date":"2024-06-14T12:23:27+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-03T03:28:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"133153094508872215124876499921987621522","date":"2024-06-01T12:05:22+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-05-30T11:51:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-30T00:06:31+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-30T00:06:30+00:00","index":"","fulltext":""},{"type":"submitted","content":"Perioperative Medicine","date":"2024-05-28T07:20:32+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"perioperative-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"peri","sideBox":"Learn more about [Perioperative Medicine](http://perioperativemedicinejournal.biomedcentral.com)","snPcode":"13741","submissionUrl":"https://submission.nature.com/new-submission/13741/3","title":"Perioperative Medicine","twitterHandle":"@EMSurgeryBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6477bba7-01df-4de9-82e5-9a767c1f9ab3","owner":[],"postedDate":"June 13th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-08-05T16:09:37+00:00","versionOfRecord":{"articleIdentity":"rs-4488858","link":"https://doi.org/10.1186/s13741-024-00435-2","journal":{"identity":"perioperative-medicine","isVorOnly":false,"title":"Perioperative Medicine"},"publishedOn":"2024-08-02 15:57:43","publishedOnDateReadable":"August 2nd, 2024"},"versionCreatedAt":"2024-06-13 20:51:09","video":"","vorDoi":"10.1186/s13741-024-00435-2","vorDoiUrl":"https://doi.org/10.1186/s13741-024-00435-2","workflowStages":[]},"version":"v1","identity":"rs-4488858","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4488858","identity":"rs-4488858","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}