Enhanced recovery after cancer surgery, with each element's compliance measured and fed back

What it is. Enhanced recovery after surgery is a bundle: preparation and information before the operation, a carbohydrate drink rather than prolonged fasting, restricted intravenous fluids, avoiding routine drains and tubes, multimodal pain control that limits opioids, and eating and walking early afterwards.

The evidence. A meta-analysis of 16 randomised trials with 2,376 patients having colorectal surgery found the pathway reduced overall complications (relative risk 0.60, 95 per cent confidence interval 0.46 to 0.76), mostly non-surgical ones such as chest infections, and shortened hospital stay by 2.28 days without increasing readmissions. In the international ERAS registry of 2,352 colorectal cancer resections in 13 centres, increasing compliance with the protocol was independently associated with fewer complications and shorter admission; restrictive fluids were associated with fewer complications, and carbohydrate loading with shorter stay.

The measured gap. A 2023 study of 151 United States hospitals that each implemented a colorectal pathway with an 18-month programme of materials, education and data capture measured six process elements: of 663 opportunities to improve, 20 per cent achieved a substantial improvement, 52 per cent minimal improvement and 28 per cent got worse. A single-institution study of 1,519 colorectal operations found that patients of low socioeconomic status had lower completion of bowel preparation and carbohydrate loading and longer stays. A pathway on paper is not a pathway delivered.

The upgrade, then, is not to adopt enhanced recovery, which most surgical units say they have, but to measure each element for each patient and feed the figures back. The corpus record `eras-perioperative-nutrition` describes the pathway itself.