This systematic review assessed the efficacy of ERAS protocols versus traditional care in colorectal surgery, concentrating on a range of patient outcomes, including hospital stay duration, postoperative complications, gastrointestinal recovery milestones, immune function, pain management and overall patient comfort. The review included eleven RCTs involving a total of 1476 participants, all of whom were adults undergoing elective colorectal procedures. The findings consistently demonstrated that ERAS protocols significantly improved patient recovery metrics, thereby supporting their integration into standard surgical practices. The studies included in this review highlighted several key similarities and differences in patient outcomes between ERAS protocols and traditional care methods.

Length of hospital stay

Multiple studies have demonstrated a substantial decrease in hospital stay durations for colorectal surgery patients managed under an ERAS pathway. For instance, Forsmo et al. (2016) found that patients in the ERAS group had a median hospital stay of 5 days compared to 8 days for those receiving standard care [18]. Similarly, Bednarski et al. (2019) reported a notable reduction in hospital stays for patients utilizing the RecoverMI approach, which integrated minimally invasive surgery with ERAS principles [19]. Shetiwy et al. (2017) further demonstrated a significantly shorter hospital stay of 4.49 days in the ERAS group compared to 13.31 days in the conventional care group [20]. Taupyk et al. (2015) and Mari et al. (2016) similarly reported reduced stays of 5.9 and 5 days, respectively, under ERAS protocols, compared to 10.9 and 7.2 days in standard care, highlighting the protocol’s role in expediting recovery [21, 26]. This reduction in hospital stays not only reflects improved recovery but also has broader implications for healthcare resource utilization, potentially resulting in reduced healthcare costs and increased bed availability for other patients.

Postoperative complications and mortality

Most studies reported a reduced rate of overall postoperative complications among ERAS patients. RCTs conducted by Li et al. (2019) and Feng et al. (2016) reported fewer total complications in the ERAS groups, with both studies showing significant reductions (p < 0.05) [24, 27]. Similarly, Shetiwy et al. (2017) reported a 40% reduction in complications in the ERAS group compared to standard care [20]. In elderly patients undergoing colorectal surgery, Ostermann et al. (2019) found that ERAS protocols reduced morbidity by 47% (35% vs. 65%, p = 0.0003), lowered infectious complications by 52% (13 vs. 29, p = 0.001), halved total postoperative complications (54 vs. 118, p = 0.0003), and prevented anastomotic leaks (0 vs. 5, p = 0.01) compared to standard care [22]. ElRahman et al. (2020) further demonstrated a significant reduction in postoperative nausea and vomiting in the ERAS group (17.5% vs. 37.5%, p = 0.045) [25]. Additionally, Iqbal et al. (2024) reported a reduction in surgical site infections (SSIs) in ERAS patients (13.33% vs. 30.0%, p = 0.1172), further emphasizing the role of ERAS in lowering infection rates [28]. The reduction in complications such as infections, bleeding, and thromboembolic events can be attributed to the multimodal approach of ERAS protocols, which emphasizes preoperative optimization, minimally invasive techniques, and postoperative care strategies aimed at improving immune function and enhancing recovery. The consistent improvement in postoperative outcomes associated with ERAS protocols reflect their potential to advance care for surgical patients.

Early return of gastrointestinal function

A notable advantage of ERAS protocols is the prompt restoration of gastrointestinal function after colorectal surgery, as demonstrated by several studies included in this review. Studies by Taupyk et al. (2015), Ostermann et al. (2019), Li et al. (2019), Mari et al. (2016), Feng et al. (2016), and Iqbal et al. (2024) showed significant improvements in gastrointestinal recovery milestones for individuals treated under the ERAS pathway, with faster return of bowel sounds and quicker times to first flatus, defecation, extubation, and ambulation [21, 22, 24, 26,27,28]. Both Shetiwy et al. (2017) and Ostermann et al. (2019) reported earlier nasogastric tube (NGT) removal in ERAS patients, with Shetiwy observing significantly faster removal (0.77 days vs. 3.26 days, p < 0.001) and Ostermann noting a higher rate of intraoperative NGT removal (87% vs. 61%, p = 0.0005) without an increase in replacements for postoperative ileus [20, 22]. Additionally, Shetiwy et al. found that intra-abdominal drains were removed significantly earlier in the ERAS group [20]. These observations affirm the effectiveness of ERAS protocols in expediting the recovery of gastrointestinal function.

Nutritional support

An important aspect of ERAS protocols is the emphasis on early nutritional support. Studies have shown that early enteral feeding can reduce the risk of complications and expedite recovery. RCTs conducted by Shetiwy et al. (2017), Mari et al. (2016), Taupyk et al. (2015), and Feng et al. (2016) demonstrated expedited nutritional recovery in ERAS patients, with earlier enteral feeding (1.89 vs. 5.46 days, p < 0.001), faster solid meal intake (1.5 vs. 3 days, p < 0.05), quicker restoration of solid diet (1.1 ± 0.3 vs. 3.6 ± 0.9 days, p < 0.05), and earlier oral intake (p < 0.05), respectively, when compared to conventional care [20, 21, 26, 27]. Forsmo et al. (2016) observed comparable enteral nutrition tolerance in both ERAS and standard care groups, indicating that ERAS protocols do not compromise nutritional status despite an accelerated recovery timeline [18]. The study by Li et al. (2019) demonstrated improved nutritional status in ERAS patients, with elevated albumin and total protein levels on postoperative day seven, while Mari et al. (2016) reported significantly higher prealbumin levels on postoperative day five (p < 0.05), further highlighting the enhanced nutritional recovery associated with ERAS protocols [24, 26].

Postoperative inflammatory markers and immune recovery

ERAS protocols have been shown to positively impact both inflammatory markers and immune function following colorectal surgery. Taupyk et al. (2015) found that CRP (C-Reactive Protein) levels were notably lower in the FTS (Fast-Track Surgery) group (p < 0.05), reflecting reduced postoperative inflammation [21]. Similarly, Mari et al. (2016) reported significantly lower IL-6 (Interleukin-6) and CRP levels in the ERAS group on postoperative days 1, 3, and 5 (p < 0.05), with IL-6 returning to preoperative levels by day 3 in the ERAS group [26]. Feng et al. (2016) observed similar reductions in CRP, IL-6, and TNF-α (Tumor Necrosis Factor alpha) in the FTS group on days 1, 4, and 6 (p < 0.05), further supporting these findings [27]. Furthermore, Feng et al. noted higher levels of immune markers such as IgG (Immunoglobulin G), IgA (Immunoglobulin A), C3 (Complement Component 3) and C4 (Complement Component 4) in the ERAS group on postoperative days 4 and 6 (p < 0.05), reflecting improved immune recovery [27].

Patient comfort and postoperative pain management

Patient comfort and effective pain control are crucial components of successful recovery after surgery. Evidence suggests that ERAS protocols improve postoperative pain management and reduce reliance on opioids. Ostermann et al. (2019) found that patients in the ERP (Enhanced Recovery Program) group had significantly lower opioid consumption (19 mg vs. 32 mg, p = 0.028) while maintaining a Visual Analogue Scale (VAS) pain score of < 3 [22]. Similarly, ElRahman et al. (2020) reported significantly reduced pain scores in ERAS patients compared to those receiving conventional care (VAS: 3 vs. 4.6, p = 0.024) [25]. These findings highlight how implementation of ERAS protocols not only accelerates recovery but also enhances patient comfort by managing pain effectively and minimizing the need for opioids in the postoperative period.

Comparison with other evidence

To gain a deeper insight into the implications of our findings, we compared our results with existing systematic reviews and meta-analysis studies that compared ERAS with conventional care in colorectal surgery. Our cumulative analysis indicates that our findings are consistent with those reported in existing literature.

Consistent with the findings of Turaga (2023), our review shows that ERAS protocols contribute to reduced length of hospital stay, fewer complications in the post-operative period, and rapid recovery milestones [8]. Li et al. (2023) reported that the implementation of ERAS effectively reduced the rate of hospital stay durations, postoperative complications and surgical site infections, supporting its broader application in clinical settings [29]. Similarly, Zhang et al. (2023) demonstrated that the ERAS cohort showed a statistically significant reduction in the time to first flatus, shorter hospital stays, and fewer postoperative complications, including surgical site infections, compared to conventional care [30]. Azhar et al. (2021) corroborated these observations, reporting earlier resumption of gastrointestinal functions such as flatus and oral intake, shorter postoperative stays, and fewer complications in ERAS patients [31]. Although this study demonstrated that the traditional care group had fewer readmissions, the ERAS group experienced fewer total complications [31]. These findings align with results from Wang et al. (2017) and Zhao et al. (2014), who similarly reported reduced complications and shorter recovery times [32, 33]. Furthermore, the meta-analysis by Althobaiti et al. (2020) reinforced these trends, highlighting substantial reductions in hospital stays, complications, and mortality rates among ERAS patients undergoing colorectal surgery [34].

ERAS protocols have also been shown to significantly improve recovery times and reduce complication rates in emergency colorectal surgeries, although variability across studies suggests that further research is needed to refine and tailor these protocols for optimal outcomes in such high-pressure settings [35]. Sauro et al. (2024), in a meta-analysis of randomized clinical trials across various surgical specialties, found that ERAS protocols reduce hospital length of stay and complications without increasing readmissions, emphasizing their broad applicability and the need for their expansion into additional surgical fields and clinical settings worldwide [36].

While these studies highlight several positive patient outcome metrics, they typically reveal no significant differences in readmission and mortality rates between the ERAS and conventional care groups. This may likely be attributed to the fact that most studies do not assess long-term outcomes associated with ERAS, potentially overlooking its impact on these more extended aspects of recovery.

Strengths of the review

This systematic review synthesizes data from eleven RCTs, providing a robust sample size of 1476 participants. The inclusion of multiple studies enhances the reliability and generalizability of the findings, offering a well-rounded perspective on the effectiveness of ERAS protocols compared to traditional care. In line with the PRISMA 2020 guidelines [14], this review adhered to a structured and transparent approach, enhancing its credibility and facilitating replication in future research. Additionally, the search encompassed multiple databases, ensuring a comprehensive exploration of the literature and the inclusion of studies with moderate to high quality.

The review assessed a wide range of patient outcomes, including hospital stay durations, postoperative complications, gastrointestinal recovery milestones, immune recovery, pain management and patient comfort. This multifaceted approach allows for an in-depth understanding of the impact of ERAS protocols on patient recovery following colorectal surgery, addressing various aspects of the surgical experience. By highlighting the collaborative nature of ERAS protocols, which involve a multidisciplinary team, the review underscores the importance of coordinated care in enhancing patient outcomes. This focus on teamwork reflects the current best practices in perioperative management.

Moreover, the review consistently demonstrated that ERAS protocols lead to improved recovery metrics, such as shorter hospital stays and reduced overall complications. These findings provide compelling evidence supporting the integration of ERAS protocols into standard surgical practices, potentially influencing clinical guidelines and policies.

Limitations and challenges of the review process

Despite the strengths of this review, it is not without limitations. Variability in ERAS protocol implementation and outcome measures among the included studies may hinder the ability to draw definitive conclusions and make direct comparisons. Furthermore, the limited sample sizes in some of the studies may affect the statistical strength and broader applicability of the results.

While most studies were assessed as having a low risk of bias, 5 RCTs exhibited ‘some concerns’ regarding the blinding of outcome assessors and/or lack of detailed randomization information when assessed using the ROB2 tool [17]. This potential for bias could influence the validity of the findings. Furthermore, many of the included studies focused primarily on short-term outcomes, such as length of hospital stay and immediate postoperative complications. There is a need for further research assessing long-term outcomes, including quality of life and functional recovery beyond the initial postoperative period.

The lack of standardized implementation of ERAS protocols across studies poses a challenge in evaluating their effectiveness uniformly. Differences in the specific components of the ERAS protocols used may contribute to variations in outcomes, complicating the interpretation of results. The review could also be influenced by publication bias, as studies with favorable results are more likely to be published compared to those with negative or inconclusive outcomes. This bias could skew the overall assessment of the effectiveness of ERAS protocols. Finally, the scope of this review is confined to studies published in English, potentially omitting relevant research published in other languages.

By addressing these strengths and limitations, the review provides a balanced perspective on the current evidence regarding ERAS protocols in colorectal surgery, highlighting both the promise and challenges of implementing these protocols in clinical practice.

Directions for future research

Future investigations into ERAS protocols for colorectal surgery should concentrate on several critical areas to deepen understanding and improve implementation. First, there is a need for large-scale multicenter trials that can provide more comprehensive data across diverse patient populations and healthcare settings. Such studies would validate existing research findings and confirm that the advantages of ERAS protocols extend to a wider range of patient demographics. Additionally, pragmatic trials, which evaluate ERAS implementation in real-world clinical settings, are essential for assessing the applicability and effectiveness of these protocols across diverse healthcare environments.

Second, long-term outcomes should be a primary focus of future investigations. While current studies often emphasize short-term recovery metrics, understanding the long-term implications of ERAS protocols such as sustained functional recovery, chronic pain, recurrence rates, and quality of life is crucial. This could involve follow-up assessments extending beyond the immediate postoperative period to capture the full impact of these protocols and provide a comprehensive understanding of patient trajectories.

Moreover, future research should focus on identifying the specific components of ERAS protocols that most significantly contribute to improved outcomes. By identifying which elements are most effective, clinicians can tailor interventions to maximize benefits for patients. For example, elements such as early mobilization, multimodal pain management, and early enteral nutrition may have varying impacts on different patient populations. Further investigation into these components could refine protocols, ensuring they are optimized to meet the unique needs of specific groups, such as elderly patients or those with significant comorbidities.

Another important direction is the standardization of ERAS protocols. Variability in implementation can result in inconsistent outcomes; therefore, developing standardized guidelines that can be adapted to different settings while preserving core principles would be beneficial. Research on the barriers to implementing ERAS in various healthcare environments, including resource-limited settings, could provide valuable insights. A recent systematic review by Ayinde et al. (2024) identified key challenges such as training deficiencies, resource limitations, and a lack of multidisciplinary collaboration, while proposing solutions like improved team coordination and targeted education to address these issues [37]. Additionally, Lovegrove et al. (2024) highlighted the importance of clinician and facility-level education in promoting ERAS adoption, particularly among nurses, and suggest that improving ERAS knowledge could enhance implementation and patient outcomes. Their findings emphasize the need for targeted educational strategies and collaborative efforts to address barriers and facilitators in ERAS adoption [38].

Finally, exploring the integration of technology and telemedicine into ERAS protocols presents a promising avenue for future research. Investigating how digital health tools can enhance patient education, monitoring, and support during the perioperative period may improve adherence to ERAS protocols and patient outcomes. Furthermore, the use of artificial intelligence to personalize treatment plans could offer tailored interventions that better meet individual patient needs, potentially leading to enhanced recovery and outcomes.

Exploring these future research avenues will offer crucial insights for optimizing ERAS protocols in colorectal surgery and adapting them to various clinical settings, thereby advancing patient care and improving recovery strategies.