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ERAS Implementation-Time To Move Forward.

E nhanced recovery programs (ERAS) or ‘‘fast-track’’ surgical programs were introduced more than 20 years ago and repeatedly documented to improve outcome across procedures, although most data come from colorectal surgery and major joint arthroplasty. Consequently, length of stay and morbidity have been reduced, as also shown recently in an integrated health care delivery system in North America. Over the years, several international guidelines have been published in colorectal surgery, but usually including somewhere between 12 and 25 components of care to be implemented for a successful program. At the same time, more than 20 publications have been published on the importance of a general adherence to ERAS protocols to achieve a successful improved outcome, including 2 recent large multicenter surveys from the United States and Canada. The most recent survey by Aarts et al should be commended by using a new and relevant definition for ‘‘optimal recovery’’ defined as discharge within 5 days of surgery, no major complications, readmissions to hospital, or mortality and concluded that the postoperative ERAS components had the greatest impact to improve recovery, confirming previous observations in a smaller patient population. Although the 2 recent surveys quote themselves as being the biggest ones, the question is what is actually new? or whether they just represent a repetition about the delay of integrating scientific knowledge into daily clinical routine? Thus, the process of how to implement ERAS has been described in detail several years ago. Consequently, the main question to be an answered is how to adjust and enhance clinical practice to evidence-based surgical care? The answers are many and include lack of knowledge, lack of acceptance, lack of ability, or wish to change or lack of clinical leadership. However, another explanation may be that the ERAS guidelines most often include about 12 to 25 elements of care that have to be implemented. Obviously, so many elements may hinder full implementation in a busy clinical department and furthermore demand intensive multidisciplinary collaboration between anesthesiologists, surgeons, nurses, and physiotherapists. For this author, it is therefore surprising that the five basic elements of care demonstrated a long time ago to be the key components for ERAS in colonic surgery [preoperative patient information, thoracic epidural anesthesia in open (but not laparoscopic) colonic surgery, avoidance of fluid overload and hypovolemia, no nasogastric tube and combined with early oral feeding and mobilization] were enough to secure enhanced recovery and length of stay within 2 to 4 days after open colonic surgery. Therefore, these five essential elements of care should be in focus and they mostly include postoperative care elements as shown again by Aarts et al in 2018. In this context, it is interesting to remember that the original European ERAS Society collaboration emphasized that ‘‘a protocol is not enough’’ to implement an ERAS programme. Furthermore, it was described in detail why one participant was successful in the implementation of the five core components in these European ERAS centers. Consequently, when outcomes are suboptimal, there is less need for adherence to all the other and less evidence-based or relevant components in most ERAS protocols. This may apply to the much emphasized need for preoperative carbohydrate loading, but where the evidence is weak. The same may apply to preoperative bowel preparation which was the evidence in the very beginning and therefore included in the successful early ERAS programs, but later abandoned in the guidelines and now again debatable. Apparently, this ERAS component was not important to achieve a successful ERAS program. However, the use of epidural analgesia (thoracic and with appropriate amount and composition) is important for open but not laparoscopic procedures, although often not sufficiently implemented or described in the programs. In summary, we do not need more studies on the effect of complete adherence to ERAS protocols, but rather to implement the well-established core elements of care. Nevertheless, we need more data on why the postoperative components of ERAS may fail to be implemented, divided into reasons such as suboptimal implementation of the care principles due to logistics or other organizational problems or whether there was a well-argued postoperative event (medical or surgical) 6,7,18 that required deviation from the ERAS protocol. In this context, emphasis must be laid on