Background:

Enhanced Recovery After Surgery (ERAS) is a multimodal, evidence-based perioperative care protocol designed to reduce surgical stress, improve postoperative recovery, and minimize hospital stay and complications. Since its development in the early 2000s by the ERAS Society, this protocol has shown consistent success across various surgical specialties. Anesthesiologists play a pivotal role in the planning and execution of ERAS pathways, influencing outcomes across the preoperative, intraoperative, and postoperative phases.

Aims:

The aim is to evaluate whether or not ERAS implementation leads to shorter hospital stays, reduced postoperative pain and opioid use, faster return of bowel function, decreased complications and readmissions, and greater patient satisfaction.

Methods:

Following PRISMA guidelines, a systematic search of PubMed was conducted for English-language studies from January 2015 to June 2025. A systematic review was performed that highlights the role of anesthesia within the ERAS framework using literature sourced from peer-reviewed publications and ERAS Society guidelines. The protocol elements were categorized into three phases: preoperative, intraoperative, and postoperative. Special attention was given to pharmacologic interventions, anesthetic regimens, and perioperative fluid and pain management, aligning with the responsibilities of anesthesiologists. Key preoperative components include patient education, optimization of comorbidities, one-month abstinence from smoking and alcohol, premedication with NSAIDs/PCM, and carbohydrate loading. Intraoperative strategies include using balanced fluid therapy, short-acting anesthetics, a mix of pain relief methods, and laparoscopic techniques when possible. Postoperative care emphasizes early mobilization, hydration, nausea control, and techniques such as chewing gum to reduce ileus.

Results:

Preoperative Components: Key elements include thorough risk assessment, patient education, smoking and alcohol abstinence for at least one month, deep vein thrombosis (DVT) prophylaxis, premedication with NSAIDs or dexamethasone, and carbohydrate loading. Mechanical bowel preparation and minimized fasting (solid food up to 6 hours, clear carbohydrate-rich liquids up to 2 hours before surgery) are also essential.Intraoperative Components: A single antibiotic dose is recommended. Fluid management involves zero-balance therapy for low-risk patients and goal-directed fluid therapy for high-risk surgeries to avoid both hypovolemia and fluid overload. Minimally invasive techniques like laparoscopy are preferred. Anaesthetic strategies favor short-acting agents and regional anesthesia. Vigilant prevention of hypothermia and avoidance of nasogastric tubes and drains are encouraged. Postoperative Components: Early ambulation, prompt catheter removal, hydration, and non-pharmacologic interventions like chewing gum help minimize ileus and speed recovery. Implementation of ERAS protocols, particularly when guided by anesthesiologists, has demonstrated significant benefits: ● Reduced postoperative pain and opioid requirement ● Earlier return of bowel function ● Decreased complication and readmission rates ● Shorter hospital stay and improved patient satisfaction

Conclusion:

ERAS protocols represent a paradigm shift in perioperative care, reducing postoperative morbidity and length of stay. Anaesthesiologists play a central role across all ERAS phases—from risk stratification and fasting minimization to optimized anaesthesia, multimodal analgesia, and early recovery facilitation. This structured review highlights the multidisciplinary nature of ERAS and reinforces the anaesthesiologist’s role as a key driver of successful outcomes.