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Open research questions in Enhanced Recovery After Surgery

29 unresolved questions extracted from the limitations and future-work sections of 275 Enhanced Recovery After Surgery papers in our library. Each links back to the study that raised it.

What the literature leaves open

  • Although traditional Chinese medicine (TCM) shows promise in supporting postoperative gastrointestinal recovery, high-quality evidence for its application in LARS is lacking.

    Efficacy and safety of the traditional Chinese medicine formulation BL-1 for the treatment of low anterior resection syndrome: study protocol for a double-blind, randomized, placebo-controlled trial · 2026 · DOI

  • No data exists regarding patient satisfaction, necessary volume of TLA, frequency of supplementary analgosedation, and associated complication rate after different kinds of breast surgeries in TLA.

    Patient satisfaction and perioperative data after breast surgery in tumescent local anaesthesia · 2026 · DOI

  • As surgical care focuses on restoring function instead of just avoiding complications, the systematic appraisal of adjunctive non-pharmacological interventions is warranted in ERAS pathways.

    Functional recovery after abdominal surgery and the emerging role of acupuncture · 2026 · DOI

  • international ERAS4OLT The Newcastle ERAS protocol for liver transplantation was introduced in 2024 following the earlier implementation of an ERAS pathway for kidney transplantation. The protocol draws on (7) while adapting them to local multidisciplinary practice. Although this protocol has only recently been introduced, it has provided a useful example of a functioning protocol which, along with other existing pathways, has informed the development of the recently liver released NHSBT guidance on ERAS transplantation. Table 2 outlines the key components of the Newcastle ERAS protocol for liver transplant recipients, which are further detailed in the relevant sections of this review. in 3.3 Key components of an ERAS programme in liver transplantation 3.3.1 Patient counselling and education Patient education promotes preparedness, empowerment and management of expectations, all of which are key elements of enhanced recovery after liver transplantation. A recent review concluded that living liver donors who received pre-operative counselling experienced improved outcomes, including lower levels of postoperative pain and fatigue, shorter recovery times, and less postoperative anxiety (82). In liver transplant recipients, inadequate patient understanding of the transplant process has been shown to be associated with reduced treatment adherence and poorer engagement with postoperative care (83). FIGURE 2 Trends in published literature on ERAS in liver transplantation for both recipient and donor surgery.

    A review of enhanced recovery after surgery in kidney and liver transplantation and outline of the Newcastle ERAS protocols · 2026 · DOI

  • include referral to smoking cessation programmes for patients using tobacco products and consideration of dietary counselling or referral for bariatric surgery for those with BMI >35 kg/m2 (26). The European Society of Organ Transplantation (ESOT) consensus statement published in 2023 strongly supports prehabilitation for solid organ transplant candidates, and data from the recently published FRAILMar RCT demonstrates that in structured exercise and nutritional significant improvements in physical performance measures and frailty indices for patients awaiting kidney transplantation (27). These findings strengthen the case for structured prehabilitation as a feasible and clinically meaningful component of kidney transplant ERAS pathways. intervention results The feasibility of prehabilitation in kidney transplant recipients is well described and can be implemented for most patients, even within the confines of dialysis (28). These may be hospital- or home-based. Hospital-based physiotherapy programmes have demonstrated decreased importantly no adverse effects (28). Similarly, home-based exercise models, often supported by digital platforms, can lead to improved outcomes and show an increased acceptance and higher adherence rates than physiotherapy or hospital-based programmes (29–31). However, inequity of access remains a challenge in the UK due to funding constraints (4, 32). length of stay and Early mobilisation following surgery is an integral part of an ERAS programme and is associated with reduction in complications, hospital length of stay and overall recovery times (20, 22). Postoperative mobilisation should be viewed as a continuation of prehabilitation, reinforcing the concept of a continuous “prehab-torehab” trajectory. The Newcastle kidney transplant ERAS protocol integrates prehabilitation and postoperative rehabilitation as a process that for and physical deconditioning during extends from the waiting list period through the postoperative frailty, nutritional ward stay. Candidates are assessed deficits transplant evaluation, with referral to physiotherapy or dietetic services where appropriate. Following the pathway emphasises mobilisation beginning on the first postoperative day, with early physiotherapy review where required. Patients are encouraged to sit out of bed within the first 24 h and progress to assisted ambulation thereafter, with mobility targets reviewed during daily ward rounds (Table 1). transplantation, 2.3.3 Fluid monitoring and replacement There is evidence to suggest that optimisation of intraoperative fluid status may reduce the risk of graft dysfunction with associated improvements in long-term kidney survival, length of stay and healthcare costs (33–36). Conversely, excessive fluid administration promotes peripheral, visceral and pulmonary oedema, impaired microcirculation and potential graft dysfunction (37–40). Kidney allografts lack autonomic autoregulation following systemic denervation, rendering perfusion dependent on pressure and flow (41). While there is some evidence that higher mean arterial pressure (MAP) may yield improved graft outcomes, there is nothing robust on which to propose MAP targets (42, 43). Furthermore, there is no evidence base to guide the choice of inotropic or vasopressor agents to achieve this. It is likely that any approach that maintains a sensible MAP, mindful of volume status and both donor and recipient baseline MAP, will yield good graft perfusion. Goal-directed haemodynamic therapy (GDHT), supported by cardiac output monitoring, is recommended by NICE for major surgery and has been shown to reduce complications and length of stay in bowel, liver and pancreatic surgery (44). In kidney reduced cardiovascular transplantation, GDHT complications, postoperative in pulmonary oedema, improved mobilisation and no increase in delayed graft function (10, 16, 45–50).

    A review of enhanced recovery after surgery in kidney and liver transplantation and outline of the Newcastle ERAS protocols · 2026 · DOI

  • transplantation is also largely aspirational. These areas are currently being addressed through various workstreams of the NHSBT national ERAS programme which may pave the way for future implementation of ERAS in these fields. Future research should focus on the impact of individual enhanced recovery components on relevant outcomes in relation to transplantation where high-quality data is lacking. Standardisation of ERAS protocols in transplantation will facilitate pathway audits and the collection of meaningful outcome data, and minimisation of variation in practice will benefit both clinician and patient. Achieving this requires strong collaboration between transplant centres and professional bodies that champion the development of enhanced recovery pathways, and it is imperative that we cultivate multidisciplinary forums where hot topics and future advances in enhanced recovery in organ transplantation are addressed.

    A review of enhanced recovery after surgery in kidney and liver transplantation and outline of the Newcastle ERAS protocols · 2026 · DOI

  • r 19. Xu J, Wu A, Filip C, Patel Z, Bernstein S, Tanveer R, et al. Active recall strategies associated with academic achievement in young adults: a systematic review. J Affect Disord. (2024) 354:191–8. doi: 10.1016/j.jad.2024.03.010 20. Serra MJ, Kaminske AN, Nebel C, Coppola KM. The use of retrieval practice in the health professions: a state-of-the-art review. Behav Sci (Basel). (2025) 15:974. doi: 10.3390/bs15070974 21. Greco M, Capretti G, Beretta L, Gemma M, Pecorelli N, Braga M. Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials. World J Surg. (2014) 38:1531–41. doi: 10.1007/s00268-013- 2416-8 22. ERAS Compliance Group. The recovery protocol compliance on elective colorectal cancer resection: results from an (2015) 261:1153–9. doi: 10.1097/SLA. international 0000000000001029 registry. Ann Surg. impact of enhanced 23. 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. Implement Sci. (2017) 12:67. doi: 10.1186/s13012-017-0597-5 24. Grant MC, Engelman DT. Enhanced recovery after surgery: overarching themes of the ERAS® society guidelines & consensus statements for adult specialty surgery. Perioper Med (Lond). (2025) 14:120. doi: 10.1186/s13741-025- 00590-0 25. Perroni G, Johnson C, Khandhar S, Veronesi G, Ambrogi V, Fernando HC. Implementation of eras for patients undergoing esophagectomy: a narrative review of the current literature and latest evidence. Curr Chall Thorac Surg. (2021) 3:37. doi: 10.21037/ccts-20-105 26. Stenberg E, Dos Reis Falcão LF, O’Kane M, Liem R, Pournaras DJ, Salminen P, et al. Guidelines for perioperative care in bariatric surgery: enhanced recovery after surgery (ERAS) society recommendations: a 2021 update. World J Surg. (2022) 46:729–51. doi: 10.1007/s00268-021-06394-9 27. Mortensen K, Nilsson M, Slim K, Schäfer M, Mariette C, Braga M, et al. Consensus guidelines for enhanced recovery after gastrectomy: enhanced recovery after surgery (ERAS®) society recommendations. Br J Surg. (2014) 101:1209–29. doi: 10.1002/bjs.9582 28. Cai H, Liu Z, Wei F, Yu M, Xu N, Li Z. 3D printing in spine surgery. Adv Exp Med Biol. (2018) 1093:345–59. doi: 10.1007/978-981-13-1396-7_27 14. Ioannidis O, Anestiadou E, Koltsida A, Ramirez JM, Fabbri N, Ubieto JM, et al. Optimizing perioperative care in esophageal surgery: the EUropean PErioperative MEdical Networking (EUPEMEN) collaborative for esophagectomy. Diseases. (2025) 13:231. doi: 10.3390/diseases13080231 29. Joliat G-R, Kobayashi K, Hasegawa K, Thomson J-E, Padbury R, Scott M, et al. Guidelines for perioperative care for liver surgery: enhanced recovery after surgery (ERAS) society recommendations 2022. World J Surg. (2023) 47:11–34. doi: 10. 1007/s00268-022-06732-5 15. Ioannidis O, Koltsida A, Anestiadou E, Ramirez JM, Fabbri N, Ubieto JM, et al.

    Advancing abdominal surgery recovery implementation: a unified framework for intensified recovery protocols by the EUropean PErioperative MEdical Networking collaborative · 2026 · DOI

  • Society the ERAS Society The EUPEMEN gastrectomy module was developed recommendations in accordance with for enhanced recovery after gastrectomy, which provide a structured, evidence-based framework across the full perioperative pathway (27). Gastric surgery requires clear operational guidance on highimpact, procedure-relevant decisions, including perioperative nutritional optimization and feeding progression, a clear strategy for gastric decompression/nasogastric tube use, selective use and early removal criteria for drains (28). The resulting protocol functions as a multidisciplinary care pathway that can be taught and reproduced consistently across sites (16). an Colon surgery, where Enhanced Recovery evidence is particularly mature, provides for demonstrating measurable adherence and outcome monitoring (27). The colon module emphasized standardized preoperative preparation, opioid-sparing anaesthesia, early mobilization, early oral intake, and avoidance of unnecessary tubes and drains (18).

    Advancing abdominal surgery recovery implementation: a unified framework for intensified recovery protocols by the EUropean PErioperative MEdical Networking collaborative · 2026 · DOI

  • Our study suggests that corrective measures should be implemented during the preoperative period. Centres providing obstetric care should review their starvation periods before operation and improvement protocols where applicable. implement quality Sip-til-Send is an initiative aimed at reducing prolonged preoperative fasting by challenging traditional fasting guidelines that require 6 h for solids and 2 h for clear fluids before surgery.24 The protocol allows patients to consume clear fluids, such as water or tea without milk, until transfer to the operation theatre complex, and in some cases includes caloric beverages for non-diabetic patients.

    The impact of perioperative fasting on metabolic status in elective caesarean section patients · 2026 · DOI

  • Available data on this topic is currently limited. One of the major strengths of this study is that it identifies the correlation between prolonged starvation and the presence of acidosis, ketosis and hypoglycaemia. The findings are clinically relevant and potentially preventable, highlighting opportunities to improve perioperative care for obstetric patients.

    The impact of perioperative fasting on metabolic status in elective caesarean section patients · 2026 · DOI

  • In conclusion, despite advancements in understanding the importance of prehabilitation, significant gaps persist in the literature, warranting further research to refine prehabilitation protocols and improve perioperative outcomes for GI cancer patients.

    Prehabilitation approaches for gastrointestinal cancer surgery: a narrative review · 2024 · DOI

  • We hypothesised that semaglutide interruption of ≤ 10 days before elective surgical procedures is insufficient to reduce or normalise the residual gastric content, despite fasting intervals that comply with current guidelines.

    Relationship between residual gastric content and peri‐operative semaglutide use assessed by gastric ultrasound: a prospective observational study · 2024 · DOI

  • The time required for complete postoper- combined with intrathecal fentanyl, are primarily limited to ative recovery varies considerably and depends on factors the early postoperative period.

    A postoperative comparative study on the effects of general versus regional anesthesia on postoperative quality of recovery after cesarean section · 2026 · DOI

  • While the dynamic change from preoperative to the lowest albumin level on postoperative day 2 (ΔAlb) has been linked to complications, their predictive value remains controversial.

    Preoperative and early postoperative albumin thresholds, rather than ΔAlb, predict severe complications after colorectal cancer surgery: a multifactorial model and nomogram · 2026 · DOI

  • Consequently, while these strategies facilitate faster recovery and better public health outcomes, future studies should focus on varied surgical contexts, the cost-effectiveness of institutional adoption, and methods to overcome individual barriers to patient engagement.

    Impact of Postoperative Instruction Delivery Methods on Patient Compliance After Minor Oral Surgeries: A Systematic Review · 2026 · DOI

  • project’s through common interdisciplinary guidelines and educational protocols, emphasized the necessity of a robust Quality Plan that could transforming clinical practice strengths, weaknesses improvement were focus of specific…

    Advancing abdominal surgery recovery implementation: a unified framework for intensified recovery protocols by the EUropean PErioperative MEdical Networking collaborative · 2026 · DOI

  • Despite a growing body of evidence, its peri‐operative safety profile remains uncertain, particularly with regard to the risk of increased residual gastric content and aspiration of gastric contents during anaesthesia.

    Relationship between residual gastric content and peri‐operative semaglutide use assessed by gastric ultrasound: a prospective observational study · 2024 · DOI

  • The current concept of Enhance Recovery After Surgery (ERAS) is widely used in adults, but it still remains unexplored in children.

    СOMPLEX APPLICATION OF THE ADAPTED ENHANCE RECOVERY AFTER SURGERY PROGRAMME IN CHILDREN UNDERGOING ORTHOPAEDIC SURGERY · 2019 · DOI

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29 open questions have been extracted from the limitations and future-work passages of 275 Enhanced Recovery After Surgery papers in our library. Each one below links back to the study that raised it, so you can read the original claim in context.

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