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preparation to the “core” items listed above, but on this subject we favour the American guidelines, sug-
gesting selective bowel preparation. Although a gradual approach can be acceptable, we again agree with
[23]
the American guidelines that the aim must be a complete and standardised protocol implementation .
Probably never, have such minimal changes in surgical organisation and mindset yielded such a huge re-
[4]
turn as with ERAS in colorectal surgery .

CONCLUSION
ERAS protocols are largely improving the experience of patients undergoing colorectal surgery but they
also represent a huge step forward in team working, hospital dynamics and trust finances, as they reduce
LOS, total hospital costs and pharmacy costs, with a contemporary reduction of complications and read-
[115]
mission rates . In a world where new scientific evidences are published on daily basis it is normal that
ERAS principles are still quite fluid, but this is not necessarily a bad thing. Some of the ERAS elements are
particularly likely to change in the near future, such as the attitude towards MBP and oral antibiotic, pre-
habilitation and immunonutrition. We can expect that with increased experience and awareness, LOS will
reduce with time and more and more patients will be operated as day cases in the future.

Despite the various attempts at standardisation, ERAS statements remain general principles whose dynam-
ic application must be adapted to the local situation and to the team preferences and must show an ample
degree of flexibility. For this reason, every team applying ERAS standards must keep in mind the need for
regular audits, quality checks and improvement.

DECLARATIONS
Author’s contributions
Literature selection and review, article drafting, and approved the final version: Tebala GD, Gordon-Dixon
A, Imtiaz M, Shrestha A, Toeima M

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
The authors declare that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.

Consent for publication
Not applicable.

Copyright
© The Author(s) 2018.

REFERENCES
1. Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg 2002;183:630-41.
2. Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg 2008;248:189-98.