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Page 2 of 18 Tebala et al. Mini-invasive Surg 2018;2:32 I http://dx.doi.org/10.20517/2574-1225.2018.37

to discharge surgical patients too early and probably unsafely and many patients regarded it only as a way
to reduce the costs for the hospital, without any benefit for them who, on the contrary, were exposed to
serious risks at home for being discharged prematurely. At the same time, many doctors were concerned
regarding the possible medico-legal risks, if complications occurred in patients after their early discharge.

On the contrary, the more recent and positive denomination of ERAS evokes a significant improvement of
the experience of the patient undergoing major surgery. ERAS protocols aim at optimising the postopera-
tive recovery as they “reduce surgical stress, maintain postoperative physiological function, and enhance
[6]
mobilization after surgery” .

In fact, it has been demonstrated that elective patients treated with ER protocols recover better and quicker
with respect to those treated under the traditional protocols. Time to first flatus, time to full oral intake
and time to full mobilisation are reduced within an ERAS protocol with respect to the traditional postop-
[4]
erative care, and this leads to improvements in patient satisfaction and reduction of costs .
General morbidity and specific medical complication rates after surgery are reduced, although the rate
of surgical complications doesn’t seem to be affected [7-11] . On a physiological level, the control of insulin-
resistance index and the reduction of the levels of cortisol and cytokines with respect to the “traditional”
management demonstrate that ERAS yields a reduction of the postoperative stress response and hence the
[12]
risk of complications .
As a consequence, postoperative LOS is reduced as well [12,13] . The UK national audit results published in
2015 confirmed that adherence to ERAS pathway is weakly but significantly associated with overall reduc-
tion of LOS. The weakness of this association may raise the hypothesis that it is more than single elements
of ERAS acting directly on LOS and that ERAS as a whole, yields a mentality change that leads to better
[14]
[15]
postoperative recovery , also in very elderly patients .
Instead of increasing the risk of complications, as initially feared, early discharge seems to be a protective
[12]
factor towards complications . Although we feel this may be considered an over optimistic message, it is
obvious that discharging a patient early in their postoperative course would allow him or her to recover
completely in their own environment, thus decreasing the risk of hospital-acquired infection and other
complications linked to prolonged hospitalisation, including psychological issues.

Clearly, it is important that every system is in place to make sure that patients are adequately followed up
at home in their early postoperative period, even if by phone only, and they have a clear pathway to access
senior review if and when needed.

Furthermore, ERAS allows an early warning for eventual complications. In fact, a patient who does not re-
cover as expected in the postoperative period - delayed recovery of their bowel function, altered vital signs
and parameters, difficulty with mobilization - is likely to be developing a complication and this should
prompt the early start of the diagnostic-therapeutic pathway to rule out or treat eventual complications.
On the contrary, a patient who clinically recovers quickly and completely, whose bowel works normally (no
need to wait a full bowel motion, but just the first flatus), his vital signs are normal and pain is easily con-
trollable can be discharged very early (even on the same day if the safety network is in place) with very low
risk of complications and readmission.

However, we would expect that a number of patients would develop complications after their discharge
and might need to be readmitted. This does not represent a failure of the ERAS pathway, as the outcome of
complicated and readmitted patients is not different from the outcome of complicated in-patients who did