From Clinic to Recovery · First Edition
Chapter 02 — Enhanced Recovery After Surgery: Explaining the Pathway to Patients
Dr. Tamer Rushdy Elalfy · 12 min read
In this chapter
Enhanced Recovery After Surgery (ERAS) is a bundle of evidence-based measures, applied before, during, and after an operation, that reduce the physical stress of surgery and help patients recover sooner. ERAS pathways began in colorectal surgery and have since been adapted for many other operations; the colorectal guideline, the reference point for most general surgery pathways, was most recently updated in 2025 [12, 13]. Preadmission education is itself a core element of the pathway, and many of the other measures depend on what the patient does. ERAS therefore works best when patients understand what is being asked of them and why.
Learning objectives After reading this chapter you should be able to:
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2.1 Patients as partners
A patient who has been told to walk on the day of surgery will do so more willingly if they know that walking protects the lungs, prevents blood clots, and helps the bowel to start working again. The same is true of stopping smoking, drinking fluids before the operation, and using non-opioid pain medicines. Explaining the reason for each step turns a list of rules into a plan the patient can own.
Preadmission education is strongly recommended for every patient. In the evidence reviewed for the 2025 colorectal guideline, preadmission education reduced anxiety, and in one trial targeted ERAS and stoma education shortened hospital stay [13]. Figure 2.1 summarizes the pathway from the patient’s point of view. It can be shown during pre-admission counseling and reused in patient handouts.
[Figure — diagram omitted in this text edition; see the figure caption below and the Word chapter file for the image]
Figure 2.1. The enhanced recovery pathway from the patient’s perspective.
2.2 What to tell patients
Table 2.1 lists the elements that apply to most general surgery operations, in the order the patient meets them. Operation-specific variations are given in the procedure chapters.
Table 2.1. Enhanced recovery: what to tell patients and why.
| Element | What to tell the patient | Why it matters |
|---|---|---|
| Pre-admission education | “You will be told what to expect, what to do, and when. Please bring your medicine list and write down your questions.” | Prepared patients are less anxious and follow instructions more reliably [13]. |
| Nutrition and blood count | “Eat regular meals that include protein. Tell us if you have lost weight without trying. We will check your blood count before the operation.” | Malnutrition and anemia increase complications; screening and correction are recommended before major surgery. |
| Stop smoking | “Stop cigarettes, shisha, and vaping. Ideally stop at least 4 weeks before surgery. Stopping closer to the operation is still worthwhile, so stop now.” | Fewer wound and chest complications. Longer abstinence gives greater benefit, and stopping shortly before surgery does not increase risk [14, 15]. |
| Alcohol | “Stop alcohol before surgery. If you drink every day, tell us how much first, because stopping suddenly can be dangerous.” | Heavy drinking increases complications [16]. Heavy daily drinkers may need supervised withdrawal. |
| Medicines | “We will tell you which medicines to stop and which to continue. Do not stop any medicine unless we tell you to.” | Avoids both bleeding and withdrawal problems (see Chapters 18 to 22). |
| Fasting | “You may eat a light meal up to 6 hours before your anesthetic, and a heavy, fatty, or fried meal up to 8 hours before. Keep drinking water and other clear fluids until 2 hours before. The anesthesia team may give you different times.” | Short fasting is safe and reduces thirst, hunger, and dehydration compared with fasting from midnight [13, 17]. |
| Carbohydrate drink (if your unit uses one) | “If we give you a special sugary drink, finish it no later than 2 hours before your operation. If you have diabetes, we will tell you whether to take it.” | Safe in healthy adults and preferred by patients to fasting [18]; its clinical benefit over clear fluids alone is uncertain. |
| Nausea prevention | “We give medicines during and after the operation to prevent sickness.” | Allows earlier eating and walking. |
| Pain control | “We will give pain medicines on a schedule so that pain does not build up. Tell us early if pain stops you from walking or breathing deeply.” | Good pain control allows movement and deep breathing, and reduces the need for opioids [19]. |
| Fewer tubes | “We avoid drains, stomach tubes, and urinary catheters unless they are needed, and we remove them early.” | Tubes limit movement and add infection risk. |
| Eating and drinking | “Most patients can sip fluids within hours of surgery and start light food the same day or the next, unless we tell you otherwise.” | Early feeding helps the bowel recover. |
| Getting up | “We will help you sit out of bed and walk on the day of surgery, as soon as it is safe, and then spend more time out of bed each day.” | Protects lungs, circulation, and muscle strength. |
| Clot prevention | “Walking and drinking enough help prevent blood clots. Depending on your risk, we may also give you a blood-thinning injection and fit stockings or leg pumps.” | Venous thromboembolism is a major preventable complication; prevention is matched to each patient’s risk. |
| Breathing exercises | “Take 10 slow, deep breaths every hour while you are awake, and cough while supporting the wound with a pillow.” | Helps keep the lungs expanded and clear. |
2.3 The weeks before surgery
The interval between the clinic visit and the operation is an opportunity. Patients who are given a clear task for these weeks arrive better prepared and often feel more in control. The 2025 ERAS colorectal guideline recommends screening every patient for malnutrition and anemia, treating malnutrition before major surgery, correcting anemia, and asking smokers and heavy drinkers to stop at least 4 weeks before the operation [13]. It makes no recommendation for any specific structured exercise program (prehabilitation), because trial results have been conflicting. General advice to stay active, for example with a daily walk, remains sensible and is easy to give.
Caution: alcohol and withdrawal For patients who drink heavily, stopping alcohol about 4 weeks before elective surgery is recommended [13, 16]. For patients who drink heavily every day, however, abrupt cessation can cause withdrawal, including seizures and delirium. Ask about alcohol at every pre-admission assessment, using a structured tool where available, and refer heavy daily drinkers for medically supervised withdrawal before elective surgery. Never advise sudden cessation without first asking how much the patient drinks. |
2.4 Fasting, carbohydrate drinks, and weight-loss injections
Standard fasting guidance for healthy adults having elective surgery is a light meal up to 6 hours before anesthesia, a meal containing fried or fatty food or meat up to 8 hours before, and clear fluids up to 2 hours before [17]. Clear fluids include water, pulp-free juice, carbohydrate drinks made for surgery, and black tea or coffee without milk. A 2023 update confirmed that healthy adults may drink carbohydrate-containing clear fluids until 2 hours before elective procedures, and that patients prefer this to fasting [18]. The 2025 ERAS guideline also recommends short fasting rather than fasting overnight, but found that a carbohydrate drink offers no clear clinical advantage over simply allowing clear fluids until 2 hours before [13]. Patients with delayed stomach emptying, bowel obstruction, poorly controlled diabetes, or other aspiration risks need individual instructions from the anesthesia team.
Explain the reason as well as the rule. Many patients believe that fasting from midnight is safer, and some fast far longer than asked, arriving thirsty, dehydrated, and anxious: “We want you to keep drinking water until [time], because coming in thirsty makes you feel worse and does not make the anesthetic safer.”
Glucagon-like peptide-1 (GLP-1) receptor agonists and dual GIP/GLP-1 receptor agonists slow stomach emptying, which has raised concern about residual stomach contents at the start of anesthesia. Guidance has changed quickly and still differs between societies. A 2024 multisociety guidance document advised that most patients can continue these medicines before elective surgery, and that those at higher risk of delayed stomach emptying (for example, during dose escalation, on higher doses, or with gastrointestinal symptoms) may be asked to follow a liquid diet for 24 hours before the procedure or may have their anesthetic plan adjusted [20]. A UK multisociety consensus published in 2025 also advised continuing these medicines, with individual risk assessment [21], whereas a 2025 consensus led by the Society for Perioperative Assessment and Quality Improvement advised continuing them but extending the preoperative fast, including 24 hours without solid food [22].
In practice, ask every patient whether they take a weekly or daily injection, or a tablet, for diabetes or weight loss. Record the product, the dose, and the date of the last dose, and tell the anesthesia team in advance. Do not tell the patient to stop or continue the medicine until the local protocol or the anesthesia team has decided. Chapter 23 gives the full approach.
2.5 Pain control without relying on opioids
Multimodal analgesia combines medicines that act in different ways, so that each can be used at a lower dose. For most general surgery operations the foundation is regular paracetamol (acetaminophen), an anti-inflammatory medicine when it is safe for the patient, and local anesthetic infiltration or a regional block, with opioids kept for breakthrough pain [19]. The procedure chapters draw on procedure-specific recommendations such as those of the PROSPECT group [23].
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Paracetamol is commonly given as 1 g every 6 hours, up to a maximum of 4 g in 24 hours for adults. Lower doses apply for low body weight (for example, under 50 kg), liver disease, malnutrition, or heavy alcohol use.
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Anti-inflammatory medicines (NSAIDs) may be unsuitable for patients with kidney disease, a history of peptic ulcer or gastrointestinal bleeding, aspirin-sensitive asthma, or a high risk of bleeding. After some bowel operations, such as rectal resection, there is concern that they may affect healing of the bowel join [13]. The surgeon and anesthesiologist decide.
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Opioids are used sparingly and for the shortest time needed. Warn patients that they cause drowsiness and constipation, and that driving must wait (see Chapter 29).
Patients often hesitate to ask for pain relief because they do not want to be a nuisance. Tell them directly: “Pain that stops you from walking, coughing, or sleeping is a reason to ask us for more help. We would rather you tell us early.” Some patients refuse all opioids because they fear addiction, while others take them for longer than needed. Explain that a short course for severe pain after surgery is appropriate, and agree in advance when it should stop.
2.6 Getting up and moving
Early mobilization is one of the most effective elements of ERAS, and one of the hardest to achieve if the patient is not prepared for it. Explain before surgery that nurses will help the patient to sit in a chair within hours of returning to the ward and to take a short walk later the same day if they are stable. After major surgery, the 2025 colorectal guideline suggests at least 3 hours out of bed each day from the first day after surgery [13]. Exact targets are set by local protocol and by the operation performed.
Give a reason that matters to the patient: “Walking keeps your lungs clear, prevents clots in your legs, and wakes up your bowel, so you will go home sooner.” Remind them that moving does not mean overexertion. Short, frequent walks are better than a single long one.
2.7 Scripts for the ward
Script: day of surgery (for nurses) “We will give you pain medicine on a regular schedule. If the pain stops you from walking or breathing deeply, tell us and we will adjust it.” “Later today, we will help you sit in the chair and take a short walk. Walking is part of the treatment.” “You can start sips of water now, and light food when we say. Tell us if you feel sick.” “Please press the call bell before you get up for the first time.” |
Five commitments patients are asked to make
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2.8 When the pathway needs adjusting
ERAS is a framework, not a rigid protocol. Frail patients, emergency cases, patients taking anticoagulants, and those with significant heart, lung, or kidney disease may need modifications. In these cases explain which parts of the standard pathway will change and why, so that the patient is not surprised when their care differs from the printed handout.
Key points
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