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Randomized trials and meta-analysis identified a significantly shorter length of stay and lower in-hospital postoperative complications (maybe secondary to the shorter length of hospital stay) .These advantages are mainly attributed to fluid restriction and epidural analgesia.
Other outcome improvements attributed to ERAS programs are shorter duration of postop‐ erative ileus , better oral intake, better pain control, less cardiopulmonary morbidity, better preservation of body mass and exercise performance , an improvement in grip strength (all of them suggesting an overall improvement in muscular function), earlier resumption of normal activities and a reduced need for daytime sleep .
Early discharge is the goal of Fast-Track protocols, and should not be offset by a higher rate of hospital readmission. However, the overall rate of readmission for patients managed with early discharge is comparable to patients with a longer median length of hospital stay .Regarding the economical issues, it must be pointed out that the increased cost in laparoscopic approach must be balanced with savings from a shorter length of hospital stay, lower morbidity and no differences in readmission rates.
7. The research initiatives The confirmation of the initial results should prompt the ERAS methodology embracing in other kind of major surgical procedures as gastric or pancreatic procedures.
The possibility of applying some components of fast-track programs in patients undergoing emergency colorectal surgery must be also evaluated, especially in order to reduce preopera‐ tive stress.
New drugs like Ketamina, Lidocaina, Alvimopan could have an important role in the future because of their properties in analgesia and in gastrointestinal resumption.
8. Summary and recommendations
The success of this program depends on pre-operative setting of expectations including the concept of patients being partners in their care and taking part-ownership of post-operative rehabilitation.
Best results are achieved when the whole multidisciplinary team believe and take part in the program and individual interventions are implemented all together.
The keys of ERAS are: patient information, preservation of gastrointestinal function, minimize organ dysfunction, active pain control and to promote the patient´s autonomy.
Early discharge is the goal of ERAS protocols and patients usually reach the discharge criteria sooner than in traditional care.
Although most of the studies tend to find a lower morbidity, there are no clear advantage in mortality and we think that more studies are needed to confirm the results and focalized in mortality and long-term results of ERAs methodology. We can conclude that at least there are no significant differences in mortality and morbidity with traditional care (ERAs methodology is not dangerous for patients and probably represents a big benefice) and ERAS are more costeffectiveness than traditional care.
Author details Raúl Sánchez-Jiménez1*, Alberto Blanco Álvarez2, Jacobo Trebol López1, Antonio Sánchez Jiménez3, Fernando Gutiérrez Conde4 and José Antonio Carmona Sáez1 *Address all correspondence to: firstname.lastname@example.org 1 Department of General Surgery, Nuestra Señora de Sonsoles Hospital, Ávila, Spain 2 Department of General Surgery, Santos Reyes Hospital, Burgos, Spain 3 Physiotherapist, Cadiz University, Cádiz, Spain 4 Department of General Surgery, University Hospital of Salamanca, Salamanca, Spain References  Kehlet H, Wilmore DW. Fast-track surgery. Br.J.Surg. 2005;92:3-4.
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