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Fast-track surgery, officially known as ERAS (Enhanced Recovery After Surgery), is a multimodal, evidence-based perioperative care strategy. Its goal is to reduce surgical stress on the body, accelerate recovery, shorten hospital stays, and improve overall patient outcomes. This approach significantly reduces the traditional postoperative period before hospital discharge.
The concept was established in the 1990s by Danish surgeon Professor Henrik Kehlet, who challenged traditional perioperative practices such as prolonged fasting, routine use of drains, excessive opioid administration, and delayed mobilization. Kehlet proved that many conventional methods were not evidence-based and, conversely, contributed to delayed recovery and increased complications.
Instead of focusing solely on surgical technique, ERAS integrates advances in anesthesiology, pain management, minimally invasive surgery, metabolic care, and multidisciplinary coordination. The primary goal is the rapid restoration of normal physiological function while maintaining safety.
Initially developed for colorectal surgery, ERAS protocols are now widely used in:
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Colorectal surgery
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Urological and renal surgery
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Gynecological surgery
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Orthopedic surgery
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Vascular surgery
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Transplantology
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Cardiac surgery
Today, the ERAS approach has reached a phase where it is causing a paradigm shift: moving from passive postoperative recovery to active, physiology-oriented rehabilitation that begins well before the operation.
Core Principles of Fast-Track Surgery
ERAS is based on several fundamental pillars:
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Reduction of the surgical stress response.
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Optimization of pain control through opioid-sparing strategies.
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Early mobilization.
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Early enteral nutrition.
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Standardized, evidence-based perioperative pathways.
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Multidisciplinary collaboration.
The ERAS Protocol in Three Phases
1. Preoperative Phase
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Patient Education: Patients receive information about the procedure, recovery stages, mobilization goals, and discharge plans.
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Optimization of Comorbidities: Glycemic control, correction of anemia, nutritional optimization, and cessation of smoking/alcohol.
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Reduced Fasting & Carbohydrate Loading: The traditional “fasting after midnight” is replaced by clear liquids up to 2 hours before surgery and solid food up to 6 hours before.
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Thrombo- and Antibiotic Prophylaxis.
2. Intraoperative Phase
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Minimally Invasive Techniques: Laparoscopic and robotic surgery to reduce tissue trauma.
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Goal-Directed Fluid Therapy (GDFT): Avoiding both hypovolemia and fluid overload.
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Maintenance of Normothermia: Active warming to reduce the risk of infection and coagulopathy.
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Multimodal Analgesia: Minimizing opioids via regional anesthesia (e.g., nerve blocks) and NSAIDs.
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Avoidance of routine tubes and drains.
3. Postoperative Phase
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Early Mobilization: Patients should sit or walk on the day of surgery to reduce pulmonary complications and thromboembolism.
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Early Oral Nutrition: Starting intake within 24 hours to support bowel motility.
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Early removal of catheters and lines.
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Functional Discharge Criteria: Discharge is based on pain control, mobility, and oral intake tolerance rather than fixed time intervals.
Specialized Applications
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Urology & Renal Surgery: ERAS reduces pain and hospital stays during nephrectomy and transplantation. The Quadratus Lumborum block is particularly effective. Recent data from the Würzburg University Clinic (Germany) showed a 72-year-old patient being discharged twice as fast as usual using this method.
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Cardiac Surgery: Focuses on early extubation (within 6 hours), shortening ICU time, and hemodynamic optimization. In Georgia, while ERAS is active, some clinics have refined it further by using parasternal nerve blocks (T2-T6), significantly reducing postoperative pain intensity.
Clinical Benefits and Challenges
ERAS reduces complications, infections, and costs while improving patient satisfaction without increasing mortality risk. However, full implementation requires institutional readiness and continuous audit. Unfortunately, the Georgian sector still lags behind many European countries by several years in these aspects. In the future, ERAS is envisioned as a personalized protocol integrated with Artificial Intelligence, maximizing healthcare efficiency globally and in Georgia.
