Background: This is the fourth updated Enhanced Recovery After Surgery (ERAS^®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS^® protocol.Methods: A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta‐analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.Results: All recommendations on ERAS^® protocol items are based on best available evidence; good‐quality trials; meta‐analyses of good‐quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly.Conclusions: The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS^® Society in this comprehensive consensus review.

Fast-track or enhanced-recovery programs integrate a range of perioperative interventions proven to maintain physiological function and facilitate postoperative recovery, especially after elective colonic resections in dedicated centers.^1-4 The Enhanced Recovery After Surgery (ERAS) Group has achieved similar results in general surgical departments using an evidence-based care platform.^5,6

Although interventions within enhanced recovery after surgery (ERAS) or fast-track programs have been shown to improve postoperative recovery in colorectal surgery,^1-4 universal implementation has not yet occurred.⁵ One reason could be that ERAS programs are considered complex and resource demanding.⁶ Another is that the ERAS concept as such possibly appears elusive because the relative contribution of each intervention in the program remains uncertain. Nevertheless, some of the elements in the ERAS program, such as omission of routine bowel preparation for colonic resections, no routine use of postoperative drains, early removal of nasogastric tubes, and early feeding and mobilization, have already been incorporated in traditional care.^5,7 Recently, a modified fast-track protocol (RAPID) with only 4 interventions,⁸ instead of 20 in the ERAS program,^9,10 was also presented.