Enhanced recovery after surgery protocols in resource-constrained settings: Feasibility, impact and cost-neutral prioritisation from a 15-month prospective observational study

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols improve postoperative outcomes in high-income settings, but evidence supporting their implementation in resource-constrained hospitals remains limited. AIM: To evaluate perioperative practices and postoperative complications following common gastrointestinal surgery and identify feasible, cost-neutral ERAS components for prioritised implementation in a resource-constrained setting. METHODS: A 15-month prospective observational study was conducted in a semi-urban government teaching hospital in India. Adult patients undergoing appendectomy, cholecystectomy, hollow viscus perforation repair, or surgery for intestinal obstruction were consecutively enrolled. Perioperative practices and postoperative complications were prospectively documented. Observed deviations from evidence-based care were mapped to ERAS principles and prioritised according to preventability, feasibility, and cost neutrality. RESULTS: Among 522 patients, 68.6% underwent emergency surgery and 45.6% developed at least one postoperative complication. The most frequent complications were surgical site infection (24.3%), postoperative ileus (19.7%), sepsis (16.0%), pneumonia (13.4%), and catheter-associated urinary tract infection (9.8%). Common perioperative deviations included prolonged fasting, delayed oral intake and mobilisation, prolonged urinary catheterisation and nasogastric tube use, and incorrect timing of prophylactic antibiotics. Mapping these findings to ERAS principles identified a limited set of high-impact, cost-neutral interventions targeting the most common complications. CONCLUSION: Selective implementation of prioritised, cost-neutral ERAS components offers a pragmatic strategy to reduce postoperative morbidity and improve surgical outcomes in resource-constrained hospitals without increasing healthcare expenditure. Prospective interventional studies are needed to validate this approach.