INTRODUCTION: The 76th World Health Assembly highlighted the urgent need for action to enhance surgical care. Given the postoperative complication rate of around 20% and the rapidly increasing surgical burden related to noncommunicable diseases, implementing the Enhanced Recovery After Surgery (ERAS) protocol is recommended, particularly in low- and middle-income countries (LMICs). This evidence synthesis aimed to assess the effectiveness of the ERAS protocol in improving short-term and intermediate surgical outcomes among patients in LMICs. METHOD: This systematic review and meta-analysis were registered in the PROSPERO database (CRD42024524807). A systematic search for observational studies and clinical trials was conducted in PubMed, Scopus, Cochrane, and Web of Science, along with online trial registries, Google Scholar, and reference search. The search strategy included keywords related to “Enhanced Recovery After Surgery,” “ERAS,” “Fast-Track Surgery,” “LMICs,” and the names of LMICs. Risk of bias was assessed using the Cochrane risk of bias and the Newcastle-Ottawa scale. RevMan 5.4.1 software was used for data collection and reporting, Mendeley was used for reference management, and RStudio for meta-analysis. relative risk (RR) and standardized mean differences (SMDs) were used to report pooled results. RESULTS: A total of 1332 studies were initially identified, and after removing duplicates, 1243 studies remained, with 56 papers eligible for full-text review. Eight studies were identified from the reference search and were added to the evidence synthesis. Thirty-five studies, 23 clinical trials, and 12 observational studies were included for review, and 33 studies were included for meta-analysis. Eighty-four percent of the publications were from South and Southeast Asia. Comparable numbers of participants were distributed in the intervention (n = 3163) and control (n = 3243) groups. The studies comprised mostly abdominal surgeries (n = 17). Each study compared ERAS protocols with routine perioperative care. Meta-analysis indicated a significant reduction of postoperative morbidity after the implementation of the ERAS protocol (RR = 0.63; 95% confidence interval CI, 0.66–0.55 with I 2 of 1.1%). Also, a significant reduction in postoperative length of hospital stay was observed when the ERAS protocol was implemented (SMD= −0.68 95% CI, −0.47 to −0.90 with I 2 = 86.7). There was no significant difference in 30-day postoperative mortality and readmission rate. CONCLUSIONS: ERAS protocols represent a practical approach to improving surgical outcomes in LMICs, with evidence showing reduced postoperative morbidity and hospital stay, without an increase in readmission or mortality. Although there could be an ERAS implementation cost, its role in expediting recovery could reduce hospitalization costs. Tailored implementation and improved adherence reporting are essential to guide future adoption and policy.
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