Comment on “Enhanced Recovery in Gynecologic Surgery: Institutional Challenges and Implementation Framework”

Translation of Enhanced Recovery After Surgery (ERAS) protocols is designed to optimize perioperative care, as well as postoperative recovery, into routine clinical practice, which is a well-acknowledged challenge. For ERAS implementation to be effective, it requires engagement from clinicians and patients, as well as caregivers and families of patients. In many cases, noncompliance with ERAS protocol cannot be distinguished from under-documentation resulting from limitations in software, errors in self-reported adherence, and misunderstanding of instructions. This review discusses barriers to implementation of ERAS protocols and practical strategies for adoption. Challenges affecting the implementation of ERAS protocols can include preoperative documentation and compliance (carbohydrate loading, bowel preparation, glycemic control, normothermia, multimodal preoperative analgesia, venous thromboembolism prophylaxis, and hair removal), intraoperative measures (prophylactic antibiotic administration, normothermia, and closing sets), and postoperative guidelines (fluid hydration, early oral nutrition, early mobilization, perioperative thromboprophylaxis, multimodal analgesia, and glycemic control). Recommendations surrounding preoperative documentation and compliance include providing clear, detailed instructions, training nurses to identify contraindications to protocols, using structured templates to facilitate accurate recording, implementing risk-based protocols as necessary for things like glycemic control, prioritizing patient education, affirming clinician education as needed, and standardizing prophylactic procedures. Recommendations for intraoperative measures include using standardized protocols and definitions, establishing mandatory checkpoints, adhering to monthly internal audits, preparing and labeling closing sets, assigning personnel to remind each other to change gloves and instruments, and instituting checklists to ensure compliance with protocols. Lastly, postoperative recommendations for ERAS implementation include implementing a standard postoperative order for locking IV fluids after oral fluids are tolerated, educating patients and care teams about early IV fluid discontinuation and early oral nutrition, defining institutional protocols for the initiation of diet and fluids postoperatively, using visual cues and reminders, integrating goals for mobility, and ensuring patient education about the steps of recovery as well as any medications they will be taking. It is well-known that ERAS protocols improve surgical outcomes and reduce complications as well as shorten recovery times. This means that the implementation of these protocols is crucial in reducing hospital costs and the burden of morbidity on patients. This review proposes strategies to overcome barriers to implementation based on the experience of ERAS protocol implementation at one hospital and encourages others to adapt these recommendations to their workflows and institutions. Multidisciplinary committees should also be implemented to assist in overcoming implementation barriers and contributing to clinician and patient education. (Summarized from Mateo-Kubach P, Santia MC, Meschini T, et al. Enhanced recovery in gynecologic surgery: institutional challenges and implementation framework. Int J Gynecol Cancer . 2026;36(2):102833. doi: 10.1016/j.ijgc.2025.102833).