From Emergency Department to Operating Room: The Role of Early Prehabilitation and Perioperative Care in Emergency Laparotomy: A Scoping Review and Practical Proposal

Background: Emergency laparotomy (EL) is associated with high morbidity and mortality compared with elective abdominal surgery. Enhanced Recovery After Surgery (ERAS) principles improve outcomes in elective settings, but their adaptation to emergencies remains inconsistent. The emergency department (ED) offers a critical opportunity for rapid risk stratification and pre-optimization, provided that interventions do not delay definitive surgery. Methods: We conducted a scoping review in accordance with PRISMA-ScR to map evidence on ED-initiated ERAS-aligned strategies for EL. PubMed, Scopus, and Cochrane were searched through February 2025. Guidelines, systematic reviews, cohort studies, consensus statements, and programmatic reports were included. Evidence was charted into five domains: (i) ERAS standards, (ii) comparative effectiveness, (iii) ED-feasible pre-optimization, (iv) risk stratification (Emergency Surgery Score [ESS], frailty, sarcopenia), and (v) oncological emergencies. Results: Twenty-five studies met inclusion criteria. ERAS Society guidelines codify rapid assessment, intraoperative multimodal care, and postoperative rehabilitation under a strict no-delay rule. Meta-analysis and cohort studies suggest ERAS-aligned pathways reduce complications and length of stay, though heterogeneity persists. Feasible ED interventions include multimodal analgesia, goal-directed fluids, early safe nutrition, respiratory preparation, and anemia/micronutrient optimization (IV iron, vitamin B12, folate, vitamin D). Sarcopenia, frailty, and ESS consistently predicted poor outcomes, supporting targeted bundle activation. Evidence from oncological emergencies, such as obstructive colorectal cancer, confirmed feasibility under no-delay governance. Conclusion: A minimal ED-initiated ERAS-aligned bundle is feasible, guideline-concordant, and may reduce complications and hospitalization in EL. This review proposes a pragmatic framework linking rapid risk stratification, opportunistic pre-optimization, and continuity into perioperative care. Future studies should test bundle fidelity, cost-effectiveness, and outcome impact in real-world emergency pathways.