The Efficacy, Safety, and Component Analysis of Enhanced Recovery After Surgery (ERAS) Protocols in Adult Patients Undergoing Emergency Laparotomy: A Systematic Review and Meta-Analysis

Background Enhanced Recovery After Surgery (ERAS) protocols are the standard of care in elective surgery, but their application in high-risk emergency laparotomy is less established. This review aims to synthesize the most current evidence on the efficacy and safety of ERAS in this setting and to identify the specific protocol components most critical for success. Methods A systematic review and meta-analysis was conducted in accordance with PRISMA 2020 guidelines and was prospectively registered with PROSPERO (CRD420251156527). PubMed/MEDLINE, Cochrane CENTRAL, and Scopus were searched for studies comparing ERAS protocols to conventional care in adults undergoing emergency laparotomy. Primary outcomes were postoperative length of stay (LOS) and major morbidity (Clavien-Dindo grade ≥ 3). A random-effects model was used for meta-analysis. Results Forty-eight studies (12 RCTs, 36 cohort studies) involving 10,894 patients were included. ERAS was associated with a significant reduction in postoperative LOS (Mean Difference: -2.85 days; 95% CI: -3.45 to -2.25) and a 34% reduction in the risk of major morbidity (Risk Ratio: 0.66; 95% CI: 0.58 to 0.75). There were no significant differences in 30-day mortality or readmission rates. Subgroup analysis revealed that the benefits were most pronounced in studies that consistently implemented a core triad of postoperative components: early mobilization, early oral nutrition, and opioid-sparing multimodal analgesia. Conclusion ERAS protocols are safe and highly effective in the emergency laparotomy setting, significantly accelerating recovery and reducing complications. The consistent application of a core set of postoperative interventions appears to be the primary driver of these improved outcomes, providing a clear target for clinical implementation.