Implementing enhanced recovery after surgery in gastrointestinal surgery: A scoping review of intervention elements, strategies, and outcomes of enhanced recovery after surgery programs.

BACKGROUND: Enhanced Recovery After Surgery programs are evidence-based surgical care pathways designed to improve clinical outcomes and accelerate recovery. Despite their benefits, implementation across surgical specialties and healthcare settings remains variable. OBJECTIVES: To identify, synthesise, and map the existing literature on Enhanced Recovery After Surgery implementation, identify core and discretionary elements, and describe reported implementation strategies and outcomes. METHODS: A scoping review based on Arksey and O'Malley's methodology was conducted. Database searches were undertaken in Medical Literature Analysis and Retrieval System Online, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature from 2015 to 2025. Eligible studies included those reporting on Enhanced Recovery After Surgery implementation in adults undergoing gastrointestinal procedures. Descriptive statistics were used to analyse the number and types of Enhanced Recovery After Surgery core vs discretionary elements, implementation strategies, and outcomes. Data were mapped to visualise the distribution of evidence across Enhanced Recovery After Surgery elements, implementation strategies, and outcomes. RESULTS: 6452 articles were identified, 370 were assessed at full text, and 150 studies were ultimately included. Engaging stakeholders was the most reported implementation strategy (54/150; 36%), while providing incentives was not used across any of the studies. 72/150 (48%) studies did not report any implementation strategies. Adherence was the most reported implementation outcome, reported in 143/150 (95.3%) studies. The average number of elements implemented was 16.8/26 (standard deviation = 3.5). Across studies, 7 ERAS elements were identified as core, and 5 as discretionary. CONCLUSIONS: Findings highlight variability in Enhanced Recovery After Surgery adherence, the likely influence of contextual factors, and limited reporting of long-term sustainability. Mapping results suggest areas requiring further investigation, particularly for implementation outcomes of acceptability, penetration, fidelity, and cost. PATIENT OR PUBLIC CONTRIBUTION: Two health consumers reviewed the manuscript, interpreted findings, and made recommendations. REVIEW REGISTRATION: Open Science Framework https://osf.io/d6qx5/overview.