The History of ERAS (Enhanced Recovery After Surgery) Society and its development in Latin America

1 Staff Anesthesiologist, Anesthesia Department, Hospital Italiano de Buenos Aires. Buenos Aires, Argentina. 2 Professor of Anesthesiology, Federal University of São Paulo, Brazil. 3 Professor of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences Department of Surgery Örebro University, Örebro, Sweden Figure 1. Number of publications indexed in PubMed per year related to Enhaced Recovery After Surgery protocols. Search criteria (ERAS + Surgery). A global problem and the rise of ERAS protocols Population growth has far exceeded that of hospital infrastructure leading to a shortage of hospital beds in many countries1-3. The number and complexity of surgeries has also been steadily growing with the development of improved surgical and anesthetic techniques. Despite these improvements, the rate of major postoperative complications has been documented to occur in approximately 25% of patients undergoing surgery as inpatients4. Nearly half of the adverse events in these studies have been suggested to be preventable5. Lowand middle-income countries have the highest burden of mistreated surgical illness 6. At the same time, many countries shifted the payment model for surgical services (from “fee-forservice” towards “pay for performance”). In the “feefor-service” model, the medical team increases its income for each service provided (procedures, complementary studies and days of hospitalization). In the “pay-forperformance” model, the payment is made for a specific operation or treatment, so any complication or extension of the hospital stay generates a higher cost for the provider and thus a lower return on the fee7,8. All together, these demographic, infrastructure and payment model shifts have generated an increased economic interest in programs that promote the optimization of existing resources and consequently an increase in efficiency. The exponential interest in Enhanced Recovery After Surgery (ERAS) programs continues its way consolidating it as one of today’s hot topic in perioperative care (Figure 1). Ultimately, beyond these factors, surgical teams continue to have the same inspiration that has always pushed them forward: To treat as many patients as possible with the best possible results. Mc Loughlin The History of ERAS (Enhanced Recovery After Surgery) Society and its development in Latin America 2 Rev Col Bras Cir 47:e20202525 However, despite these drivers for better care, the medical community is very slow to adopt change and embrace novel treatments proven to improve outcomes for patients. For instance, fasting from midnight to the day of surgery remains standard of care in many units and countries despite no data to support its practice and changes in recommendations that data back more than 25 years9.


Figure 1. Number of publications indexed in PubMed per year related to Enhaced Recovery After Surgery protocols. Search criteria (ERAS + Surgery).
A global problem and the rise of ERAS protocols P opulation growth has far exceeded that of hospital infrastructure leading to a shortage of hospital beds in many countries [1][2][3] . The number and complexity of surgeries has also been steadily growing with the development of improved surgical and anesthetic techniques. Despite these improvements, the rate of major postoperative complications has been documented to occur in approximately 25% of patients undergoing surgery as inpatients 4 . Nearly half of the adverse events in these studies have been suggested to be preventable 5 . Low-and middle-income countries have the highest burden of mistreated surgical illness 6 .
At the same time, many countries shifted the payment model for surgical services (from "fee-forservice" towards "pay for performance"). In the "feefor-service" model, the medical team increases its income for each service provided (procedures, complementary studies and days of hospitalization). In the "pay-forperformance" model, the payment is made for a specific operation or treatment, so any complication or extension of the hospital stay generates a higher cost for the provider and thus a lower return on the fee 7,8 .
All together, these demographic, infrastructure and payment model shifts have generated an increased economic interest in programs that promote the optimization of existing resources and consequently an increase in efficiency. The exponential interest in Enhanced Recovery After Surgery (ERAS) programs continues its way consolidating it as one of today's hot topic in perioperative care ( Figure 1).
Ultimately, beyond these factors, surgical teams continue to have the same inspiration that has always pushed them forward: To treat as many patients as possible with the best possible results.

Rev Col Bras Cir 47:e20202525
However, despite these drivers for better care, the medical community is very slow to adopt change and embrace novel treatments proven to improve outcomes for patients. For instance, fasting from midnight to the day of surgery remains standard of care in many units and countries despite no data to support its practice and changes in recommendations that data back more than 25 years 9 .

The ERAS ® Society
Fast-track surgery was fist coined as a term for a bundle of care elements that speed up recovery time after cardiac surgery in the US 10 .
It was further developed, conceptualized and popularized by Kehlet in colorectal surgery showing amazing improvements in recovery bringing hospital stay down from weeks to a couple of days 11 . The programs of the ERAS ® Society represent a further development of these ideas by employing a standardized method to identify evidence based perioperative care elements that improve outcomes 12 for various types of operations (www.erassociety.org).
The ERAS ® Society is a non for profit multi professional and multi-disciplinary medical society that had its origins in Europe at the beginning of the millennium as an initiative of several surgical groups interested in promoting a multimodal and integral care of the surgical patient.   The fundamental tool for its implementation is the systematic registration of each patient in a unified database for all centers and its use by the unit for continuous audit of processes and outcomes.

How to implement the ERAS ® Society program
All ERAS ® Society implementation programs (www.erassociety.org) are run by trainers that have been through the formal ERAS® Implementation program and further training to become trainers.
These trainers follow all teams of any Implementation program from start to finish and coach each unit individually. This is necessary since care varies very much from one hospital to another, from one department to another and even from one induvial doctor to another 13,14 . The Implementation program begins with the formation of a local multidisciplinary work team that sets up weekly meetings where they will analyze the situation and plan actions. system. This is key to get the best results, since it has been reported that training without audit is not sufficient to achieve the best compliance and the best results 15 .
Once the team is formed, its members will carry out a training stage consisting of 4 seminars This phenomenon is not exclusive to our region, a recent study conducted in the United States showed that patients receive on average only 55% of the guidelines recommendations that are allegedly followed by the medical centers 16 .
Thus, it is only during the second session that the team will for the first time be able to see what is actually going on in their unit by using the audit tool to reveal not only outcomes but also processes of care that will help explain why they may have certain adverse outcomes. Based