The biggest barrier to optimizing surgical outcome is ignorance of the nature of surgical stress and the means to control it. This is discussed in detail in my book called 50 Years Lost in Medical Advance: The Discovery of Hans Selye’s Stress Mechanism. The purpose of anesthesia is to control surgical stress. Stress is any form of nervous stimulation or tissue disruption that harmfully hyperactivates the mammalian stress mechanism (MSM). Normally the MSM repairs tissues and regulates organs efficiently and unobtrusively, but when it becomes harmfully hyperactivated by combinations of environmental stresses it begins to waste its substrates and produce excessive and defective versions of its products. This manifests as disease. The control of surgical stress requires synergistic combinations of anesthesia and analgesia that prevent harmful nervous hyperactivity induced by surgery. At present there is no clinically available means to control the stress of tissue disruption. www.stressmechanism.com

• Limited Resources (Financial, Human, and Infrastructure):Financial constraints: ERAS can require initial investments in terms of specialized equipment, staff training, and sometimes even nutritional supplements. Many resource-limited settings lack the budget for these upfront costs, even though ERAS ultimately leads to long-term cost savings. Workforce shortages: A critical barrier is the lack of sufficient healthcare professionals (nurses, physiotherapists, dietitians, anesthesiologists, surgeons) to dedicate to the intensive, multidisciplinary coordination required by ERAS. Patients often need more immediate attention in the early post-operative period to facilitate early mobilization and feeding, which strains an already stretched workforce.Inadequate infrastructure: Limited access to essential equipment (e.g., for optimal pain management, patient monitoring), rehabilitation services, and even basic hospital space can impede the full implementation of ERAS pathways.
• Resistance to Change and Lack of Knowledge:Traditional practices: Healthcare professionals may be accustomed to long-standing, traditional perioperative care practices (e.g., prolonged fasting, delayed mobilization, routine use of drains/catheters). Overcoming these deeply ingrained beliefs and practices can be challenging. Lack of awareness/education: Insufficient knowledge about ERAS principles, evidence, and benefits among healthcare providers (and even patients) can lead to reluctance in adopting new protocols. Many may not be convinced of its efficacy or feasibility in their specific context. Absence of strong leadership and institutional support: Without a champion or strong endorsement from hospital management and clinical leaders, the drive to implement ERAS can falter. A lack of top-down support, clear policies, and organizational commitment makes sustained change difficult.
• Poor Communication and Multidisciplinary Collaboration: Siloed care: Healthcare in many settings can be fragmented, with different departments and specialties working in "silos." ERAS, by its very nature, requires seamless coordination and communication among surgeons, anesthesiologists, nurses, dietitians, and physiotherapists throughout the patient's journey.Lack of standardized protocols: In the absence of clear, standardized, and context-specific ERAS protocols, individual practitioners may follow varied approaches, leading to inconsistent care and hindering overall program effectiveness. Difficulty in team building: Bringing together diverse professional groups with different perspectives and establishing a cohesive, collaborative ERAS team can be a significant challenge.
• Patient-Related Factors:Patient misconceptions: Patients may have their own deeply held beliefs about post-surgical recovery (e.g., "I need to rest extensively," "I shouldn't eat soon after surgery") that contradict ERAS principles. Socioeconomic disparities and comorbidities: Patients in resource-limited settings may present with higher rates of comorbidities or unique social and economic challenges that can affect their ability to comply with ERAS recommendations (e.g., limited social support for early discharge, poor nutritional status pre-surgery). Limited patient education: Inadequate patient education and counseling pre- and post-operatively can hinder their understanding and participation in their own recovery process, which is a cornerstone of ERAS.
• Lack of Monitoring and Audit Systems: Absence of data collection and feedback: Without robust systems for auditing compliance with ERAS protocols and tracking patient outcomes, it's difficult to assess the effectiveness of implementation, identify areas for improvement, and demonstrate the benefits to stakeholders.Difficulty in maintaining compliance: Even when ERAS is initially adopted, maintaining high levels of adherence over time can be challenging without continuous monitoring, feedback, and ongoing education
• References
• Effectiveness of an Enhanced Recovery After Surgery (ERAS) Program in Hip Arthroplasty in a Developing Country: A Propensity Score-Matched Study from Vietnam DOI https://doi.org/10.2147/JMDH.S521828
• Revolutionizing Surgical Care: The Power of Enhanced Recovery After Surgery (ERAS) . 2023 Nov 14;15(11):e48795. doi: 10.7759/cureus.48795
• https://www.facs.org/for-medical-professionals/news-publications/news-and-articles/bulletin/2025/may-2025-volume-110-issue-5/eras-protocols-are-proven-effective-but-implementation-is-challenging/
• Developing Implementation Strategies for the Adoption of the Enhanced Recovery After Surgery (ERAS) Protocols: A Co‐Design Study : 2025 Apr 3;28(2):e70254. doi: 10.1111/hex.70254

Thank you for the valuable insights and contributions to the discussion on barriers to implementing ERAS protocols in resource-limited settings. I appreciate your expertise and the collaborative spirit demonstrated here.