From enhanced recovery after surgery to fastest recovery after surgery: How fast is too fast in gastrointestinal tumor surgery?

Abstract

Enhanced recovery after surgery (ERAS) has transformed perioperative care in gastrointestinal surgery by reducing surgical stress, shortening hospital stay, and improving patient-centered outcomes. However, as ERAS pathways have become widely standardized, further acceleration of recovery appears to have reached a practical plateau. The emerging concept of fastest recovery after surgery (FRAS) challenges this limit by emphasizing the intensified timing and synchronized integration of established perioperative interventions. Recent retrospective data suggests that FRAS may enable ultra-short postoperative recovery, achieving a median hospital stay of approximately 22 hours without increasing complication rates, while also improving early quality of life and patient satisfaction. Importantly, FRAS does not rely on a single novel intervention but on the coordinated optimization of multiple ERAS components, including ultra-early oral intake, restrictive fluid management, and early drain removal. This raises a key conceptual question: Whether recovery follows a linear trajectory or requires a threshold-based shift across multiple perioperative domains. Nevertheless, FRAS should not be considered a universal protocol. Its feasibility appears limited to carefully selected patients treated in experienced centers. From an editorial perspective, FRAS is best understood not as a replacement for ERAS but as its strategic extension, emphasizing individualized, patient-tailored recovery pathways. Accordingly, the future of perioperative care may depend less on pursuing uniformly faster recovery and more on defining the optimal recovery trajectory based on patient-specific factors and perioperative risk.

Key Words: Enhanced recovery after surgery; Fastest recovery after surgery; Patient selection; Perioperative care

Core Tip: Enhanced recovery after surgery (ERAS) has transformed perioperative care in gastrointestinal surgery, yet further acceleration of recovery appears to have reached a practical plateau. The emerging concept of fastest recovery after surgery (FRAS) challenges this limit by emphasizing synchronized optimization of perioperative interventions rather than simple acceleration of individual ERAS components. Importantly, FRAS should not be viewed as a universal protocol but as a selective strategy that depends on appropriate patient selection, institutional experience, and clearly defined safety thresholds.

INTRODUCTION

Enhanced recovery after surgery (ERAS) has fundamentally reshaped perioperative care in gastrointestinal surgery over the past two decades[1-4]. By integrating evidence-based interventions aimed at reducing surgical stress, preserving physiological function, and promoting early mobilization, ERAS protocols have consistently demonstrated improvements in postoperative outcomes, including reduced complication rates, shorter hospital stays, and enhanced patient satisfaction. As a result, ERAS has transitioned from a novel perioperative strategy into a widely adopted standard of care across diverse surgical settings[5-8].

The widespread implementation of ERAS pathways has led to a high degree of standardization in perioperative management[9-11]. Core elements such as early oral intake, multimodal analgesia, and goal-directed fluid therapy are now routinely incorporated into clinical practice. Consequently, the initial dramatic gains associated with ERAS adoption have gradually evolved into more incremental improvements in recovery outcomes.

THE SUCCESS AND THE NATURAL LIMIT OF ERAS (THE ERAS PLATEAU)

Despite its undeniable success, a critical question remains: Has perioperative recovery optimization reached its practical limit, or is further acceleration still achievable?

Over the past two decades, ERAS has transformed perioperative care in gastrointestinal surgery by reducing surgical stress, preserving physiological function, and improving patient-centered outcomes. These strategies have consistently shortened hospital stay, reduced complication rates, and accelerated functional recovery, leading to their widespread adoption as standard clinical practice[1,2,9,12,13].

In our view, the diminishing incremental gains observed in contemporary ERAS practice suggest that recovery may no longer progress along a linear continuum, but instead approach a threshold beyond which further acceleration requires a fundamentally different conceptual approach.

However, as ERAS pathways have become increasingly widespread and standardized, a new clinical reality has emerged. While early implementation of ERAS yielded marked and sometimes dramatic improvements, contemporary practice suggests that further reductions in hospital stay and gains in functional recovery have become more modest and incremental. In other words, the widespread adoption of high-yield ERAS interventions has progressively narrowed the margin for additional improvement in recovery speed[14-16].

Importantly, this observation does not reflect a failure of ERAS, but rather represents a natural consequence of its success. With the near-complete integration of ERAS principles into perioperative care, the achievable benefits appear to be approaching a “natural limit”. This phenomenon, increasingly discussed in the literature as the ERAS plateau, reflects a stage at which further gains are constrained not by the absence of effective interventions, but by limitations related to timing, intensity, and synchronization of their application[3,17-20].

At this juncture, a fundamental question arises: Does this practical ceiling represent the endpoint of perioperative recovery optimization, or does room for further advancement still exist? This question has driven renewed interest in strategies aimed at achieving faster, shorter, and more intensive recovery trajectories beyond conventional ERAS frameworks. Recently, this conceptual shift has gained emerging clinical context through a cohort study comparing ERAS with the emerging concept of fastest recovery after surgery (FRAS) in patients undergoing gastrointestinal tumor surgery[4].

Recently, Zhou et al[4] reported an ultrashort postoperative recovery trajectory, achieving a median hospital stay of approximately 22 hours without an increase in complication rates. These findings challenge the perceived limits of ERAS and suggest that the so-called “ERAS plateau” may not represent a definitive ceiling, but rather a transitional phase toward a new paradigm of accelerated recovery.

While these findings are promising, the current evidence base for FRAS remains limited, predominantly derived from single-center retrospective data, and lacks large-scale prospective validation. These gaps highlight the need for cautious interpretation and underscore the importance of further research to define the boundaries and generalizability of accelerated recovery strategies.

WHAT IS FRAS-AND WHAT IT IS NOT: CONCEPTUAL CLARIFICATION

The pursuit of “faster recovery” in the post-ERAS era has led to heterogeneous interpretations of the concept of FRAS. To avoid conceptual ambiguity, it is essential to clearly define what FRAS is not before attempting to describe what it represents. Without such clarification, FRAS risks being misconstrued either as a more aggressive iteration of existing ERAS protocols or as a rebranding of ambulatory or same-day surgery pathways.

First, FRAS should not be interpreted as a simple acceleration or replication of ERAS. Conventional ERAS protocols aim to optimize recovery by standardizing multiple perioperative components based on established evidence[21].

In contrast, FRAS does not merely advocate earlier implementation of these components; rather, it represents an approach in which both the timing and intensity of interventions are deliberately recalibrated and applied in a coordinated manner. In other words, FRAS is not defined by advancing individual interventions in isolation, but by the synchronized application of evidence-based elements beyond a critical threshold.

Similarly, FRAS should not be equated with ambulatory surgery or same-day discharge models. While ambulatory surgery primarily focuses on the logistics and timing of hospital discharge, FRAS encompasses the entire recovery trajectory from a physiological and functional perspective. Early discharge may be a potential consequence of FRAS, but it is not its defining objective. Instead, FRAS emphasizes the quality, continuity, and robustness of recovery rather than discharge timing alone.

Within this framework, FRAS represents not a quantitative increase in speed beyond ERAS, but a qualitative threshold shift. Recovery is conceptualized not as a linear process that accelerates incrementally, but as a phenomenon that gains meaningful momentum only when multiple perioperative domains are optimized simultaneously and with sufficient intensity. In the absence of such a threshold shift, isolated measures, such as early oral intake, fluid restriction, or early drain removal, are unlikely to produce substantial improvements in recovery speed when applied independently[14].

Accordingly, FRAS should be viewed less as a novel protocol and more as a shift in the conceptual approach to perioperative recovery. Built upon the established foundations of ERAS, this perspective seeks not merely to “go faster”, but to redefine recovery by aligning timing, intensity, and patient selection in a more deliberate and integrated manner.

CORE COMPONENTS OF FRAS: WHAT DOES IT DO DIFFERENTLY?

The defining feature that distinguishes FRAS from conventional ERAS lies not in the isolated application of individual perioperative interventions, but in their coordinated implementation with appropriate timing, intensity, and sequencing. Many elements long embedded within ERAS pathways, such as early oral intake, restrictive intravenous fluid management, and early drain removal, are not novel in themselves[13,14,16,22].

Within the FRAS framework, however, these interventions are repositioned, with synchronization emerging as the central principle. Ultra-early oral intake represents one of the most visible components of FRAS. Early stimulation of gastrointestinal function in the postoperative period plays a key role in preventing ileus and promoting functional recovery. Yet, when implemented in isolation, early oral intake rarely translates into meaningful acceleration of recovery. In FRAS, this intervention is deliberately aligned with fluid management and mobilization strategies, allowing multiple physiological systems to adapt within the same temporal window.

Similarly, restrictive intravenous fluid management constitutes a core pillar of FRAS, though its objective extends beyond simple volume reduction. Excessive fluid administration is known to contribute to tissue edema, delayed gastrointestinal recovery, and impaired mobilization. Within a FRAS-oriented approach, fluid strategies are structured to complement early oral intake and early mobilization, thereby facilitating a more rapid physiological restoration.

Early drain removal is another characteristic feature of FRAS. Prolonged drain placement may not only compromise patient comfort, but also delay mobilization and negatively influence patients’ perception of recovery. In FRAS, drain management prioritizes removal at the earliest safe opportunity, coordinated with other accelerated interventions and without increasing complication risk.

Taken together, the success of FRAS does not rely on a single “transformative” intervention. Rather, its added value stems from the holistic application of evidence-based measures as an integrated package, delivered with deliberate timing and sufficient intensity. The impact of these interventions is not purely additive; instead, meaningful acceleration appears to occur once a critical threshold is crossed. Consequently, within FRAS, timing becomes as decisive as the intervention itself[14].

This concept is further supported by emerging evidence demonstrating that coordinated, bundle-based perioperative strategies can substantially improve postoperative outcomes, even when individual components alone confer limited benefit[14,23,24].

“HOW FAST IS TOO FAST?” WHERE DOES THE SAFETY THRESHOLD LIE?

Accelerating postoperative recovery inevitably raises the question of where safety boundaries begin. Although the ultra-short hospital stays reported with FRAS are clinically appealing, they also necessitate a critical reassessment of potential risks. In this context, the central issue is not speed itself, but rather the consequences of uncontrolled or poorly contextualized acceleration on patient safety[4].

Early discharge represents one of the most visible outcomes of FRAS-based strategies; however, discharge timing does not always equate to genuine recovery. When discharge criteria are insufficiently defined, subclinical complications may emerge in the home setting, leading to increased readmissions, emergency department utilization, and erosion of patients’ perception of safety. In such situations, apparent gains in recovery speed may be misleading rather than clinically meaningful.

Patient perception constitutes an additional and often underappreciated dimension of accelerated recovery. While rapid discharge may be interpreted as a positive milestone by some patients, others, particularly those with limited social support, may experience a sense of premature abandonment. Consequently, recovery speed must remain aligned not only with clinical parameters but also with patient expectations and available support structures.

Taken together, a fundamental principle emerges: Faster is not inherently better. Safety must precede speed, and FRAS retains its value only insofar as this priority is preserved. When implemented without clearly defined safety criteria, accelerated recovery strategies may compromise patient safety and undermine the intended benefits of FRAS.

Importantly, accumulating evidence suggests that accelerated recovery pathways are not intrinsically harmful when appropriately implemented. Even in biologically vulnerable populations, including patients receiving neoadjuvant chemotherapy, elderly individuals, and those with significant comorbidities, well-structured ERAS protocols have been shown to reduce inflammatory burden, enhance functional recovery, and maintain safety without increasing complication rates across a broad range of surgical settings[25-35].

Conversely, extending postoperative interventions beyond patients’ physiological needs within accelerated pathways may disrupt the balance between recovery and safety, increasing complication rates without measurable benefit. These observations suggest that the safety threshold of accelerated recovery is determined less by speed itself and more by physiological readiness and coordinated perioperative care[5,36,37].

Large-scale cohort data further support this perspective. Among older colorectal cancer patients managed within ERAS pathways, the benefits of accelerated recovery appear largely confined to those aged 65-80 years, whereas patients over 80 years derive more limited reductions in morbidity despite shorter hospital stays[38].

Clinical guidelines have similarly emphasized that accelerated recovery strategies should complement, rather than replace, individualized clinical judgment, particularly in older or comorbid patient populations[39].

A CONCEPTUAL FRAMEWORK FOR PATIENT SELECTION IN FRAS

The most critical determinant of whether FRAS can be implemented safely and sustainably lies in identifying which patients are suitable for accelerated recovery. FRAS should therefore be regarded as a selective strategy rather than a universally applicable perioperative protocol. Accordingly, patient selection represents the cornerstone of successful FRAS implementation (Figure 1).

Figure 1 From enhanced recovery after surgery plateau to fastest recovery after surgery: Conceptual framework and patient selection for safe accelerated recovery. Conceptual framework illustrating the transition from enhanced recovery after surgery (ERAS) to fastest recovery after surgery (FRAS) and the role of patient selection. A: ERAS leads to progressive improvement in postoperative recovery but eventually reaches a plateau with diminishing returns despite further optimization of individual components; B: FRAS represents a non-linear advancement beyond this plateau through synchronized implementation of perioperative interventions, including ultra-early oral intake, restrictive fluid management, and early drain removal, enabling accelerated recovery without compromising safety, as supported by recent clinical evidence; C: Safe application of FRAS depends on appropriate patient selection, integrating patient-related (e.g., functional status, American Society of Anesthesiologists class, frailty, nutritional status), surgical (e.g., minimally invasive approach, procedural complexity), and center-related factors to identify suitable candidates for accelerated recovery. ERAS: Enhanced recovery after surgery; FRAS: Fastest recovery after surgery; ASA: American Society of Anesthesiologists.

Patient-related factors directly define the physiological limits of accelerated recovery. Advanced age, higher American Society of Anesthesiologists (ASA) scores, poor nutritional status, and limited functional reserve are key determinants of reduced postoperative adaptive capacity. Frailty, in particular, represents a central constraint on physiological reserve; in such patients, strengthening reserve may be necessary before any attempt to accelerate recovery[40-42].

In these patients, accelerated recovery strategies must therefore be applied with caution. By contrast, patients with lower ASA scores, adequate nutritional status, and preserved physiological reserve are most likely to benefit from FRAS-based strategies. Patients receiving neoadjuvant chemotherapy provide a paradigmatic example, in whom pre-existing physiological stress may necessitate reinforcement of reserve prior to considering accelerated recovery pathways[27,36,43-48].

Surgery-related factors constitute an equally integral component of patient selection. Minimally invasive approaches, owing to reduced tissue trauma and more predictable postoperative trajectories, provide a more favorable substrate for FRAS. Conversely, prolonged operative time, intraoperative complications, or unexpected technical challenges may warrant real-time reassessment of accelerated recovery goals. Thus, FRAS eligibility should not be determined solely during preoperative evaluation, but dynamically adjusted according to intraoperative findings.

Center- and team-related experience represents a frequently underestimated, yet decisive, determinant of FRAS feasibility. In institutions lacking established expertise with standardized ERAS pathways, FRAS cannot be expected to be applied safely. Without robust multidisciplinary coordination, clearly defined discharge criteria, and surveillance mechanisms capable of detecting early complications, accelerated recovery strategies are unlikely to be sustainable[49-53].

Taken together, these variables support the development of a conceptual patient selection framework for FRAS. Rather than a linear checklist, age, physiological reserve, nutritional status, surgical approach, and center experience should be integrated within a decision-tree model. Such a framework delineates not only who may benefit from FRAS, but also who should not be exposed to accelerated recovery (Figure 2).

Figure 2 Clinical decision algorithm for the implementation of fastest recovery after surgery. Stepwise clinical decision algorithm for the safe implementation of fastest recovery after surgery (FRAS). The process begins with assessment of patient-related factors, including physiological reserve, frailty status, and nutritional condition, to determine suitability for accelerated recovery. Patients meeting these criteria proceed to surgical evaluation, where procedural complexity, minimally invasive approach, and intraoperative course are considered. Institutional readiness represents a critical prerequisite and includes established enhanced recovery after surgery (ERAS) experience, multidisciplinary coordination, and the ability to detect and manage early postoperative complications. Only when all conditions are satisfied should the FRAS protocol be implemented, incorporating synchronized perioperative strategies such as ultra-early oral intake, restrictive fluid management, and early drain removal. Continuous postoperative reassessment is essential, and patients who do not meet predefined discharge criteria should be transitioned to a conventional ERAS pathway. This algorithm emphasizes that FRAS is a selective, patient-centered strategy rather than a universally applicable protocol. ERAS: Enhanced recovery after surgery; FRAS: Fastest recovery after surgery; ASA: American Society of Anesthesiologists.

Accordingly, FRAS should be positioned not as a uniform acceleration target but as a framework guiding individualized perioperative decision-making. FRAS should therefore be viewed as a selective strategy rather than a universal protocol.

This perspective safeguards patient safety while enabling the true potential of accelerated recovery to be realized in appropriately selected populations.

FRAS: A PROTOCOL OR A PHILOSOPHY?

When interpreted as a rigid and universally applicable protocol, FRAS risks constraining its own potential. Its true value lies not in predefined speed targets, but in a conceptual shift that places patient-specific recovery dynamics at the center of perioperative decision-making. In this sense, FRAS represents a deliberate departure from the notion of “one speed fits all”.

Future success of FRAS will depend less on uniform implementation and more on individualized clinical judgment. Beyond physiological reserve, psychosocial factors, support systems, and patient expectations increasingly shape the safe limits of accelerated recovery. Accordingly, FRAS should be regarded not as a standardized acceleration protocol, but as a conceptual framework for personalized perioperative care.

This perspective is supported by large-scale meta-analyses demonstrating that ERAS pathways consistently reduce length of hospital stay and postoperative complications without increasing mortality or reoperation rates. However, the absence of a clear benefit in hard endpoints suggests that acceleration alone is insufficient for all patient profiles, reinforcing the need for a more individualized recovery philosophy[54,55].

FUTURE PERSPECTIVES

The future of FRAS is likely to focus less on achieving ever-shorter hospital stays and more on improving the predictability and safety of recovery. Risk stratification models capable of estimating early complication risk and discharge readiness are expected to play an increasingly central role, enabling more objective patient selection and boundary setting for accelerated recovery[51,56-58].

Digital follow-up platforms and remote monitoring technologies may further extend FRAS beyond hospital walls. Patient-reported outcomes, mobile health applications, and wearable devices could provide real-time insights into whether recovery is not only rapid, but also sustainable and safe. In this context, artificial intelligence-assisted decision-support systems may emerge as valuable adjuncts for discharge timing and early identification of patients requiring intervention[59-64].

Collectively, these developments position FRAS not as a static protocol, but as a data-informed and continuously adaptive approach to perioperative care, one that aligns accelerated recovery with the evolving paradigm of personalized surgery over the coming decade.

CONCLUSION

While ERAS protocols have clearly demonstrated safety and efficiency across gastrointestinal surgery, accumulating evidence suggests that successful recovery is determined not simply by acceleration, but by alignment between recovery speed and physiological readiness. In this context, FRAS should not be viewed as a paradigm replacing ERAS, but rather as its natural and inevitable evolution, built upon established gains, yet demanding greater selectivity and precision.

FRAS illustrates that further acceleration of recovery may indeed be possible; however, it also underscores that such acceleration must remain controlled, patient-centered, and context-specific. When applied selectively and within clearly defined safety boundaries, FRAS may enhance recovery trajectories. Conversely, when pursued as a universal target, its potential benefits may rapidly erode.

Accordingly, the central question is no longer “how fast”? but rather “for whom, under which conditions, and within which safety limits”? In this context, the future of perioperative recovery may depend less on pursuing ever-faster pathways and more on defining the right recovery trajectory for the right patient[54].