Specialty: Colorectal

In this ten-minute education session, Associate Professor Ulf Gustafsson, colorectal surgeon at Karolinska University Hospital in Stockholm and first author of the guideline, presents what has changed in the 2025 ERAS® Society guideline for elective colorectal surgery. It is aimed at colorectal surgeons, anaesthesiologists, ERAS® nurses and ERAS® teams who work with the colorectal protocol. You will learn how the new guideline was developed, which recommendations have been strengthened or weakened, and why a low level of evidence does not necessarily mean that an intervention is unimportant.

Dr Gustafsson starts with the history of the colorectal guideline, from the first version in 2005 to this fourth update, published in the journal Surgery in 2025, and reminds viewers that implementing the full ERAS® protocol reduces complications by about 50% and shortens length of stay by two to three days. The new guideline follows a standardised methodology using the GRADE system: the work took almost a year, around 3,400 studies were read on antibiotics alone, and more than 800 studies were graded. He then goes through the main changes. Prehabilitation is not recommended, as there was not enough evidence, although results from ongoing RCTs may change this. Smoking cessation and IV iron keep moderate evidence, while the evidence for stopping alcohol four weeks before surgery is somewhat lower. No specific predictive tool, such as ASA or POSSUM, is recommended. The timing of thromboprophylaxis is more liberal, there is more evidence for immunonutrition but no recommended formula, and preoperative carbohydrate loading is still recommended despite weaker evidence. The evidence for minimally invasive surgery is much stronger, with no clear difference between robotic and laparoscopic surgery. Epidurals are not recommended in minimally invasive surgery but remain a recommendation in open surgery, and the mobilisation target has been lowered from six to three hours per day. The session ends with how the new guideline is being translated into the ERAS® Interactive Audit System (EIAS).

Recorded: 26 January 2026
Duration: 10 minutes
Language: English (subtitles in English, French, German, Spanish, Portuguese and Swedish)

Speakers

• Associate Professor Ulf Gustafsson
  Senior Consultant Surgeon and Head of the Division of Coloproctology, Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden; Interim Chair and Guideline Co-Chair, ERAS® Society – first author of the 2025 ERAS® Society colorectal guideline; presents the methodology and the changes in the new guideline.

Chapters

• 00:00 Introduction
• 00:25 History of the ERAS® colorectal guidelines
• 01:22 What the ERAS® protocol achieves
• 02:05 Interventions by level of evidence
• 03:30 Methodology: the GRADE system
• 04:30 What has changed since the previous guideline
• 04:43 Preoperative optimisation and prehabilitation
• 05:28 Smoking, IV iron and alcohol
• 06:04 Predictive tools
• 06:33 Thromboprophylaxis and immunonutrition
• 07:11 Preoperative carbohydrate loading
• 07:28 Minimally invasive surgery
• 08:02 Epidural analgesia
• 08:23 Postoperative mobilisation
• 08:58 Conclusions

Related resources

• Guidelines for perioperative care in elective colorectal surgery: ERAS® Society recommendations 2025 (Gustafsson et al., Surgery 2025)
• ERAS® colorectal protocol
• ERAS® Interactive Audit System (EIAS) – Encare's audit system for ERAS® compliance and outcomes
• ERAS® Implementation Program (EIP) – the structured implementation programme
• ERAS® Society guidelines
• ERAS® Society – guidelines and the ERAS® programme

Want to see how EIAS supports the updated colorectal protocol and ERAS® audit in your hospital? Book a demo