Girmay MedhinAbebaw FekaduTihitena NegussiePeniel Kenna2026-03-062026-03-062025-04-19https://etd.aau.edu.et/handle/123456789/7862Introduction: Close to a third of the global disease burden is accounted for by surgical conditions. The 76th World Health Assembly Agenda item 13.1 highlighted urgent actions needed to enhance surgical care. With 18-25% postoperative complication rate, application of the Enhanced Recovery After Surgery (ERAS) protocol is advised. The aim of this study was to assess the effectiveness of the ERAS protocol in improving short-term and intermediate surgical patient outcomes in Low- and Middle- Income Countries (LMICs). Methodology: We conducted systematic review and meta-analysis and the protocol was registered in the PROSPERO database (CRD42024524807). A systematic search for observational studies and clinical trials was conducted in PubMed, Scopus, Cochrane, and Web of Sciences along with online trial registries and Google Scholar. Search strategy includes keywords related to “Enhanced Recovery After Surgery”, “ERAS”, “Fast-Track Surgery”, “LMICs”, and names of LMICs. Reference sections of the included studies were manually searched. Risk of bias of included studies were assessed using Cochrane risk of bias and Newcastle-Ottawa scale. Results: A total of 1332 studies were initially identified and after removing duplicates, 1243 studies remained, with 56 papers eligible for full-text review. Eight studies were identified from reference section and were added to evidence synthesis. Thirty-five studies, 23 clinical trials and 12 observational studies were included for review and 33 studies were included for meta-analysis. Eighty-four percent of the publications were from south and southeast Asia. Comparable number of participants were distributed in the intervention (3,163) and control (3,243) groups. The studies comprised mostly abdominal surgeries (n=17). Each study compared ERAS protocols with routine perioperative care. Meta-analysis indicated significant reduction of postoperative morbidity following the implementation of the ERAS protocol [(RR=0.73; 95%CI, 0.55 to 0.76) with (I^2) of 1.1% (P-value of 0.44)]. Also, significant reduction in postoperative length of hospital stay was observed when ERAS protocol was implemented [(SMD= -0.67 [95%CI -0.54 to -0.82]) with I^2 = 76.8]. There was no significant difference in postoperative mortality and readmission rate. Conclusion: Improved patient outcomes related to reduced postoperative complication rate and length of hospital stay were observed with ERAS application. The ERAS protocol appears promising in LMICs for enhancing surgical patient outcomes; Hence, we recommend its application. Although there could be ERAS implementation cost, its role in expediting patient recovery could reduce costs related to hospitalization.enERASLMICPostoperative MortalityPostoperative MorbidityLength of StayThesis