Enhanced recovery after surgery in colorectal surgery: Do average benefits mask heterogeneous effects in patients underrepresented in trials?

Table 2 Key limitations and their implications

Limitation	Nature of the constraint	Implication for conclusions
Narrative review design	Non-systematic study selection; author judgement in synthesis	Different reviewers might emphasis different evidence
Indirect evidence for core thesis	No prospective study has tested whether distinguishing deviation types improves outcomes	Central claim is hypothesis-generating, not confirmatory
Post hoc nature of subgroup signals	Signals of heterogeneity derive from unplanned analyses	Cannot distinguish effect modification from confounding
Cross-domain theoretical frameworks	Goodhart’s Law and automation bias untested in ERAS settings	Theoretical discussion is heuristic, not evidentiary
Geographic concentration of equity evidence	Racial and socioeconomic disparities data predominantly from United States	Findings may not generalize to universal coverage health systems
English-language restriction	Grey literature and non-English publications excluded	Language bias and publication bias cannot be quantified
Single-discipline authorship	Authors are clinicians with expertise spanning surgery and ultrasound medicine	Risk of oversimplification in psychology and equity literatures
Temporal scope	Search conducted to July 2026	New evidence may have since emerged
Scope limited to elective colorectal surgery	Findings may not extend to emergency surgery or other specialties	Boundary of applicability is defined but untested
High-income country orientation of recommendations	Stratified audit presupposes electronic audit infrastructure	Applicability to low-resource settings is uncertain

ERAS: Enhanced recovery after surgery.