ERAS program adherence-institutionalization, major morbidity and anastomotic leakage after elective colorectal surgery: the iCral2 multicenter prospective study

Surg Endosc. 2022 Jun;36(6):3965-3984. doi: 10.1007/s00464-021-08717-2. Epub 2021 Sep 14.


Background: Enhanced recovery after surgery (ERAS) programs influence morbidity rates and length of stay after colorectal surgery (CRS), and may also impact major complications and anastomotic leakage rates. A prospective multicenter observational study to investigate the interactions between ERAS program adherence and early outcomes after elective CRS was carried out.

Methods: Prospective enrolment of patients submitted to elective CRS with anastomosis in 18 months. Adherence to 21 items of ERAS program was measured upon explicit criteria in every case. After univariate analysis, independent predictors of primary endpoints [major morbidity (MM) and anastomotic leakage (AL) rates] were identified through logistic regression analyses including all significant variables, presenting odds ratios (OR).

Results: Institutional ERAS protocol was declared by 27 out of 38 (71.0%) participating centers. Median overall adherence to ERAS program items was 71.4%. Among 3830 patients included in the study, MM and AL rates were 4.7% and 4.2%, respectively. MM rates were independently influenced by intra- and/or postoperative blood transfusions (OR 7.79, 95% CI 5.46-11.10; p < 0.0001) and standard anesthesia protocol (OR 0.68, 95% CI 0.48-0.96; p = 0.028). AL rates were independently influenced by male gender (OR 1.48, 95% CI 1.06-2.07; p = 0.021), intra- and/or postoperative blood transfusions (OR 4.29, 95% CI 2.93-6.50; p < 0.0001) and non-standard resections (OR 1.49, 95% CI 1.01-2.22; p = 0.049).

Conclusions: This study disclosed wide room for improvement in compliance to several ERAS program items. It failed to detect any significant association between institutionalization and/or adherence rates to ERAS program with primary endpoints. These outcomes were independently influenced by gender, intra- and postoperative blood transfusions, non-standard resections, and standard anesthesia protocol.

Keywords: Anastomotic leakage; Colorectal surgery; ERAS; Major morbidity.

Publication types

  • Multicenter Study
  • Observational Study

MeSH terms

  • Anastomotic Leak / epidemiology
  • Anastomotic Leak / etiology
  • Anastomotic Leak / prevention & control
  • Colorectal Surgery* / adverse effects
  • Enhanced Recovery After Surgery*
  • Humans
  • Institutionalization
  • Length of Stay
  • Male
  • Morbidity
  • Postoperative Complications / epidemiology
  • Postoperative Complications / etiology
  • Postoperative Complications / prevention & control
  • Prospective Studies