Enhanced recovery protocols: compliance and outcome in elective vs. emergency colorectal surgery

The feasibility and impact of Enhanced Recovery after Surgery (ERAS) protocols in emergency settings remain poorly understood due to patient instability, limited preoperative optimization, and inconsistent protocol adherence. Therefore, this study aimed to evaluate ERAS implementation in emergency colorectal surgery compared to elective cases.

Using the ERAS^® Interactive Audit System (EIAS) database, a retrospective analysis was performed, encompassing all patients undergoing elective (n = 690) or urgent (n = 128) colorectal surgery between May 2016 and October 2024. Both groups were matched using 2:1 Propensity Scored Matching (PSM) and compared considering demographics, perioperative factors, and results. Postoperative complication rates, anastomotic leakage and compliance to the ERAS protocol were primary endpoints.

The number of elective cases was significantly higher than the number of emergency cases. Baseline characteristics and nature of the underlying disease appeared more favorable in the elective group. PSM analysis showed similar baseline characteristics between both groups. Within the emergency group the open approach was significantly higher compared to the elective group (p = 0.014). The compliance rate to ERAS was significantly lower in the emergency group compared to the elective group (71.12 ± 14.43 vs. 76.39 ± 12.59; p < 0.001). There was no significant difference in the rates of anastomotic leakage, major organ-specific complications, or mortality between both groups.

ERAS implementation in emergency colorectal surgery is feasible despite lower compliance. Serious complications and mortality rates were similar to elective cases, highlighting the importance of developing specific ERAS protocols for emergency colorectal surgery.