Implementation of an Enhanced Recovery After Surgery (ERAS) Pathway Is Associated with Improved Short-Term Outcomes After Colorectal Surgery: A Retrospective Bi-Centre Study

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Abstract
Background: Enhanced Recovery After Surgery (ERAS) pathways have become the standard of care in elective colorectal surgery. However, implementation remains heterogeneous across institutions, and the relative contribution of ERAS pathways and minimally invasive surgery to improved postoperative outcomes remains uncertain. This study evaluated the association between ERAS implementation and short-term outcomes in two university-affiliated colorectal units with different levels of ERAS adoption. Methods: A retrospective bi-centre observational study was conducted, and comprised 802 consecutive patients who underwent elective colorectal resection between January 2016 and December 2024. Patients managed according to a standardized ERAS pathway (Group 1, n = 406) were compared with patients who received conventional perioperative care (Group 2, n = 396). Primary endpoints included postoperative morbidity, anastomotic leakage, and length of hospital stay (LOS). Secondary endpoints included mortality, readmission, postoperative complications, and hospitalization-related costs. Multivariable logistic regression was performed, adjusting for age, sex, ASA score, tumour stage, and tumour location. Results: Baseline demographic characteristics were largely comparable between groups, although patients in the conventional care group had a higher proportion of ASA III–IV status. Overall postoperative morbidity was significantly lower in the ERAS cohort (8.6% vs. 20.9%, p < 0.001), together with a lower incidence of anastomotic leakage (1.2% vs. 4.5%, p < 0.001). Median LOS was reduced from 9 to 8 days overall and, among patients who underwent laparoscopic surgery, from 6 to 4 days (p = 0.010). After multivariable adjustment, conventional perioperative management remained independently associated with higher postoperative morbidity (OR 2.62, 95% CI 1.60–4.09; p < 0.001) and anastomotic leakage (OR 1.92, 95% CI 1.01–4.98; p = 0.048). Mortality, surgical site infections, intra-abdominal abscesses, and other postoperative complications were comparable between groups. Based on regional reimbursement tariffs, ERAS implementation was associated with an estimated annual reduction of 567 hospital bed-days. Conclusions: Implementation of a standardized ERAS pathway was associated with reduced postoperative morbidity, lower anastomotic leakage rates, and shorter hospital stay after elective colorectal surgery. These benefits persisted after adjustment for major clinical confounders, supporting the effectiveness of standardized perioperative care. The greatest reduction in hospital stay was observed when ERAS was combined with minimally invasive surgery, emphasizing the complementary role of these strategies in optimizing postoperative recovery.

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