Updates in Surgery

https://doi.org/10.1007/s13304-021-01115-2

ORIGINAL ARTICLE

Implementation barriers for Enhanced Recovery After Surgery

(ERAS) in rectal cancer surgery: a comparative analysis of compliance
with colon cancer surgeries
Patricia Tejedor1,2 · Santiago González Ayora2 · Mario Ortega López2 · Miguel León Arellano2 ·
Hector Guadalajara2 · Damián García‑Olmo2 · Carlos Pastor2,3

Received: 29 March 2021 / Accepted: 11 June 2021

© Italian Society of Surgery (SIC) 2021

Abstract
We aim to analyze differences in compliance between colon and rectal cancer surgeries under Enhanced Recovery After
Surgery (ERAS) for colorectal procedures, and to detect implementation barriers for rectal cancer surgeries. Patients who
underwent elective rectal cancer surgeries under ERAS were case-matched based on gender, age, and P-POSSUM with
an equal number of patients who underwent colonic surgeries. Achievements of ≥ 70% of ERAS items were considered
an acceptable level of compliance. A multivariate analysis was carried out to identify independent risk factors for lower
compliance. A total of 434 patients were included over a 5-year period. After matching, there were 111 patients in each
group. Overall compliance was significantly lower in the rectal surgery group (73% vs 82%, p = 0.001). A good compliance
rate differed from 55% in rectal vs 77.5% in colonic procedures (p = 0.000). We identified three independent risk factors
for lower compliance rates: open surgical approach, the use of epidural catheter, and the presence of postoperative ileus.
Our data showed that rectal cancer surgeries are more exigent to success on ERAS interventions when compared to colonic
resections. There is a need to introduce specific modifications on the protocols for colorectal surgeries when applied to these
particular procedures.

Keywords Colorectal cancer · Enhanced Recovery After Surgery · ERAS · Perioperative care · Rectal surgery

Introduction benefits of ERAS programs in reduction of medical and sur-

In the last few decades, the Enhanced Recovery After Sur-
gery (ERAS) programs have been widely implemented in
many surgical disciplines in hopes to obtain the best possible
recovery for patients after surgery. Focused on colorectal
surgery, the ERAS programs have proven a better postop-
erative recovery compared to the traditional way of care [1].
To date, there exists solid evidence-based literature on the
* Patricia Tejedor
patricia.tejedor@hotmail.com
1 undergo neoadjuvant chemoradiation therapy (nCRT). (2)
Colorectal Surgery Department, University Hospital
Gregorio Marañón, Calle del Dr. Esquerdo, 46, Madrid,
Spain
2
Colorectal Surgery Department, University Hospital
Fundación Jiménez Díaz, Madrid, Spain
3
Colorectal Surgery Department, University Clinic of Navarre,
Madrid, Spain
gical complications after colorectal surgery, also showing a
significant reduction in length of hospital stay (LOS) [2–5].
It has been described that the grade of compliance with
as many possible interventions of the ERAS program has
a direct impact on reducing postoperative morbidity after
colorectal surgery [6, 7]. However, the term “colorectal sur-
gery” involves a wide range of divergent surgeries in the
large bowel; from a right or left colectomy to a low anterior
resection or abdominoperineal excision (APE). In addi-
tion, in terms of colorectal cancer surgery, the differences
between colon and rectal surgeries are quite significant: (1)
A significant percentage of patients with rectal cancer will
There is usually a lower percentage of laparoscopic rectal
cancer surgeries and higher conversion rates when com-
pared to colon cancer surgeries. (3) Patients who undergo
rectal cancer surgeries will have a higher chance of hav-
ing a temporary or a permanent stoma, which is known to
increase postoperative complications and prolong the return

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to patient’s baseline status [8]. All these particular charac-
teristics of rectal cancer surgeries may increase the risk of
developing postoperative complications and will include
many barriers to achieve a successful implementation of
ERAS protocols [9, 10].
Whether ERAS programs may be equally effective for
both colon and rectal cancer surgeries is still under inves-
tigation. In fact, most ERAS Society recommendations are
defined for colorectal surgery regardless of the type of sur-
gery. In 2012 and 2018, the ERAS Guidelines published sug-
gestions to differentiate rectal/pelvic surgeries from colonic
resections [10, 11]. These recommendations regarding rec-
tal cancer surgeries were: to intensify preoperative educa-
tion on the management of stomas, and to add mechanical
bowel preparation (MBP) in cases of rectal cancer requiring
a diverting stoma and recommendations in the management
of urinary catheters due to the high risk of postoperative
urinary retention. Despite these minor changes, the main
ERAS protocol remained unaffected. Therefore, the majority
of centers continue to apply nearly the same protocols with-
out differentiating between laparoscopic or open surgeries,
colonic or rectal resections, and surgeries with or without
stoma creation [10, 11].
Our group designed the present study with the aim to ana-
lyze the differences in compliance between colon and rectal
cancer surgeries under a standardized ERAS protocol for
colorectal procedures. As a secondary objective, we aimed
to detect ERAS implementation barriers for rectal cancer
surgeries and possible areas of improvement for this specific
group of patients.
Methods
A retrospective review was performed from a prospec-
tively maintained database, selecting consecutive patients
who underwent elective colon and rectal cancer surgeries
under ERAS care at a tertiary center (University Hospital
Fundación Jiménez Díaz) between September 2015 and
September 2019. The study was initiated after obtaining
approval by the local institutional review board committee.
A multidisciplinary task force composed of surgeons, anes-
thesiologist, nurses, and physical therapists was convened
at the beginning of the study to implement and monitor
compliance among the interventions. A nurse coordinator
was assigned to routinely assess ERAS compliance from the
patient’s medical records and to report monthly the results to
the study committee. All participants gave written, informed
consent prior to study inclusion. The study was reported
according to the RECOvER Checklist recommended for
ERAS studies [12].
We included any patient undergoing elective surgery for
colonic or rectal cancer, either by an open or laparoscopic
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Updates in Surgery
approach, with the possible presence of temporary or per-
manent stoma, treated under a standardized ERAS proto-
col on an intention to treat principle. Exclusion criteria
included: (1) emergency surgeries; (2) extended en-block
resections (multivisceral resections); (3) palliative surger-
ies; (4) transanal resections.
The data obtained for analysis included variables related
to patient’s preoperative characteristics (age, gender, pre-
vious comorbidities, preoperative anemia and nutritional
status, and nCRT), POSSUM Score, type of intervention
based on tumor location, and the need for a stoma creation.
Short-term postoperative complications were graded as
minor vs. major categories using the Clavien–Dindo clas-
sification [13]. Patients with either clinical or radiological
leakage defined by CT scan were included as anastomotic
leakages. The length of hospital stay (LOS), rates, and
causes of readmissions during the first 30-day postopera-
tive period were also documented.
The study population was divided into two groups based
on the location of the tumor from the anterior peritoneal
reflection: a study group of those patients who underwent
rectal cancer surgery (by opening and dissecting the Doug-
las pouch) and a control group of patients who underwent
colonic resections (with integrity of Douglas pouch). A
propensity-matched analysis was then performed in a 1:1
design based on the following preoperative and intraopera-
tive variables: gender, age (stratified by: under 70, 70–80,
and over 80 years old), and P-POSSUM morbidity and
mortality.
ERAS protocol and grades of compliance
Our ERAS protocol includes a set of 18 interventions that
were implemented in the study on the basis of our previ-
ously published protocols [14, 15]. Our ERAS pathway is
shown in Fig. 1.
The data on compliance were obtained by a review
of patients’ electronic medical charts. Compliance was
assessed similarly to Gustafsson et al. [16] including ele-
ments that were primarily decided by the staff and deliv-
ered before and during the 1st postoperative day (POD1).
It was calculated as the number of interventions fulfilled
out of five items analyzed and expressed as a percentage
(Compliance = elements fulfilled/5*100). Five pre- and
postoperative elements have been included in the cal-
culation of the compliance and are highlighted in bold
in Fig. 1. Intraoperative elements and those for whom
compliance was nearly 100% have been excluded from
analysis. A compliance ≥ 70% has been considered an
acceptable level compliance. Any missing data (written
information) about the duration or termination on ERAS
interventions were considered as non-compliant.
Updates in Surgery

1. Preoperative counseling and stoma education and marking (if necessary)

2. Nutritional optimization. Initiation of supplemental nutritional drinks throughout
Preoperative the day before.
period 3. Anaemia optimization (if necessary)
4. Bowel mechanical preparation (rectum surgery)
5. Preoperative antithrombotic prophylaxis
6. Antibiotic prophylaxis 30-60 minutes before the first incision
7. Intraoperative goal-directed fluid therapy and avoidance of hypothermia
8. Intraoperative pneumatic legs compression
Intraoperative 9. Minimally invasive surgical access when feasible
period 10. Avoidance of drainage when possible under surgeon criteria
11. Multimodal analgesia, abdominal wall blockade, epidural catheter in selected
cases and prevention of postoperative nausea and vomiting
12. Avoidance of nasogastric tubes
Postoperative 13. Continuous postoperative oxygenation therapy and glycaemic control
period 14. Full mobilization on the first postoperative day
15. Early oral feeding (meaning 6-8 hours after surgery) and soft-food diet on
the second postoperative day
16. Intravenous fluid restriction on the first POD
17. Removal of urinary catheter on the first POD (colon and rectal surgeries)
18. Respiratory physiotherapy

Fig. 1  Enhanced recovery program. Bold: variables included in the calculation of the partial compliance

Statistical analysis
Descriptive statistics were calculated with mean and
standard deviation (SD) or median and interquartile range
(LQR-UQR) for quantitative variables. Comparisons of
differences between group means were carried out using
ANOVA for variables with normal distribution, and the
Mann–Whitney U test for quantitative variables with non-
parametric distribution (group medians). We used Chi-
squared analysis with Fisher’s exact test when any value
observed in the contingency table was less than five to
compare proportion variables. Odds ratios (OR) and 95%
confidence interval (CI) were computed for dichotomous
and continuous risk factors between groups and a logistic
regression was performed, selecting those variables that
showed a p < 0.25 in the univariate analysis.
Sample size calculations estimated that 81 patients
would be required in each group to detect statistical
results, assuming an expected difference of 20% in com-
pliance between groups (α = 0.05, β = 0.20).
All statistical analyses were conducted using ­SPSS® ver-
sion 22 software (SPSS, Inc., Chicago, IL) and p values of
< 0.05 were considered statistically significant.
Results
A cohort of 434 patients who underwent surgery for colorec-
tal cancer over a 5-year period were included in the ERAS
protocol. Overall, 131 patients were diagnosed with rectal
cancer and 303 with colonic cancer. Within the rectal cancer
group, 77% (n = 101) underwent laparoscopic surgery vs.
58.7% (n = 178) in the colonic cancer group (p = 0.000); the
rate of conversion was 8% and 6%, respectively.
Of them, 111 patients underwent surgery for rectal cancer
and were case-matched 1:1 with 111 patients who under-
went colonic resections. Demographics and patient’s base-
line characteristics are presented in Table 1. In each group,
59% were men and 41% were women, with a mean age of 68
(59–75) years. The preoperative nutritional status based on

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 Updates in Surgery

Table 1  Patient’s demographic characteristics

Overall (n = 434) p value Propensity-matched (n = 222) p value
Study group (rec- Control group Study group (rec- Control group
tal resections) (colonic resections) tal resections) (colonic resections)
n = 131 n = 303 n = 111 n = 111

Sex (M:F) 59:41 56:44 0.548 59:41 59:41 1

Age (median, IQR) 68 (59–78) 72 (63–79) 0.012 68 (59–78) 68 (61–78) 0.616
Diabetes 16 (12%) 64 (21%) 0.024 10 (9%) 23 (21%) 0.013
Anticoagulation 8 (6%) 40 (13%) 0.028 3 (3%) 13 (12%) 0.008
Albumin (g/dL) (median, IQR) 4 (3.9–4.3) 4 (3.9–4.2) 0.572 4 (3.9–4.3) 4.1 (3.9–4.3) 0.823
Hemoglobin (g/dL) (median, IQR) 13.3 (12–14) 12.9 (11–14) 0.044 13.3 (12–14) 13.1 (11–15) 0.591
P-POSSUM morbidity (median, IQR) 30.1 (21–43) 35 (24–54) 0.155 30.1 (21–43) 30.1 (21–43) 1
P-POSSUM mortality (median, IQR) 5.3 (4–8) 6.4 (4–12) 0.167 5.3 (4–8) 5.3 (4–8) 1
Laparoscopic approach 101 (77.1%) 178 (58.7%) 0.000 87 (78.4%) 61 (55%) 0.000

mean albumin values was similar for both groups, as well as
the hemoglobin levels. P-POSSUM morbidity and mortality
were the same in both groups after matching (30.1 and 5.3,
respectively).
For the group of rectal cancer patients, 63% underwent
nCRT. The low anterior resection (LAR) was the most com-
mon performed surgery in the study group (n = 86, 78%)
followed by APE (n = 16, 14%) and Hartmanns’ procedure
(n = 9, 8%). The rate of patients with a temporary stoma
following an LAR was 76% (n = 65). In the control group
(colonic resections), the most frequent procedure was right
colectomies (n = 66, 60%) followed by left colectomies/sig-
moidectomies (n = 41, 37%) and total colectomies (n = 4,
3%). Two cases in this group (3%) needed a temporary
stoma.
Laparoscopic surgery was performed in 78.4% (n = 87) of
the patients in the study group vs. 55% (n = 61) in the control
groups (p = 0.000). Overall, laparoscopic surgery increased
over time, from 46% in 2015 to 85% in 2019. In the study
group, it raised from 60 to 89%. In the control group, the
laparoscopic approach also improved from 40 to 75%; right
colectomy was the intervention with the lower rate of lapa-
roscopic approach (40%), although the trend was towards
an increase over time (from 20 to 50%). The percentage of
patients with an epidural catheter placed in the laparoscopic
surgery group was significantly lower compared to the open
approach (40% vs. 62%, p = 0.002).
A detailed comparison of compliance rates with the
ERAS interventions between the two groups is presented
in Table 2. We found significant differences between rectal
and colonic resections in the following elements: mechani-
cal bowel preparation (if necessary) and carbohydrate
drinks, early mobilization, and early intake (POD1). Rates
of stopping intravenous fluid therapy (POD1) presented low
adherence in both groups, with no statistical differences.
Early removal of urinary catheter (POD1) was significantly
lower in the study group (54% vs. 73% in the control group,
p = 0.003). Overall compliance was significantly lower in
the study group (73 ± 20% vs. 82% ± 18% in the control
group, p = 0.001). The percentage of patients in the study

Table 2  Comparison of Study group Control group p value

compliance rates with ERAS (rectal resec- (colonic resec-
interventions between the two tions) tions)
groups n = 111 n = 111

Mechanical bowel preparation and carbohydrate drinks 110 (99%) 101 (91%) 0.005
Early mobilization (­ PODa 1) 90 (81%) 104 (94%) 0.005
Early intake (POD 1) 102 (92%) 109 (98%) 0.029
Early suspension of intravenous fluids (POD 1) 43 (39%) 57 (51%) 0.059
Early urinary catheter removal (POD 1) 60 (54%) 81 (73%) 0.003
Overall compliance (mean ± SD) 73.2 ± 20% 82% ± 18% 0.001
Compliance ≥ 70% 61 (55%) 86 (77.5%) 0.000

Statistically significant differences are indicated in bold

SD standard deviation
a
Postoperative day

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Updates in Surgery

group with suitable compliance (≥ 70%) was 55%, being
significantly higher when performing laparoscopic surgery
(64% vs. 21% in open surgery, p = 0.000). No differences
were found within the control group between laparoscopic
and open approach, with an overall percentage of 77.5% of
patients achieving a suitable compliance (vs. 55% in the con-
trol group, p = 0.000).
A central line was placed more commonly in rectal than
colonic resections (41% vs. 24%, p = 0.01), as well as epi-
dural catheter placement (60% vs. 36%, p = 0.000). The use
of the catheter gradually decreased over time, from 85% in
2015 to 44% in 2019 (p = 0.004). The presence of epidural
catheter delayed the removal of the urinary catheter (50%
vs. 76%, p = 0.000). The rate of acute urinary retention was
clearly higher in the rectal surgery group, reaching 11%
(vs. 3% in the colonic group, p = 0.016). In addition, in this
group the epidural catheter was related to the presence of
higher rates of urinary retention (11% vs. 3% without cath-
eter, p = 0.009), as well as longer LOS (7 (5–9) days vs. 5
(4–7) days, p = 0.032).
Major postoperative complications were similar between
groups. The rate of clinical anastomotic leakage was
slightly superior in the study group (9% vs. 7%, p = 0.593),
and showed similar rates of reintervention. Postoperative
ileus was higher in the study group (18.9% vs. 16.2% in the
control group, p = 0.597). LOS was 1 day longer for rectal
resections (6 (5–9) days vs. 5 (4–7) days for colonic surgery,
p = 0.000). The readmission rate was similar in both groups
(4% vs. 6% in the control group, p = 0.388).
In a multivariate analysis, the independent risk factors
identified for a low compliance (< 70%) after rectal cancer
surgery were the open approach (OR 5.1, CI 95% 1.6–16,
p = 0.006), the placement of the epidural catheter (OR 4.5,
CI 95% 1.7–12.1, p = 0.003), and the development of a
postoperative ileus (OR 7.2, CI 95% 2.1–24.9, p = 0.002).
Urinary retention or the need of a stoma creation was not
risk factor for low compliance with the ERAS elements;
however, cases with stoma resulted in an increased LOS (7
(5–9) vs. 5 (4–7) days, p = 0.039) (Table 3).
Discussion
Our study showed significant lower rates of ERAS compli-
ance for most interventions of the protocol in the group of
patients that underwent rectal resections, compared to a pro-
pensity-case-matched control group that underwent colonic
resections. Patients undergoing rectal cancer surgeries
showed significant lower percentages of overall compliance
compared to the group of colonic surgeries. We identified
three independent risk factors for low compliance (< 70%)
in the study group; the open approach, the placement of an
epidural catheter, and the postoperative ileus.
As highlighted before, there is lack of evidence regarding
differences in outcomes based on colon or rectal surgeries
under ERAS protocols. To date, there are no prospective
or clinical trials evaluating the grade of implementation of
ERAS, only for rectal cancer patients. In fact, in most ERAS
studies, the group of rectal surgeries is usually under-rep-
resented compared to colon surgeries as a few centers have
adequate numbers of both types of surgeries to establish
robust conclusions. A recent study from Poland compared
the outcomes of ERAS in colon (150 patients) vs. rectal (82
patients) laparoscopic surgeries in a prospective study [9].
They concluded, similarly to our study, that laparoscopic
rectal resections showed lower compliance with ERAS inter-
ventions and were associated with a prolonged LOS.
Likewise, in our study, overall compliance was signifi-
cantly lower for rectal vs. colonic cancer surgeries show-
ing rates of 73% vs. 82%, respectively. These observed

Table 3  Results from the Compliance Compliance p value OR (CI95%) p value

univariate and multivariate < 70% (n = 50) ≥ 70% (n = 61) Univariate analysis Multi-
analysis on variables influencing variate
a low compliance in the study analysis
group (rectal resections)
nCRT​ 32 (65%) 38 (62%) 0.744 – –
Open approach 19 (38%) 5 (8%) 0.000* 5.1 (1.6–16) 0.006
Epidural 39 (78%) 27 (44%) 0.000* 4.5 (1.7–12.1) 0.003
Central line 28 (56%) 17 (28%) 0.003* 2.1 (0.8–5.4) 0.110
Stoma 43 (86%) 47 (77%) 0.231* 1.1 (0.3–3.9) 0.832
Drainage 47 (94%) 54 (89%) 0.254 – –
Urinary retention 7 (14%) 5 (8%) 0.327 – –
Postoperative ileus 16 (32%) 5 (8%) 0.001* 7.2 (2.1–24.9) 0.002
Major complications 8 (16%) 4 (7%) 0.099 1.3 (0.2–7.7) 0.773

Statistically significant differences are indicated in bold

nCRT​neoadjuvant chemoradiotherapy
*
Variables included in the multivariate analysis

13

differences in compliance with ERAS interventions in rectal
vs. colon cancer surgeries observed may be explained by
lower rates of compliance in two main ERAS interventions;
early oral feeding and early stopping intravenous fluids.
Early oral feeding was achieved in nearly 90% of cases in
the first postoperative day, but was significantly lower in
the rectal group, while stopping intravenous fluids on POD1
had low compliance rates in both groups (39% rectal vs.
51% colonic groups). Perioperative fluid management as a
single ERAS element has been described as a major inde-
pendent predictor of postoperative outcomes. In particular,
fluid overload increased the risk of cardiopulmonary com-
plications [17]. We observed that a short urine output, the
presence of nausea, and delays in patient’s oral intake were
the most important reasons for prolonging intravenous fluid
therapy.
Three independent variables were identified in the multi-
variate analysis as predictors of low compliance rates with
protocol in rectal cancer surgeries: the placement of an epi-
dural catheter, the development of postoperative ileus, and
open surgery. Our study observed significantly higher rates
of epidural catheter in patients undergoing rectal surgery
compared to the colon group (60% vs. 36%). Pain manage-
ment was one of the cornerstones of ERAS programs in
colorectal surgery. In this sense, a Cochrane review pub-
lished in 2016 confirmed a positive effect of the epidural in
reduction of postoperative pain and a faster return to normal
bowel function in patients undergoing colorectal surgery
[18]. On the other hand, there are some disadvantages of
an extensive use of epidural catheters. In compliance with
other ERAS interventions, such removal of urinary cath-
eter or full mobilization on POD1 is affected by the use
of epidural catheters. We observed a direct relationship
between the presence of epidural catheter and the develop-
ment of urinary retention from 11 to 3% without catheters,
as previously described in the literature [19]. Consequently,
a delayed removal of the urinary catheter over the first post-
operative day was observed in more than 75% of patients
who had an epidural catheter, affecting mainly those patients
in the rectal cancer group. According to our results and as
stated in the international guidelines for ERAS, the optimal
time for removing the urinary catheter should be modified
up to 72 h following surgeries with a high risk of urinary
retention (male patients, rectal cancer, and epidural catheter
placement) [10, 11, 20, 21].
Another possible disadvantage of epidural catheters could
be a negative impact on hospital LOS. There are some dis-
parities about the effect of epidural catheters on LOS, as
some studies observed decreased LOS in patients undergo-
ing colorectal surgeries, while others found an increased
LOS, similarly to our study. The Cochrane meta-analysis
found a positive impact on LOS in patients who underwent
open, but not laparoscopic procedures [4]. As a result, the
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Updates in Surgery
majority of groups have changed from epidural catheters
to the practice of multimodal analgesia or ‘transversus
abdominis plane’ (TAP) block even for laparoscopic rectal
cancer surgeries, while reserving the use of epidural cath-
eters to planned open surgery or in those cases expecting a
high conversion risk.
To date, there is a large based evidence in the literature
showing the decisive impact in the postoperative course of
using laparoscopic compared to an open approach for colo-
rectal surgeries. Until the publication of the LAFA 2011,
there were no randomized trials exploring the potential ben-
efits of adding laparoscopic surgery and ERAS. In this mul-
ticenter trial, patients undergoing segmental colonic resec-
tions were randomized in a 2 × 2 design to laparoscopic or
open surgery and to ERAS vs. standard care protocols. The
results showed that the combination of laparoscopic surgery
and ERAS resulted in a significantly faster recovery, reduced
LOS compared to other groups, and laparoscopy was the
only independent factor for reducing both LOS and mor-
bidity [22]. As a consequence, the updated ERAS Society
guidelines published in 2019 [11] strongly recommended the
use of the laparoscopic approach for colonic resections. The
goal should be achieving at least 75% of laparoscopic colon
resections to reach the level of implementation of other ele-
ments of ERAS protocols. In comparison with the literature,
the observed global rates of laparoscopic colonic resections
in our study were low (55% for colon surgeries group). We
believe that a possible explanation for these disparities is
the fact that during the first years of the study, we performed
the majority of right colectomies by an open instead of a
laparoscopic approach (20% vs. 50% in the latest years of
the study).
The use of minimally invasive surgery (MIS) showed
similar benefits in rectal and colonic resections when
compared to the open approach. However, the implemen-
tation of laparoscopy for rectal cancer is technically chal-
lenging specifically when facing bulky rectal cancers in
obese, male patients and this technique demands a longer
learning curve for the majority of surgeons. Although
the use of MIS for rectal cancer is increasing, it is per-
formed much less in comparison with colonic surgeries;
only 66% of rectal cancer patients underwent MIS in the
ESCP snapshot published in 2018 [23]. A recent pub-
lished meta-analysis comparing the different approaches
for rectal cancer observed that patients who underwent
open surgery had increased LOS and longer time to nor-
mal intestinal function when compared to MIS [24]. In
our study, in contrast with the colon surgery group, we
observed a 77% of laparoscopic surgeries in the rectal
cancer group and open surgery was identified as an inde-
pendent risk factor for lowering compliance with ERAS
interventions. We believe that the reason for our observed
disparities in the use of laparoscopy between the study
Updates in Surgery
groups was that rectal cancers were treated mainly by
surgeons with extensive laparoscopic experience, while
colonic resections were treated by all colorectal surgeons
indistinctively. In line with the literature, our study also
identified that an open approach for rectal cancer surger-
ies was an independent risk factor for lowering compli-
ance with ERAS interventions.
The third risk factor identified as an independent risk
factor for lower rates of compliance in rectal cancer sur-
geries was the presence of postoperative ileus. Although
we did not observed differences in terms of morbidity
between the study groups, one in four patients who under-
went rectal surgeries developed postoperative ileus. Ileus
after rectal cancer surgery is multifactorial and several
variables have been linked to ileus such open surgery
because of bowel manipulation, dehydration, and elec-
trolyte imbalance due to preoperative bowel preparation
or a diverting ileostomy creation that may cause intermit-
tent mechanical bowel obstructions. In our study, the rate
of patients with diverting stoma was high (76%), also due
to a high rate of nearly 70% of cases that had nCRT. We
expected that the creation of a stoma would have had a
negative impact on compliance with ERAS interventions;
even though this variable has not being identified as an
independent predictive factor, patients with a stoma had
a significant increase in LOS of 2 more days.
We hypothesized that patient’s preoperative educa-
tion, previous stoma site marking, and an in-hospital
supervised follow-up by a dedicated stoma nurse/team
would have a positive result in compliance with ERAS
interventions. However, the current evidence to support
patient’s stoma education and better clinical outcomes
is still lacking. In a recent published review including
five studies (two randomized-controlled trials), on the
effect of preoperative stoma counseling only two found
a reduction in LOS, and there were different conclusions
in terms of reduction of stoma-related postoperative com-
plications [25].
Limitations
This study has some limitations that deserve to be men-
tioned. First, our study was not a randomized-controlled
trial; however, we introduced a propensity-matched analy-
sis to obtain two homogeneous groups to be compared.
This was a retrospective, observational study with a small
sample size. However, we have performed a sample size
calculation to estimate the number of patients needed to
detect statistical differences.
On the other hand, our database did not gather details
regarding how epidural anesthesia was managed.
Conclusions
In conclusion, based on the existing literature, there is a
lack of present evidence in whether ERAS protocol has
the same effects on colon or rectal cancers. We believe
undoubtedly that ERAS protocols should be applied to
as many numbers of colorectal surgeries. However, our
data showed that rectal cancer surgeries are more exigent
to success on ERAS interventions when compared to
colon resections. In this sense, we identified in our study
population three main barriers for ERAS in rectal can-
cer surgeries that should be avoided when possible: an
open approach, the placement of an epidural catheter, and
the development of postoperative ileus. Further studies
on ERAS and rectal cancer should be directed to predict
patients at risk of failure to adopt the program and to intro-
duce specific modifications on the protocols for colorectal
surgeries when applied to these particular surgeries.
Acknowledgements The authors would like to thank Dr. Sara Rosen-
stone Calvo for editing this manuscript.
Author contributions PT and CP contributed equally in analyzing
the data and writing the manuscript. The rest of the authors critically
revised the paper for important intellectual content. All authors have
contributed to the work and agreed on the final version.
Funding No funding.
Declarations
Conflict of interest Authors have no conflict of interest.
Research involving human participants and/or animals All procedures
performed in studies involving humans were in accordance with ethical
standards of the institutional research committee and the 1964 Helsinki
declaration and its later amendments.
Informed consent Informed consent was obtained from all participants.
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