# Reliability of Simplified Versions of Enhanced Recovery After Surgery (ERAS) in Colorectal Surgery: A Retrospective Cohort Study

## TL;DR

This study compares the effectiveness of simplified versions of ERAS protocols in colorectal cancer surgery, finding that some simplified protocols perform as well or better than the full ERAS program for certain outcomes.

## Contribution

The study evaluates the predictive accuracy of simplified ERAS protocols in colorectal surgery, identifying their potential as alternatives to the full program.

## Key findings

- Nygren protocol outperformed ERAS in predicting stoma-free and complication-free outcomes.
- RAPID and Basse protocols performed better than ERAS in predicting readmission avoidance.
- ERAS had the highest predictive value for severe complications but low accuracy for readmission avoidance.

## Abstract

Introduction

Enhanced recovery after surgery (ERAS) programs have transformed perioperative care. However, adherence to all ERAS components can be challenging, and the contribution of individual components remains uncertain. This study evaluates ERAS compliance and compares its predictive accuracy with four simplified protocols: a) remove, ambulate, postoperative analgesia, introduce diet (RAPID), b) Basse, c) Nygren, and d) Aarts in colorectal cancer surgery.

Methods

A retrospective cohort study was conducted at Vila Santa Catarina Hospital (São Paulo, Brazil) and included patients undergoing elective colorectal resection for adenocarcinoma (2015-2022). ERAS compliance was measured by adherence to 22 components and compared with four simplified protocols (elements four to 12). Outcomes analyzed included stoma-free status, avoidance of readmission, absence of overall and severe complications, and mortality. Predictive accuracy was assessed via area under the curve (AUC) from receiver operating characteristic (ROC) curves (p<0.05).

Results

The study included 410 patients (mean age: 62.3 ±11.5 years; 53.4% female). Laparoscopic surgery was predominant (90%), followed by robotic (6.3%) and open (3.7%) approaches. Mean ERAS compliance was 76.9% (±9%). Postoperative outcomes were 66.3% stoma-free, 92.7% avoided readmission, 68.5% had no complications, 85.9% had no severe complications, and 98.1% survived. ERAS had the highest predictive value for severe complications (AUC: 0.69), similar to Nygren (0.68). Nygren outperformed ERAS for stoma-free (0.7 vs. 0.66) and complications (0.63 vs. 0.62). ERAS had low accuracy for readmission avoidance (AUC: 0.51), with RAPID and Basse performing better. No protocol showed significant superiority in predicting mortality (p>0.05).

Conclusions

Simplified protocols, especially Nygren and RAPID, showed competitive or superior predictive performance for certain outcomes. While ERAS remains a strong standard, simplified versions appear promising.