title: Do we really need the full compliance with ERAS protocol in laparoscopic colorectal surgery? A prospective cohort study.
abstract: BACKGROUND
  Although the relation between adherence to the ERAS protocol and clinical outcomes was extensively studied, there is still ongoing discussion on the need and feasibility of full compliance in laparoscopic colorectal surgery. In this study, we aimed to verify whether a strict adherence to the protocol (>90%) leads to further improvement in clinical outcomes compared to high (70-90%) and low (<70%) compliance groups.
  
  
  METHODS
  The analysis included consecutive prospectively registered patients operated laparoscopically for colorectal cancer between January 2012 and December 2015. Patients were divided into three groups depending on the compliance with the ERAS protocol: <70% (Group 1), 70-90% (Group 2), >90% (Group 3). The measured outcomes were: complication rate, readmission rate, recovery parameters (tolerance of early oral diet on 1st postoperative day and mobilization of a patient on the day of surgery), length of stay (LOS).
  
  
  RESULTS
  Group 1 consisted of 70, Group 2 of 65 and Group 3 of 116 patients. There were no statistical differences between the groups based on demographic parameters, stage of cancer and operative parameters (operative time, blood loss, conversion rate). The overall compliance with the protocol in the study group was 85.6 ± 11.9%. There was a significant decrease in complication rate with increasing compliance (35.7% vs. 36.4% vs. 16.4%, p = 0.0024) and severity of complications according to the Clavien-Dindo classification (p = 0.0198). Moreover, we observed differences in recovery parameters between the groups: tolerance of oral diet on the 1st postoperative day (52.8% vs. 79.5% vs. 87.9%, p < 0.0001), mobilization of a patient on the day of surgery (68.6% vs. 92.3% vs. 99.1%, p < 0.0001), respectively. We also observed that with compliance increase, the median LOS decreased (6 vs. 4 vs. 3 days, p < 0.0001).
  
  
  CONCLUSIONS
  Full implementation of the ERAS protocol significantly improves short term outcomes both in comparison to the high- and low-compliant groups.
authors.affiliation: 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501 Kraków, Poland. Electronic address: magdalena.pisarska@uj.edu.pl.
authors.forename: Magdalena
authors.initials: M
authors.lastname: Pisarska
authors.affiliation: 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501 Kraków, Poland.
authors.forename: Michał
authors.initials: M
authors.lastname: Pędziwiatr
authors.affiliation: 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501 Kraków, Poland.
authors.forename: Piotr
authors.initials: P
authors.lastname: Małczak
authors.affiliation: 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501 Kraków, Poland.
authors.forename: Piotr
authors.initials: P
authors.lastname: Major
authors.affiliation: Department of Oncology, University Hospital Krakow, Śniadeckich 10, 31-501 Kraków, Poland.
authors.forename: Sebastian
authors.initials: S
authors.lastname: Ochenduszko
authors.affiliation: 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501 Kraków, Poland.
authors.forename: Anna
authors.initials: A
authors.lastname: Zub-Pokrowiecka
authors.affiliation: 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501 Kraków, Poland.
authors.forename: Jan
authors.initials: J
authors.lastname: Kulawik
authors.affiliation: 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501 Kraków, Poland.
authors.forename: Andrzej
authors.initials: A
authors.lastname: Budzyński
mesh_terms: D000368:Aged; D002985:Clinical Protocols; D015331:Cohort Studies; D015179:Colorectal Neoplasms / Q000601:surgery*; D004434:Early Ambulation; D004435:Eating; D005260:Female; D006801:Humans; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D010359:Patient Readmission; D019990:Perioperative Care / Q000592:standards*; D011183:Postoperative Complications
keywords: Colorectal cancer; Compliance with ERAS protocol; Enhanced recovery after surgery; Fast-track surgery; Laparoscopy