Cost Analysis of Enhanced Recovery Programs in Colorectal, Pancreatic, and Hepatic Surgery: A Systematic Review

  • Gaëtan-Romain Joliat
  • Martin Hübner
  • Didier Roulin
  • Nicolas DemartinesEmail author
Scientific Review



Enhanced recovery programs (ERPs) have been shown to improve postoperative outcomes after abdominal surgery. This study aimed to review the current literature to assess if ERPs in colorectal, pancreas, and liver surgery induce cost savings.


A systematic review was performed including prospective and retrospective studies comparing conventional management versus ERP in terms of costs. All kinds of ERP were considered (fast-track, ERAS®, or home-made protocols). Studies with no mention of a clear protocol and no reporting of protocol compliance were excluded.


Thirty-seven articles out of 144 identified records were scrutinized as full articles. Final analysis included 16 studies. In colorectal surgery, two studies were prospective (1 randomized controlled trial, RCT) and six retrospective, totaling 1277 non-ERP patients and 2078 ERP patients. Three of the eight studies showed no difference in cost savings between the two groups. The meta-analysis found a mean cost reduction of USD3010 (95% CI: 5370–650, p = 0.01) in favor of ERP. Among the five included studies in pancreas surgery (all retrospective, 552 non-ERP vs. 348 ERP patients), the mean cost reduction in favor of the ERP group was USD7020 (95% CI: 11,600–2430, p = 0.003). In liver surgery, only three studies (two retrospective and 1 RCT, 180 non-ERP vs. 197 ERP patients) were found, which precluded a sound cost analysis.


The present systematic review suggests that ERPs in colorectal and pancreas surgery are associated with cost savings compared to conventional perioperative management. Cost data in liver surgery are scarce.



We thank the authors of the included studies who provided additional data.



Compliance with ethical standards

Conflict of interest



  1. 1.
    Adamina M, Gié O, Demartines N et al (2013) Contemporary perioperative care strategies. Br J Surg 100:38–54PubMedCrossRefPubMedCentralGoogle Scholar
  2. 2.
    Wind J, Polle SW, Fung Kon Jin PHP et al (2006) Systematic review of enhanced recovery programmes in colonic surgery. Br J Surg 93:800–809PubMedCrossRefPubMedCentralGoogle Scholar
  3. 3.
    Gatt M, Anderson ADG, Reddy BS et al (2005) Randomized clinical trial of multimodal optimization of surgical care in patients undergoing major colonic resection. Br J Surg 92:1354–1362PubMedCrossRefPubMedCentralGoogle Scholar
  4. 4.
    Adamina M, Kehlet H, Tomlinson GA et al (2011) Enhanced recovery pathways optimize health outcomes and resource utilization: a meta-analysis of randomized controlled trials in colorectal surgery. Surgery 149:830–840PubMedCrossRefPubMedCentralGoogle Scholar
  5. 5.
    Grant MC, Yang D, Wu CL et al (2017) Impact of Enhanced recovery after surgery and fast track surgery pathways on healthcare-associated infections: results from a systematic review and meta-analysis. Ann Surg 265:68–79PubMedCrossRefGoogle Scholar
  6. 6.
    Varadhan KK, Neal KR, Dejong CHC et al (2010) The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. Clin Nutr 29:434–440PubMedCrossRefPubMedCentralGoogle Scholar
  7. 7.
    Muller S, Zalunardo MP, Hubner M et al (2009) A fast-track program reduces complications and length of hospital stay after open colonic surgery. Gastroenterology 136:842–847PubMedCrossRefGoogle Scholar
  8. 8.
    Gouvas N, Tan E, Windsor A et al (2009) Fast-track vs standard care in colorectal surgery: a meta-analysis update. Int J Colorectal Dis 24:1119–1131PubMedCrossRefPubMedCentralGoogle Scholar
  9. 9.
    Zhuang C-L, Ye X-Z, Zhang X-D et al (2013) Enhanced recovery after surgery programs versus traditional care for colorectal surgery: a meta-analysis of randomized controlled trials. Dis Colon Rectum 56:667–678PubMedCrossRefGoogle Scholar
  10. 10.
    Nicholson A, Lowe MC, Parker J et al (2014) Systematic review and meta-analysis of enhanced recovery programmes in surgical patients. Br J Surg 101:172–188PubMedCrossRefGoogle Scholar
  11. 11.
    Lee L, Mata J, Ghitulescu GA et al (2015) Cost-effectiveness of enhanced recovery versus conventional perioperative management for colorectal surgery. Ann Surg 262:1026–1033PubMedCrossRefGoogle Scholar
  12. 12.
    Williamsson C, Karlsson N, Sturesson C et al (2015) Impact of a fast-track surgery programme for pancreaticoduodenectomy. Br J Surg 102:1133–1141PubMedCrossRefGoogle Scholar
  13. 13.
    He F, Lin X, Xie F et al (2015) The effect of enhanced recovery program for patients undergoing partial laparoscopic hepatectomy of liver cancer. Clin Transl Oncol 17:694–701PubMedCrossRefGoogle Scholar
  14. 14.
    Moher D, Liberati A, Tetzlaff J et al (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 339:b2535PubMedPubMedCentralCrossRefGoogle Scholar
  15. 15.
    Stroup DF, Berlin JA, Morton SC et al (2000) Meta-analysis of observational studies in epidemiology: a proposal for reporting. meta-analysis of observational studies in epidemiology (MOOSE) group. JAMA 283:2008–2012PubMedCrossRefGoogle Scholar
  16. 16.
    Moher D, Pham B, Klassen TP et al (2000) What contributions do languages other than English make on the results of meta-analyses? J Clin Epidemiol 53:964–972PubMedCrossRefGoogle Scholar
  17. 17.
    Ottawa Hospital Research Institute. Accessed 30 Jul 2018
  18. 18.
    Downs SH, Black N (1998) The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health 52:377–384PubMedPubMedCentralCrossRefGoogle Scholar
  19. 19.
    Hozo SP, Djulbegovic B, Hozo I (2005) Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol 5:13PubMedPubMedCentralCrossRefGoogle Scholar
  20. 20.
    Roulin D, Donadini A, Gander S et al (2013) Cost-effectiveness of the implementation of an enhanced recovery protocol for colorectal surgery. Br J Surg 100:1108–1114PubMedCrossRefGoogle Scholar
  21. 21.
    Vlug MS, Wind J, Hollmann MW et al (2011) Laparoscopy in combination with fast track multimodal management is the best perioperative strategy in patients undergoing colonic surgery: a randomized clinical trial (LAFA-study). Ann Surg 254:868–875PubMedCrossRefGoogle Scholar
  22. 22.
    Miller TE, Thacker JK, White WD et al (2014) Reduced length of hospital stay in colorectal surgery after implementation of an enhanced recovery protocol. Anesth Analg 118:1052–1061PubMedCrossRefGoogle Scholar
  23. 23.
    Thiele RH, Rea KM, Turrentine FE et al (2015) Standardization of care: impact of an enhanced recovery protocol on length of stay, complications, and direct costs after colorectal surgery. J Am Coll Surg 220:430–443PubMedCrossRefGoogle Scholar
  24. 24.
    Wick EC, Galante DJ, Hobson DB et al (2015) Organizational culture changes result in improvement in patient-centered outcomes: implementation of an integrated recovery pathway for surgical patients. J Am Coll Surg 221:669–677PubMedCrossRefGoogle Scholar
  25. 25.
    Nelson G, Kiyang LN, Crumley ET et al (2016) Implementation of enhanced recovery after surgery (ERAS) across a provincial healthcare system: the ERAS alberta colorectal surgery experience. World J Surg 40:1092–1103PubMedCrossRefGoogle Scholar
  26. 26.
    Geltzeiler CB, Rotramel A, Wilson C et al (2014) Prospective study of colorectal enhanced recovery after surgery in a community hospital. JAMA Surg 149:955–961PubMedCrossRefGoogle Scholar
  27. 27.
    King PM, Blazeby JM, Ewings P et al (2006) The influence of an enhanced recovery programme on clinical outcomes, costs and quality of life after surgery for colorectal cancer. Colorectal Dis 8:506–513PubMedCrossRefGoogle Scholar
  28. 28.
    Stephen AE, Berger DL (2003) Shortened length of stay and hospital cost reduction with implementation of an accelerated clinical care pathway after elective colon resection. Surgery 133:277–282PubMedCrossRefGoogle Scholar
  29. 29.
    Kariv Y, Delaney CP, Senagore AJ et al (2007) Clinical outcomes and cost analysis of a “fast track” postoperative care pathway for ileal pouch-anal anastomosis: a case control study. Dis Colon Rectum 50:137–146PubMedCrossRefGoogle Scholar
  30. 30.
    Archibald LH, Ott MJ, Gale CM et al (2011) Enhanced recovery after colon surgery in a community hospital system. Dis Colon Rectum 54:840–845PubMedCrossRefGoogle Scholar
  31. 31.
    Ren L, Zhu D, Wei Y et al (2012) Enhanced recovery after surgery (ERAS) program attenuates stress and accelerates recovery in patients after radical resection for colorectal cancer: a prospective randomized controlled trial. World J Surg 36:407–414PubMedCrossRefGoogle Scholar
  32. 32.
    Sammour T, Zargar-Shoshtari K, Bhat A et al (2010) A programme of enhanced recovery after surgery (ERAS) is a cost-effective intervention in elective colonic surgery. N Z Med J 123:61–70PubMedGoogle Scholar
  33. 33.
    Pritts TA, Nussbaum MS, Flesch LV et al (1999) Implementation of a clinical pathway decreases length of stay and cost for bowel resection. Ann Surg 230:728–733PubMedPubMedCentralCrossRefGoogle Scholar
  34. 34.
    Lovely JK, Maxson PM, Jacob AK et al (2012) Case-matched series of enhanced versus standard recovery pathway in minimally invasive colorectal surgery. Br J Surg 99:120–126PubMedCrossRefGoogle Scholar
  35. 35.
    Bosio RM, Smith BM, Aybar PS et al (2007) Implementation of laparoscopic colectomy with fast-track care in an academic medical center: benefits of a fully ascended learning curve and specialty expertise. Am J Surg 193:413–415PubMedCrossRefPubMedCentralGoogle Scholar
  36. 36.
    Archer SB, Burnett RJ, Flesch LV et al (1997) Implementation of a clinical pathway decreases length of stay and hospital charges for patients undergoing total colectomy and ileal pouch/anal anastomosis. Surgery 122:699–703PubMedCrossRefGoogle Scholar
  37. 37.
    Tan JJY, Foo AYZ, Cheong DMO (2005) Colorectal clinical pathways: a method of improving clinical outcome? Asian J Surg 28:252–256PubMedCrossRefGoogle Scholar
  38. 38.
    Joliat G-R, Labgaa I, Petermann D et al (2015) Cost-benefit analysis of an enhanced recovery protocol for pancreaticoduodenectomy. Br J Surg 102:1676–1683PubMedCrossRefGoogle Scholar
  39. 39.
    Morgan KA, Lancaster WP, Walters ML et al (2016) Enhanced recovery after surgery protocols are valuable in pancreas surgery patients. J Am Coll Surg 222:658–664PubMedCrossRefPubMedCentralGoogle Scholar
  40. 40.
    Richardson J, Di Fabio F, Clarke H et al (2015) Implementation of enhanced recovery programme for laparoscopic distal pancreatectomy: feasibility, safety and cost analysis. Pancreatology 15:185–190PubMedCrossRefGoogle Scholar
  41. 41.
    Kagedan DJ, Devitt KS, Tremblay St-Germain A et al (2017) The economics of recovery after pancreatic surgery: detailed cost minimization analysis of an enhanced recovery program. HPB (Oxford) 19:1026–1033CrossRefGoogle Scholar
  42. 42.
    Shao Z, Jin G, Ji W et al (2015) The role of fast-track surgery in pancreaticoduodenectomy: a retrospective cohort study of 635 consecutive resections. Int J Surg 15:129–133PubMedCrossRefGoogle Scholar
  43. 43.
    Dai J, Jiang Y, Fu D (2017) Reducing postoperative complications and improving clinical outcome: enhanced recovery after surgery in pancreaticoduodenectomy—a retrospective cohort study. Int J Surg 39:176–181PubMedCrossRefGoogle Scholar
  44. 44.
    Porter GA, Pisters PW, Mansyur C et al (2000) Cost and utilization impact of a clinical pathway for patients undergoing pancreaticoduodenectomy. Ann Surg Oncol 7:484–489PubMedCrossRefGoogle Scholar
  45. 45.
    Kennedy EP, Rosato EL, Sauter PK et al (2007) Initiation of a critical pathway for pancreaticoduodenectomy at an academic institution–the first step in multidisciplinary team building. J Am Coll Surg 204:917–923 (discussion 923–924) PubMedCrossRefGoogle Scholar
  46. 46.
    Kennedy EP, Grenda TR, Sauter PK et al (2009) Implementation of a critical pathway for distal pancreatectomy at an academic institution. J Gastrointest Surg 13:938–944PubMedCrossRefGoogle Scholar
  47. 47.
    Vanounou T, Pratt W, Fischer JE et al (2007) Deviation-based cost modeling: a novel model to evaluate the clinical and economic impact of clinical pathways. J Am Coll Surg 204:570–579PubMedCrossRefGoogle Scholar
  48. 48.
    Kowalsky SJ, Zenati MS, Steve J et al (2018) A combination of robotic approach and eras pathway optimizes outcomes and cost for pancreatoduodenectomy. Ann Surg 269(6):1138–1145CrossRefGoogle Scholar
  49. 49.
    Joliat G-R, Labgaa I, Hübner M et al (2016) Cost-benefit analysis of the implementation of an enhanced recovery program in liver surgery. World J Surg 40:2441–2450PubMedCrossRefGoogle Scholar
  50. 50.
    Page AJ, Gani F, Crowley KT et al (2016) Patient outcomes and provider perceptions following implementation of a standardized perioperative care pathway for open liver resection. Br J Surg 103:564–571PubMedCrossRefGoogle Scholar
  51. 51.
    Liang X, Ying H, Wang H et al (2016) Enhanced recovery program versus traditional care in laparoscopic hepatectomy. Medicine (Baltimore) 95:e2835CrossRefGoogle Scholar
  52. 52.
    Sánchez-Pérez B, Aranda-Narváez JM, Suárez-Muñoz MA et al (2012) Fast-track program in laparoscopic liver surgery: theory or fact? World J Gastrointest Surg 4:246–250PubMedPubMedCentralCrossRefGoogle Scholar
  53. 53.
    Lin D-X, Li X, Ye Q-W et al (2011) Implementation of a fast-track clinical pathway decreases postoperative length of stay and hospital charges for liver resection. Cell Biochem Biophys 61:413–419PubMedPubMedCentralCrossRefGoogle Scholar
  54. 54.
    Thanh NX, Chuck AW, Wasylak T et al (2016) An economic evaluation of the enhanced recovery after surgery (ERAS) multisite implementation program for colorectal surgery in Alberta. Can J Surg 59:415–421PubMedPubMedCentralCrossRefGoogle Scholar
  55. 55.
    Nelson G, Kiyang LN, Chuck A et al (2016) Cost impact analysis of enhanced recovery after surgery program implementation in alberta colon cancer patients. Curr Oncol 23:e221–e227PubMedPubMedCentralCrossRefGoogle Scholar
  56. 56.
    Fine MJ, Pratt HM, Obrosky DS et al (2000) Relation between length of hospital stay and costs of care for patients with community-acquired pneumonia. Am J Med 109:378–385PubMedCrossRefGoogle Scholar
  57. 57.
    Taheri PA, Butz DA, Greenfield LJ (2000) Length of stay has minimal impact on the cost of hospital admission. J Am Coll Surg 191:123–130PubMedCrossRefGoogle Scholar
  58. 58.
    Lee L, Li C, Landry T et al (2014) A systematic review of economic evaluations of enhanced recovery pathways for colorectal surgery. Ann Surg 259:670–676PubMedCrossRefGoogle Scholar
  59. 59.
    Berian JR, Ban KA, Liu JB et al (2017) Adherence to enhanced recovery protocols in NSQIP and association with colectomy outcomes. Ann Surg 269:486–493CrossRefGoogle Scholar
  60. 60.
    Bakker N, Cakir H, Doodeman HJ et al (2015) Eight years of experience with enhanced recovery after surgery in patients with colon cancer: impact of measures to improve adherence. Surgery 157:1130–1136PubMedCrossRefGoogle Scholar
  61. 61.
    Lemanu DP, Singh PP, Stowers MDJ et al (2014) A systematic review to assess cost effectiveness of enhanced recovery after surgery programmes in colorectal surgery. Colorectal Dis 16:338–346PubMedCrossRefGoogle Scholar
  62. 62.
    Visioni A, Shah R, Gabriel E et al (2018) Enhanced Recovery after surgery for noncolorectal surgery?: a systematic review and meta-analysis of major abdominal surgery. Ann Surg 267:57–65PubMedCrossRefGoogle Scholar
  63. 63.
    Kagedan DJ, Ahmed M, Devitt KS et al (2015) Enhanced recovery after pancreatic surgery: a systematic review of the evidence. HPB (Oxford) 17:11–16CrossRefGoogle Scholar
  64. 64.
    Coolsen MME, van Dam RM, van der Wilt AA et al (2013) Systematic review and meta-analysis of enhanced recovery after pancreatic surgery with particular emphasis on pancreaticoduodenectomies. World J Surg 37:1909–1918PubMedCrossRefGoogle Scholar
  65. 65.
    Xiong J, Szatmary P, Huang W et al (2016) Enhanced recovery after surgery program in patients undergoing pancreaticoduodenectomy: a PRISMA-Compliant systematic review and meta-analysis. Medicine (Baltimore) 95:e3497CrossRefGoogle Scholar
  66. 66.
    Melloul E, Hübner M, Scott M et al (2016) Guidelines for perioperative care for liver surgery: enhanced recovery after surgery (ERAS) society recommendations. World J Surg 40:2425–2440PubMedCrossRefGoogle Scholar
  67. 67.
    Hughes MJ, McNally S, Wigmore SJ (2014) Enhanced recovery following liver surgery: a systematic review and meta-analysis. HPB (Oxford) 16:699–706CrossRefGoogle Scholar
  68. 68.
    Lei Q, Wang X, Tan S et al (2014) Fast-track programs versus traditional care in hepatectomy: a meta-analysis of randomized controlled trials. Dig Surg 31:392–399PubMedCrossRefGoogle Scholar
  69. 69.
    Song W, Wang K, Zhang R-J et al (2016) The enhanced recovery after surgery (ERAS) program in liver surgery: a meta-analysis of randomized controlled trials. Springerplus 5:207PubMedPubMedCentralCrossRefGoogle Scholar
  70. 70.
    Ahmed EA, Montalti R, Nicolini D et al (2016) Fast track program in liver resection: a PRISMA-compliant systematic review and meta-analysis. Med (Baltimore) 95:e4154CrossRefGoogle Scholar
  71. 71.
    Damania R, Cocieru A (2017) Impact of enhanced recovery after surgery protocols on postoperative morbidity and mortality in patients undergoing routine hepatectomy: review of the current evidence. Ann Transl Med 5:341PubMedPubMedCentralCrossRefGoogle Scholar
  72. 72.
    Page AJ, Ejaz A, Spolverato G et al (2015) Enhanced recovery after surgery protocols for open hepatectomy–physiology, immunomodulation, and implementation. J Gastrointest Surg 19:387–399PubMedCrossRefGoogle Scholar
  73. 73.
    Stowers MDJ, Lemanu DP, Hill AG (2014) Health economics in Enhanced Recovery After Surgery programs. Can J Anaesth 62:219–230PubMedCrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2019

Authors and Affiliations

  1. 1.Department of Visceral SurgeryLausanne University Hospital CHUVLausanneSwitzerland

Personalised recommendations