Skip to main content

Active and passive compliance in an enhanced recovery programme



Enhanced recovery after surgery (ERAS) is a well-established and accepted practice following colorectal surgery and has been demonstrated to reduce hospital length of stay (LOS) and 30-day morbidity. Despite evidence to support the individual elements on which the programme is based, there remains uncertainty as to how many and which of these are required to realise its benefits. Furthermore, elements of an ERAS programme might either precipitate or reflect recovery, in which case compliance could have a role in the improvement or prediction of outcome.

Materials and methods

A multidimensional prospective database of 799 consecutive patients undergoing colorectal surgery within an established ERAS programme at a single institution was interrogated. After application of exclusion criteria, 614 patients were studied. The novel concept of ‘active compliance’ is introduced. An ERAS element is classified as ‘active’ if the participation of the patient is required to achieve its compliance. This contrasts with ‘passive’ compliance, where an intervention is delivered to the patient without their direct contribution. The short-term surgical outcomes of this cohort are reported with reference to ERAS protocol compliance.


Compliance with the passive elements of the programme was higher than with the active elements. Univariate and multivariate analyses demonstrate that poor compliance with active but not passive elements of the programme was significantly associated with major morbidity. Receiver operator characteristic curve analysis demonstrated active compliance to be a stronger predictor of both major morbidity (AUC 0.71 vs. AUC 0.56) and length of stay (AUC 0.83 vs. 0.57) when compared with passive compliance.


The results suggest that poor active compliance may be a surrogate marker of morbidity which can be recognised in the early post-operative period. This implies the potential for timely diagnosis and intervention. This aspect of ERAS compliance is clinically relevant yet has achieved scant attention. Independent validation of our observations is required.

This is a preview of subscription content, access via your institution.

Fig. 1


  1. Fearon KC, Ljungqvist O, Von Meyenfeldt M, Revhaug A, Dejong CH, Lassen K, Nygren J, Hausel J, Soop M, Andersen J, Kehlet H (2005) Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr (Edinburgh Scotland) 24(3):466–477

    CAS  Article  Google Scholar 

  2. Lassen K, Hannemann P, Ljungqvist O, Fearon K, Dejong CH, von Meyenfeldt MF, Hausel J, Nygren J, Andersen J, Revhaug A (2005) Patterns in current perioperative practice: survey of colorectal surgeons in five northern European countries. BMJ (Clinical research ed; 330(7505): 1420–1421

  3. Polle SW, Wind J, Fuhring JW, Hofland J, Gouma DJ, Bemelman WA (2007) Implementation of a fast-track perioperative care program: what are the difficulties? Dig Surg 24(6):441–449

    Article  PubMed  Google Scholar 

  4. Varadhan KK, Neal KR, Dejong CH, Fearon KC, Ljungqvist O, Lobo DN (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 (Edinburgh Scotland) 29(4):434–440

    Article  Google Scholar 

  5. Lei QC, Wang XY, Zheng HZ, Xia XF, Bi JC, Gao XJ, Li N (2015) Laparoscopic versus open colorectal resection within fast track programs: an update meta-analysis based on randomized controlled trials. J Clin Med Res 7(8):594–601

    Article  PubMed  PubMed Central  Google Scholar 

  6. Zhuang CL, Ye XZ, Zhang XD, Chen BC, Yu Z (2013) Enhanced recovery after surgery programs versus traditional care for colorectal surgery: a meta-analysis of randomized controlled trials. Dis Colon Rectum 56(5):667–678

    Article  PubMed  Google Scholar 

  7. Spanjersberg WR, van Sambeeck JD, Bremers A, Rosman C, van Laarhoven CJ (2015) Systematic review and meta-analysis for laparoscopic versus open colon surgery with or without an ERAS programme. Surg Endosc 29(12):3443–3453

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  8. Gianotti L, Beretta S, Luperto M, Bernasconi D, Valsecchi MG, Braga M (2014) Enhanced recovery strategies in colorectal surgery: is the compliance with the whole program required to achieve the target? Int J Colorectal Dis 29(3):329–341

    Article  PubMed  Google Scholar 

  9. Lloyd GM, Kirby R, Hemingway DM, Keane FB, Miller AS, Neary P (2010) The RAPID protocol enhances patient recovery after both laparoscopic and open colorectal resections. Surg Endosc 24(6):1434–1439

    CAS  Article  PubMed  Google Scholar 

  10. Ahmed J, Khan S, Gatt M, Kallam R, MacFie J (2010) Compliance with enhanced recovery programmes in elective colorectal surgery. Br J Surg 97(5):754–758

    CAS  Article  PubMed  Google Scholar 

  11. Gustafsson UO, Hausel J, Thorell A, Ljungqvist O, Soop M, Nygren J (2011) Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Arch Surg 146(5):571–577

    Article  PubMed  Google Scholar 

  12. Bakker N, Cakir H, Doodeman HJ, Houdijk AP (2015) Eight years of experience with enhanced recovery after surgery in patients with colon cancer: impact of measures to improve adherence. Surgery 157(6):1130–1136

    Article  PubMed  Google Scholar 

  13. The impact of enhanced recovery protocol compliance on elective colorectal cancer resection: results from an International Registry (2015) Ann Surg; 261(6): 1153–1159

  14. Cakir H, van Stijn MF, Lopes Cardozo AM, Langenhorst BL, Schreurs WH, van der Ploeg TJ, Bemelman WA, Houdijk AP (2013) Adherence to enhanced recovery after surgery and length of stay after colonic resection. Colorectal Dis 15(8):1019–1025

    CAS  Article  PubMed  Google Scholar 

  15. Gillissen F, Hoff C, Maessen JM, Winkens B, Teeuwen JH, von Meyenfeldt MF, Dejong CH (2013) Structured synchronous implementation of an enhanced recovery program in elective colonic surgery in 33 hospitals in the Netherlands. World J Surg 37(5):1082–1093

    Article  PubMed  Google Scholar 

  16. Smart NJ, White P, Allison AS, Ockrim JB, Kennedy RH, Francis NK (2012) Deviation and failure of enhanced recovery after surgery following laparoscopic colorectal surgery: early prediction model. Colorectal Dis 14(10):e727–e734

    CAS  Article  PubMed  Google Scholar 


  18. Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, de Santibanes E, Pekolj J, Slankamenac K, Bassi C, Graf R, Vonlanthen R, Padbury R, Cameron JL, Makuuchi M (2009) The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 250(2):187–196

    Article  PubMed  Google Scholar 

  19. Spanjersberg WR, Reurings J, Keus F, van Laarhoven CJ. Fast track surgery versus conventional recovery strategies for colorectal surgery. The Cochrane database of systematic reviews 2011(2): CD007635

  20. Ahmed J, Khan S, Lim M, Chandrasekaran TV, MacFie J (2012) Enhanced recovery after surgery protocols—compliance and variations in practice during routine colorectal surgery. Colorectal Dis 14(9):1045–1051

    CAS  Article  PubMed  Google Scholar 

  21. Delaney CP, Fazio VW, Senagore AJ, Robinson B, Halverson AL, Remzi FH (2001) ‘Fast track’ postoperative management protocol for patients with high co-morbidity undergoing complex abdominal and pelvic colorectal surgery. Br J Surg 88(11):1533–1538

    CAS  Article  PubMed  Google Scholar 

  22. Pedziwiatr M, Kisialeuski M, Wierdak M, Stanek M, Natkaniec M, Matlok M, Major P, Malczak P, Budzynski A (2015) Early implementation of enhanced recovery after surgery (ERAS(R)) protocol—compliance improves outcomes: a prospective cohort study. Int J Surg (London England) 21:75–81

    Article  Google Scholar 

  23. Feroci F, Lenzi E, Baraghini M, Garzi A, Vannucchi A, Cantafio S, Scatizzi M (2013) Fast-track colorectal surgery: protocol adherence influences postoperative outcomes. Int J Colorectal Dis 28(1):103–109

    Article  PubMed  Google Scholar 

  24. Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N, McNaught CE, Macfie J, Liberman AS, Soop M, Hill A, Kennedy RH, Lobo DN, Fearon K, Ljungqvist O (2013) Guidelines for perioperative care in elective colonic surgery: enhanced recovery after surgery (ERAS((R))) society recommendations. World J Surg 37(2):259–284

    CAS  Article  PubMed  Google Scholar 

  25. Nygren J, Thacker J, Carli F, Fearon KC, Norderval S, Lobo DN, Ljungqvist O, Soop M, Ramirez J (2013) Guidelines for perioperative care in elective rectal/pelvic surgery: enhanced recovery after surgery (ERAS((R))) society recommendations. World J Surg 37(2):285–305

    CAS  Article  PubMed  Google Scholar 

  26. Vlug MS, Bartels SA, Wind J, Ubbink DT, Hollmann MW, Bemelman WA (2011) Which fast track elements predict early recovery after colon cancer surgery? Colorectal Dis 14(8):1001–1008

    Article  Google Scholar 

  27. CardioQ-ODM oesophageal doppler monitor [MTG3] (2011) In. London: National Institute for Health Care Excellence

  28. Levy BF, Scott MJ, Fawcett W, Fry C, Rockall TA (2011) Randomized clinical trial of epidural, spinal or patient-controlled analgesia for patients undergoing laparoscopic colorectal surgery. Br J Surg 98(8):1068–1078

    CAS  Article  PubMed  Google Scholar 

  29. Vlug MS, Wind J, Hollmann MW, Ubbink DT, Cense HA, Engel AF, Gerhards MF, van Wagensveld BA, van der Zaag ES, van Geloven AA, Sprangers MA, Cuesta MA, Bemelman WA (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(6):868–875

    Article  PubMed  Google Scholar 

  30. Aarts MA, Okrainec A, Glicksman A, Pearsall E, Victor JC, McLeod RS (2012) Adoption of enhanced recovery after surgery (ERAS) strategies for colorectal surgery at academic teaching hospitals and impact on total length of hospital stay. Surg Endosc 26(2):442–450

    Article  PubMed  Google Scholar 

  31. Feroci F, Lenzi E, Baraghini M, Garzi A, Vannucchi A, Cantafio S, Scatizzi M (2013) Fast-track surgery in real life: how patient factors influence outcomes and compliance with an enhanced recovery clinical pathway after colorectal surgery. Surg Laparosc Endosc Percutan Tech 23(3):259–265

    Article  PubMed  Google Scholar 

  32. Keller DS, Bankwitz B, Woconish D, Champagne BJ, Reynolds HL Jr, Stein SL, Delaney CP (2014) Predicting who will fail early discharge after laparoscopic colorectal surgery with an established enhanced recovery pathway. Surg Endosc 28(1):74–79

    Article  PubMed  Google Scholar 

  33. Harrison OJ, Smart NJ, White P, Brigic A, Carlisle ER, Allison AS, Ockrim JB, Francis NK (2014) Operative time and outcome of enhanced recovery after surgery after laparoscopic colorectal surgery. JSLS 18(2):265–272

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations


Corresponding author

Correspondence to John T. Jenkins.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Thorn, C.C., White, I., Burch, J. et al. Active and passive compliance in an enhanced recovery programme. Int J Colorectal Dis 31, 1329–1339 (2016).

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:


  • Enhanced recovery after surgery
  • Length of stay
  • Surgical morbidity