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Enhanced recovery pathway in open and minimally invasive colorectal cancer surgery: a prospective study on feasibility, compliance, and outcomes in a high-volume resource limited tertiary cancer center

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Enhanced recovery program (ERP) has demonstrated improved postoperative outcomes with increased compliance to pathway. However, there is scarce data on feasibility and safety in resource limited setting. The objective was to assess compliance with ERP and its impact on postoperative outcomes and return to intended oncological treatment (RIOT).


A single center prospective observational audit was conducted from 2014 to 2019, in elective colorectal cancer surgery. Before implementation, multi-disciplinary team was educated regarding ERP. Compliance to ERP protocol and its elements was recorded. Impact of quantum of compliance (≥80% vs. <80%) to ERP on postoperative morbidity, mortality, readmission, stay, re-exploration, functional GI recovery, surgical-specific complications, and RIOT was evaluated for open and minimal invasive surgery (MIS).


During study, 937 patients underwent elective colorectal cancer surgery. Overall compliance with ERP was 73.3%. More than 80% compliance was observed in 332 (35.4%) patients in the entire cohort. Patients with <80% compliance had significantly higher overall, minor and surgery-specific complications, longer postoperative stay, delayed functional GI recovery for both open and MIS procedures. RIOT was observed in 96.5% patients. Duration to RIOT was significantly shorter following open surgery with ≥80% compliance. Compliance <80% to ERP was identified as one of the independent predictors for developing postoperative complications.


The study demonstrates beneficial impact of increased compliance to ERP on postoperative outcomes following open and minimally invasive surgery for colorectal cancer. Within a resource limited setting, ERP was found to feasible, safe, and effective in both open and minimally invasive colorectal cancer surgery.

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Data and analysis to support the findings can be obtained from the corresponding author on request.


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Authors and Affiliations



Martin Thomas Data acquisition, preparation of initial draft. Vandana Agarwal concept, design, analysis, interpretation of data, and approval of final draft; Ashwin DeSouza data verification, critical revision of the draft. Riddhi Joshi data acquisition. Minal Mali data acquisition. Karuna Panhale data acquisition. Omkar K. Salvi statistical analysis. Reshma Ambulkar critical revision of the draft. Shailesh Shrikhande concept, design, interpretation of data, approval of final draft. Avanish Saklani critical revision of the draft.

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Correspondence to Vandana Agarwal.

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Thomas, M., Agarwal, V., DeSouza, A. et al. Enhanced recovery pathway in open and minimally invasive colorectal cancer surgery: a prospective study on feasibility, compliance, and outcomes in a high-volume resource limited tertiary cancer center. Langenbecks Arch Surg 408, 99 (2023).

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