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Does adherence to perioperative enhanced recovery pathway elements influence patient-reported recovery following colorectal resection?



Patient-reported outcome measures (PROMs) are pivotal to promote patient-centered perioperative care. Adherence to enhanced recovery programs (ERPs) is associated with improved clinical outcomes (i.e., morbidity, length of stay), but the impact of adherence on PROMs is uncertain. The objective of this study was to evaluate the extent to which adherence to an ERP for colorectal surgery is associated with postoperative recovery as assessed using PROMs.

Methods and procedures

100 patients were included [median age 63 (IQR 50–71) years, 81 laparoscopic, 37 rectal surgery]. Overall adherence to the ERP and adherence to specific ERP elements were analyzed. Adjusted linear regression was used to evaluate the association of adherence with PROMs assessing early recovery [Abdominal surgery impact scale (ASIS) and Multidimensional fatigue inventory (MFI) on POD2] and late recovery (Duke Activity Status Index, RAND-36 Physical and Mental Summary Scores, Life-Space Mobility Assessment at 4 weeks after surgery). Missing data were addressed using multiple imputations.


Median adherence to the ERP was 80% (16/20 elements, IQR 70–90%). Overall adherence was associated with ASIS scores on POD2 (4% increase per additional element, 95% CI 1–8%; p = 0.018). When specific ERP elements were analyzed, ASIS scores were associated with adherence to PONV prophylaxis (34% increase, 95% CI 5–63%; p = 0.023) and early solid food diet (20% increase, 95% CI 5–35%; p = 0.009). MFI General fatigue and MFI Mental fatigue scores on POD2 were associated with adherence to PONV prophylaxis (36% decrease, 95% CI − 64 to − 8%, p = 0.014 and 22% decrease, 95% CI − 44 to − 8%, p = 0.042). Overall adherence and adherence to specific elements were not associated with PROMs at 4 weeks after surgery.


Our findings suggest that, from the perspective of patients, adherence to an ERP for colorectal surgery impacts early, but not late postoperative recovery. This result may reflect the lack of PROMs able to validly measure postoperative recovery beyond hospital discharge.

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  1. Kehlet H, Wilmore DW (2008) Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg 248:189–198

    Article  Google Scholar 

  2. Greco M, Capretti G, Beretta L, Gemma M, Pecorelli N, Braga M (2014) Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials. World J Surg 38:1531–1541

    Article  Google Scholar 

  3. 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, Enhanced Recovery After Surgery Society fPC, European Society for Clinical N, Metabolism, International Association for Surgical M, Nutrition (2013) Guidelines for perioperative care in elective colonic surgery: enhanced recovery after surgery (ERAS((R))) society recommendations. World J Surg 37:259–284

    Article  Google Scholar 

  4. Messenger DE, Curtis NJ, Jones A, Jones EL, Smart NJ, Francis NK (2017) Factors predicting outcome from enhanced recovery programmes in laparoscopic colorectal surgery: a systematic review. Surg Endosc 31:2050–2071

    Article  Google Scholar 

  5. Pecorelli N, Hershorn O, Baldini G, Fiore JF Jr, Stein BL, Liberman AS, Charlebois P, Carli F, Feldman LS (2017) Impact of adherence to care pathway interventions on recovery following bowel resection within an established enhanced recovery program. Surg Endosc 31:1760–1771

    Article  Google Scholar 

  6. Aarts MA, Rotstein OD, Pearsall EA, Victor JC, Okrainec A, McKenzie M, McCluskey SA, Conn LG, McLeod RS (2018) Postoperative ERAS interventions have the greatest impact on optimal recovery: experience with implementation of ERAS across multiple hospitals. Ann Surg 267(6):992–997

    Article  Google Scholar 

  7. Lee L, Dumitra T, Fiore JF Jr, Mayo NE, Feldman LS (2015) How well are we measuring postoperative “recovery” after abdominal surgery? Qual Life Res 24:2583–2590

    Article  Google Scholar 

  8. Neville A, Lee L, Antonescu I, Mayo NE, Vassiliou MC, Fried GM, Feldman LS (2014) Systematic review of outcomes used to evaluate enhanced recovery after surgery. Br J Surg 101:159–170

    Article  CAS  Google Scholar 

  9. Lee L, Tran T, Mayo NE, Carli F, Feldman LS (2014) What does it really mean to “recover” from an operation?. Surgery 155:211–216

    Article  Google Scholar 

  10. Gabriel SE, Normand S-LT (2012) Getting the methods right—the foundation of patient-centered outcomes research. N Engl J Med 367:787–790

    Article  CAS  Google Scholar 

  11. Fiore JF Jr, Figueiredo S, Balvardi S, Lee L, Nauche B, Landry T, Mayo NE, Feldman LS (2018) How do we value postoperative recovery?: a systematic review of the measurement properties of patient-reported outcomes after abdominal surgery. Ann Surg 267:656–669

    Article  Google Scholar 

  12. Feldman LS, Lee L, Fiore J Jr (2015) What outcomes are important in the assessment of enhanced recovery after surgery (ERAS) pathways?. Can J Anaesth 62:120–130

    Article  Google Scholar 

  13. Abola RE, Bennett-Guerrero E, Kent ML, Feldman LS, Fiore JF Jr, Shaw AD, Thacker JKM, Gan TJ, Miller TE, Hedrick TL, McEvoy MD, Mythen MG, Bergamaschi R, Gupta R, Holubar SD, Senagore AJ, Wischmeyer PE, Carli F, Evans DC, Guilbert S, Kozar R, Pryor A, Thiele RH, Everett S, Grocott M (2017) American society for enhanced recovery and perioperative quality initiative joint consensus statement on patient-reported outcomes in an enhanced recovery pathway. Anesth Analg

  14. von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP, Initiative S (2007) The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet 370:1453–1457

    Article  Google Scholar 

  15. Fiore JF Jr, Castelino T, Pecorelli N, Niculiseanu P, Balvardi S, Hershorn O, Liberman S, Charlebois P, Stein B, Carli F, Mayo NE, Feldman LS (2017) Ensuring early mobilization within an enhanced recovery program for colorectal surgery: a randomized controlled trial. Ann Surg 266:223–231

    Article  Google Scholar 

  16. Slankamenac K, Graf R, Barkun J, Puhan MA, Clavien PA (2013) The comprehensive complication index: a novel continuous scale to measure surgical morbidity. Ann Surg 258:1–7

    Article  Google Scholar 

  17. Baldini G, Fawcett WJ (2015) Anesthesia for colorectal surgery. Anesthesiol Clin 33:93–123

    Article  Google Scholar 

  18. Urbach DR, Harnish JL, McIlroy JH, Streiner DL (2006) A measure of quality of life after abdominal surgery. Qual Life Res 15:1053–1061

    Article  Google Scholar 

  19. Datta I, O’Connor B, Victor JC, Urbach DR, McLeod RS (2009) Abdominal Surgery Impact Scale (ASIS) is responsive in assessing outcome following IPAA. J Gastrointest Surg 13:687–694

    Article  Google Scholar 

  20. Smets EM, Garssen B, Bonke B, De Haes JC (1995) The Multidimensional Fatigue Inventory (MFI) psychometric qualities of an instrument to assess fatigue. J Psychosom Res 39:315–325

    Article  CAS  Google Scholar 

  21. Zargar-Shoshtari K, Hill AG (2009) Postoperative fatigue: a review. World J Surg 33:738–745

    Article  Google Scholar 

  22. Hopman WM, Towheed T, Anastassiades T, Tenenhouse A, Poliquin S, Berger C, Joseph L, Brown JP, Murray TM, Adachi JD, Hanley DA, Papadimitropoulos E, Group TCMOSR (2000) Canadian normative data for the SF-36 health survey. Can Med Assoc J 163:265–271

    CAS  Google Scholar 

  23. Hlatky MA, Boineau RE, Higginbotham MB, Lee KL, Mark DB, Califf RM, Cobb FR, Pryor DB (1989) A brief self-administered questionnaire to determine functional capacity (The Duke Activity Status Index). Am J Cardiol 64:651–654

    Article  CAS  Google Scholar 

  24. Brown CJ, Roth DL, Allman RM, Sawyer P, Ritchie CS, Roseman JM (2009) Trajectories of life-space mobility after hospitalization. Ann Intern Med 150:372–378

    Article  Google Scholar 

  25. Mata J, Fiore JF Jr, Pecorelli N, Stein BL, Liberman S, Charlebois P, Feldman LS (2017) Predictors of adherence to enhanced recovery pathway elements after laparoscopic colorectal surgery. Surg Endosc 32(4):1812–1819

    Google Scholar 

  26. Hendry PO, Hausel J, Nygren J, Lassen K, Dejong CH, Ljungqvist O, Fearon KC (2009) Determinants of outcome after colorectal resection within an enhanced recovery programme. Br J Surg 96:197–205

    Article  CAS  Google Scholar 

  27. 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 Percutaneous Tech 23:259–265

    Google Scholar 

  28. Li P, Stuart EA, Allison DB (2015) Multiple imputation: a flexible tool for handling missing data. JAMA 314:1966–1967

    Article  CAS  Google Scholar 

  29. Fairclough DL, Cella DF (1996) Functional Assessment of Cancer Therapy (FACT-G): non-response to individual questions. Qual Life Res 5:321–329

    Article  CAS  Google Scholar 

  30. 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 157:1130–1136

    Article  Google Scholar 

  31. Berian JR, Ban KA, Liu JB, Ko CY, Feldman LS, Thacker JK (2017) Adherence to enhanced recovery protocols in nsqip and association with colectomy outcomes. Ann Surg

  32. Franck M, Radtke FM, Apfel CC, Kuhly R, Baumeyer A, Brandt C, Wernecke KD, Spies CD (2010) Documentation of post-operative nausea and vomiting in routine clinical practice. J Int Med Res 38:1034–1041

    Article  CAS  Google Scholar 

  33. Hill RP, Lubarsky DA, Phillips-Bute B, Fortney JT, Creed MR, Glass PS, Gan TJ (2000) Cost-effectiveness of prophylactic antiemetic therapy with ondansetron, droperidol, or placebo. Anesthesiology 92:958–967

    Article  CAS  Google Scholar 

  34. Brown SR, Mathew R, Keding A, Marshall HC, Brown JM, Jayne DG (2014) The impact of postoperative complications on long-term quality of life after curative colorectal cancer surgery. Ann Surg 259:916–923

    Article  Google Scholar 

  35. Tahiri M, Sikder T, Maimon G, Teasdale D, Hamadani F, Sourial N, Feldman LS, Guralnick J, Fraser SA, Demyttenaere S, Bergman S (2016) The impact of postoperative complications on the recovery of elderly surgical patients. Surg Endosc 30:1762–1770

    Article  Google Scholar 

  36. Lawrence VA, Hazuda HP, Cornell JE, Pederson T, Bradshaw PT, Mulrow CD, Page CP (2004) Functional independence after major abdominal surgery in the elderly. J Am Coll Surg 199:762–772

    Article  Google Scholar 

  37. Dowson H, Cowie A, Ballard K, Gage H, Rockall T (2008) Systematic review of quality of life following Laparoscopic and open colorectal surgery. Colorectal Dis 10:751–768

    Article  Google Scholar 

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Correspondence to Julio F. Fiore Jr..

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The Steinberg-Bernstein Centre for Minimally Invasive Surgery (McGill University Health Centre, Montreal, Canada) is supported by an unrestricted educational Grant from Medtronic. Nicolò Pecorelli, Saba Balvardi, A. Sender Liberman, Patrick Charlebois, Barry Stein, Franco Carli, Liane S. Feldman, Julio F. Fiore Jr have no conflicts of interests or financial ties to disclose.

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Pecorelli, N., Balvardi, S., Liberman, A.S. et al. Does adherence to perioperative enhanced recovery pathway elements influence patient-reported recovery following colorectal resection?. Surg Endosc 33, 3806–3815 (2019).

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  • Patient-reported outcome measures
  • Postoperative recovery
  • Enhanced recovery
  • Outcome and process assessment (Health Care)
  • Colorectal surgery