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ERAS program adherence-institutionalization, major morbidity and anastomotic leakage after elective colorectal surgery: the iCral2 multicenter prospective study

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Abstract

Background

Enhanced recovery after surgery (ERAS) programs influence morbidity rates and length of stay after colorectal surgery (CRS), and may also impact major complications and anastomotic leakage rates. A prospective multicenter observational study to investigate the interactions between ERAS program adherence and early outcomes after elective CRS was carried out.

Methods

Prospective enrolment of patients submitted to elective CRS with anastomosis in 18 months. Adherence to 21 items of ERAS program was measured upon explicit criteria in every case. After univariate analysis, independent predictors of primary endpoints [major morbidity (MM) and anastomotic leakage (AL) rates] were identified through logistic regression analyses including all significant variables, presenting odds ratios (OR).

Results

Institutional ERAS protocol was declared by 27 out of 38 (71.0%) participating centers. Median overall adherence to ERAS program items was 71.4%. Among 3830 patients included in the study, MM and AL rates were 4.7% and 4.2%, respectively. MM rates were independently influenced by intra- and/or postoperative blood transfusions (OR 7.79, 95% CI 5.46–11.10; p < 0.0001) and standard anesthesia protocol (OR 0.68, 95% CI 0.48–0.96; p = 0.028). AL rates were independently influenced by male gender (OR 1.48, 95% CI 1.06–2.07; p = 0.021), intra- and/or postoperative blood transfusions (OR 4.29, 95% CI 2.93–6.50; p < 0.0001) and non-standard resections (OR 1.49, 95% CI 1.01–2.22; p = 0.049).

Conclusions

This study disclosed wide room for improvement in compliance to several ERAS program items. It failed to detect any significant association between institutionalization and/or adherence rates to ERAS program with primary endpoints. These outcomes were independently influenced by gender, intra- and postoperative blood transfusions, non-standard resections, and standard anesthesia protocol.

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References

  1. Eskicioglu C, Forbes SS, Aarts MA et al (2009) Enhanced recovery after surgery (ERAS) programs for patients having colorectal surgery: a meta-analysis of randomized trials. J Gastrointest Surg 13:2321–2329

    Article  PubMed  Google Scholar 

  2. Spanjersberg WR, Reurings J, Keus F, van Laarhoven CJ (2011) Fast track surgery versus conventional recovery strategies for colorectal surgery. Cochrane Database Syst Rev. https://doi.org/10.1002/14651858.CD007635.pub2

    Article  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  4. Kahokehr A, Robertson P, Sammour T et al (2011) Perioperative care: a survey of New Zealand and Australian colorectal surgeons. Colorectal Dis 13:1308–1313

    Article  CAS  PubMed  Google Scholar 

  5. Arsalani-Zadeh R, Ullah S, Khan S, Macfie J (2010) Current pattern of perioperative practice in elective colorectal surgery; a questionnaire survey of ACPGBI members. Int J Surg 8:294–298

    Article  PubMed  Google Scholar 

  6. Ahmed J, Khan S, Lim M et al (2012) Enhanced recovery after surgery protocols - compliance and variations in practice during routine colorectal surgery. Colorectal Dis 14:1045–1051

    Article  CAS  PubMed  Google Scholar 

  7. Maessen J, Dejong CH, Hausel J et al (2007) A protocol is not enough to implement an enhanced recovery program for colorectal resection. Br J Surg 94:224–231

    Article  CAS  PubMed  Google Scholar 

  8. Nygren J, Hausel J, Kehlet H et al (2005) A comparison in five European Centers of case mix, clinical management and outcomes following either conventional or fast-track perioperative care in colorectal surgery. Clin Nutr 24:455–461

    Article  PubMed  Google Scholar 

  9. Lassen K, Hannemann P, Ljungqvist O et al (2005) Patterns in current perioperative practice: survey of colorectal surgeons in five northern European countries. BMJ 330:1420–1421

    Article  PubMed  PubMed Central  Google Scholar 

  10. Gillissen F, Hoff C, Maessen JM et al (2013) Structured synchronous implementation of an enhanced recovery program in elective colonic surgery in 33 hospitals in The Netherlands. World J Surg 37:1082–1093

    Article  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  12. Smart NJ, White P, Allison AS et al (2012) Deviation and failure of enhanced recovery after surgery following laparoscopic colorectal surgery: early prediction model. Colorectal Dis 14:e727–e734

    Article  CAS  PubMed  Google Scholar 

  13. ERAS Compliance Group (2015) The impact of enhanced recovery protocol compliance on elective colorectal cancer resection: results from an international registry. Ann Surg 261:1153–1159

    Article  Google Scholar 

  14. Braga M, Scatizzi M, Borghi F et al (2018) Identification of core items in the enhanced recovery pathway. Clin Nutr ESPEN 25:139–144

    Article  PubMed  Google Scholar 

  15. Aarts MA, Rotstein OD, Pearsall EA et al (2018) Postoperative ERAS interventions have the greatest impact on optimal recovery: experience with implementation of ERAS across multiple hospitals. Ann Surg 267:992–997

    Article  PubMed  Google Scholar 

  16. Gustafsson UO, Hausel J, Thorell A et al (2011) Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Arch Surg 146:571–577

    Article  PubMed  Google Scholar 

  17. 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 40:1092–1103

    Article  PubMed  Google Scholar 

  18. Ripollés-Melchor J, Ramírez-Rodríguez JM, Casans-Francés R et al (2019) Association between use of enhanced recovery after surgery protocol and postoperative complications in colorectal surgery: the postoperative outcomes within enhanced recovery after surgery protocol (POWER) study. JAMA Surg 154:725–736

    Article  PubMed  PubMed Central  Google Scholar 

  19. van Zelm R, Coeckelberghs E, Sermeus W et al (2020) Effects of implementing a care pathway for colorectal cancer surgery in ten European hospitals: an international multicenter pre-post-test study. Updates Surg 72:61–71

    Article  PubMed  Google Scholar 

  20. 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 254:868–875

    Article  PubMed  Google Scholar 

  21. Berian JR, Ban KA, Liu JB et al (2019) Adherence to enhanced recovery protocols in NSQIP and association with colectomy outcomes. Ann Surg 269:486–493

    Article  PubMed  Google Scholar 

  22. Catarci M, Benedetti M, Maurizi A et al (2021) ERAS pathway in colorectal surgery: structured implementation program and high adherence for improved outcomes. Updates Surg 73:123–137

    Article  PubMed  Google Scholar 

  23. Leakage ICA, (iCral) study group, (2019) Colorectal surgery in Italy: a snapshot from the iCral study group. Updates Surg 71:339–347

    Article  Google Scholar 

  24. Italian ColoRectal Anastomotic Leakage (iCral) Study Group (2020) Anastomotic leakage after elective colorectal surgery: a prospective multicentre observational study on use of the Dutch leakage score, serum procalcitonin and serum C-reactive protein for diagnosis. BJS Open 4:499–507

    Article  Google Scholar 

  25. Italian ColoRectal Anastomotic Leakage (iCral) study group (2020) Risk factors for adverse events after elective colorectal surgery: beware of blood transfusions. Updates Surg 72:811–819

    Article  Google Scholar 

  26. Borghi F, Migliore M, Italian ColoRectal Anastomotic Leakage (iCral) study group (2021) Management and 1-year outcomes of anastomotic leakage after elective colorectal surgery. Int J Colorectal Dis 36:929–939

    Article  PubMed  Google Scholar 

  27. Gustafsson UO, Scott MJ, Schwenk W et al (2013) Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. World J Surg 37:259–284

    Article  CAS  PubMed  Google Scholar 

  28. Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications. A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213

    Article  PubMed  PubMed Central  Google Scholar 

  29. Clavien PA, Barkun J, de Oliveira ML et al (2009) The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 250:187–196

    Article  PubMed  Google Scholar 

  30. Rahbari NN, Weitz J, Hohenberger W et al (2010) Definition and grading of anastomotic leakage following anterior resection of the rectum: a proposal by the International Study Group of Rectal Cancer. Surgery 147:339–351

    Article  PubMed  Google Scholar 

  31. Spinelli A, Anania G, Arezzo A et al (2020) Italian multi-society modified Delphi consensus on the definition and management of anastomotic leakage in colorectal surgery. Updates Surg 72:781–792

    Article  PubMed  Google Scholar 

  32. Kim JH (2019) Multicollinearity and misleading statistical results. Korean J Anesthesiol 72:558–569

    Article  PubMed  PubMed Central  Google Scholar 

  33. Kaiser MJ, Bauer JM, Ramsch C et al (2009) Validation of the Mini Nutritional Assessment short-form (MNA-SF): a practical tool for identification of nutritional status. J Nutr Health Aging 13(9):782

    Article  CAS  PubMed  Google Scholar 

  34. von Elm E, Altman DG, Egger M et al (2008) The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol 61:344–349

    Article  Google Scholar 

  35. Law WI, Chu KW, Ho JW, Chan CW (2000) Risk factors for anastomotic leakage after low anterior resection with total mesorectal excision. Am J Surg 179:92–96

    Article  CAS  PubMed  Google Scholar 

  36. Milone M, Degiuli M, Allaix ME et al (2020) Mid-transverse colon cancer and extended versus transverse colectomy: results of the Italian society of surgical oncology colorectal cancer network (SICO CCN) multicenter collaborative study. Eur J Surg Oncol 46:1683–1688

    Article  CAS  PubMed  Google Scholar 

  37. Wang X, Zheng Z, Chen M et al (2021) Subtotal colectomy, extended right hemicolectomy, left hemicolectomy, or splenic flexure colectomy for splenic flexure tumors: a network meta-analysis. Int J Colorectal Dis 36:311–322

    Article  CAS  PubMed  Google Scholar 

  38. Aquina CT, Blumberg N, Probst CP et al (2016) Large variation in blood transfusion use after colorectal resection: a call to action. Dis Colon Rectum 59:408–411

    Article  Google Scholar 

  39. Gustafsson UO, Scott MJ, Hubner M et al (2019) Guidelines for perioperative care in elective colorectal surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations: 2018. World J Surg 43:659–695

    Article  CAS  PubMed  Google Scholar 

  40. Ficari F, Borghi F, Catarci M et al (2019) Enhanced recovery pathways in colorectal surgery: a consensus paper by the Associazione Chirurghi Ospedalieri Italiani (ACOI) and the PeriOperative Italian Society (POIS). G Chir 40(4 Suppl.):1–40

    CAS  PubMed  Google Scholar 

  41. Lanier WL (2006) A three-decade perspective on anesthesia safety. Am Surg 72:985–989

    Article  PubMed  Google Scholar 

  42. Ban KA, Gibbons MM, Ko CY et al (2019) Evidence review conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery: focus on anesthesiology for colorectal surgery. Anesth Analg 128:879–889

    Article  PubMed  Google Scholar 

  43. Carmichael JC, Keller DS, Baldini G et al (2017) Clinical practice guideline for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons (ASCRS) and Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Surg Endosc 31:3412–3436

    Article  PubMed  Google Scholar 

  44. Smith SR, Gilmore OJ (1985) Surgical drainage. Br J Hosp Med 33:308–315

    CAS  PubMed  Google Scholar 

  45. Petrowsky H, Demartines N, Rousson V, Clavien PA (2004) Evidence-based value of prophylactic drainage. Ann Surg 240:1074–1085

    Article  PubMed  PubMed Central  Google Scholar 

  46. Pisarska M, Gajewska N, Małczak P et al (2018) Is it possible to maintain high compliance with the Enhanced Recovery after Surgery (ERAS) protocol? - A cohort study of 400 consecutive colorectal cancer patients. J Clin Med 7:412. https://doi.org/10.3390/jcm7110412

    Article  PubMed Central  Google Scholar 

  47. Caricato M, Baiocchi GL, Crafa F et al (2020) Colorectal surgery in Italy during the Covid19 outbreak: a survey from the iCral study group. Updates Surg 72:249–257

    Article  PubMed  PubMed Central  Google Scholar 

  48. Sica GS, Campanelli M, Bellato V, Monteleone G (2020) Gastrointestinal cancer surgery and enhanced recovery after surgery (ERAS) during COVID-19 outbreak. Langenbecks Arch Surg 405:357–358

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  49. Braga M, Pecorelli N, Scatizzi M et al (2017) Enhanced recovery program in high-risk patients undergoing colorectal surgery: results from the PeriOperative Italian Society registry. World J Surg 41:860–867

    Article  PubMed  Google Scholar 

  50. Benedetti M, Ciano P, Pergolini I et al (2019) Early diagnosis of anastomotic leakage after colorectal surgery by the Dutch leakage score, serum procalcitonin and serum C-reactive protein: study protocol of a prospective multicentre observational study by the Italian ColoRectal Anastomotic Leakage (iCral). G Chir 40:20–25

    CAS  PubMed  Google Scholar 

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Acknowledgements

† iCral study group investigators and co-authors: Gianluca Guercioni1, MD, Paolo Ciano1, MD, Michele Benedetti1, MD, Simone Cicconi1, MD, Irene Marziali1, MD, Elisa Bertocchi2, MD, Amedeo Altamura3, MD, Francesco Rubichi3, MD, Antonio Sciuto4, MD, Ugo Pace5, MD, Andrea Fares Bucci5, MD, Desirée Cianflocca6, MD, Marco Migliore6, MD, Basilio Pirrera7, MD, Vincenzo Alagna7, MD, Diletta Cassini8, MD, Grazia Maria Attinà9, MD, Claudio Arcudi10, MD, Bruno Sensi10, MD, Roberto Campagnacci11, MD, Angela Maurizi11, MD, Massimo Basti12, MD, Diletta Frazzini12, MD, Valerio Caracino12, MD, Corrado Pedrazzani13, MD, Giulia Turri13, MD, Stefano Mancini14, MD, Andrea Sagnotta14, MD, PhD, Marco Scatizzi15, MD, Lorenzo Pandolfini15, MD, Alessandro Falsetto15, MD, Gian Luca Baiocchi16, MD, FACS, Sarah Molfino16, MD, Mauro Totis17, MD, Marco Braga17, MD, Andrea Liverani18, MD, Tatiana Di Cesare18, MD, Stefano Scabini19, MD, Antonio Martino19, MD, Raffaele De Luca20, MD, Michele Simone20, MD, Alessandro Carrara21, MD, Giuseppe Tirone21, MD, Michele Motter21, MD, Marco Caricato22, MD, FACS, Gabriella Teresa Capolupo22, MD, FACS, Pietro Amodio23, MD, Raffaele Macarone Palmieri23, MD, Maurizio Pavanello24, MD, Carlo Di Marco24, MD, Andrea Muratore25, MD, Patrizia Marsanic25, MD, Alberto Patriti26, MD, Valerio Sisti26, MD, Andrea Lucchi27, MD, FACS, Giacomo Martorelli27, MD, Marco Clementi28, MD, Stefano Guadagni28, MD, Graziano Longo29, MD, Federico Tomassini29, MD, Simone Santoni29, MD, Nereo Vettoretto30, MD, Emanuele Botteri30, MD, Andrea Armellini30, MD, Giuseppe Brisinda31, MD, Maria Michela Chiarello31, MD, Maria Cariati31, MD, Stefano Berti32, MD, Andrea Gennai32, MD, Gabriele Anania33, MD, Serena Rubino33, MD, Walter Siquini34, MD, Alessandro Cardinali34, MD, Mariantonietta Di Cosmo35, MD, Daniele Zigiotto35, MD, Lucio Taglietti36, MD, Silvia Ruggiero36, MD, Alberto Di Leo37, MD, Jacopo Andreuccetti37, MD, Paolo Millo38, MD, Manuela Grivon38, MD, Diana Giannarelli39, MS, PhD.

From the 1General Surgery Unit, “C. e G. Mazzoni” Hospital, Ascoli Piceno; 2General Surgery Unit, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella (VR); 3General Surgery Unit, Cardinale G. Panico Hospital, Tricase (LE); 4General Surgery Unit, ASL Napoli 2 Nord, Pozzuoli (NA); 5Colorectal Surgical Oncology, Istituto Nazionale per lo Studio e la Cura dei Tumori, “Fondazione Giovanni Pascale IRCCS-Italia”, Napoli; 6General & Oncologic Surgery Unit, Department of Surgery, Santa Croce e Carle Hospital, Cuneo; 7General Surgery Unit, Infermi Hospital, Rimini; 8General Surgery Unit, ASST Nord Milano, Sesto San Giovanni (MI); 9General Surgery Unit, San Camillo-Forlanini Hospital, Roma; 10Minimally Invasive Surgery Unit, Policlinico Tor Vergata University Hospital, Roma; 11General Surgery Unit, “C. Urbani” Hospital, Jesi (AN); 12General Surgery Unit, Spirito Santo Hospital, Pescara; 13General & HPB Surgery Unit, University Hospital, Verona; 14General & Oncologic Surgery Unit, San Filippo Neri Hospital, ASL Roma 1; 15General Surgery Unit, Santa Maria Annunziata Hospital, Firenze; 16General Surgery Unit 3, Department of Clinical and Experimental Sciences, University of Brescia; 17Colorectal Surgery Unit, San Gerardo Hospital, ASST Monza; 18General Surgery Unit, Regina Apostolorum Hospital, Albano Laziale (RM); 19General & Oncologic Surgery Unit, IRCCS “San Martino” National Cancer Center, Genova; 20Department of Surgical Oncology, IRCCS Istituto Tumori “Giovanni Paolo II”, Bari; 21General Surgery Unit 2, Santa Chiara Hospital, Trento; 22Colorectal Surgery Unit, Policlinico Campus BioMedico, Roma; 23General & Oncologic Surgery Unit, Belcolle Hospital, Viterbo; 24General Surgery Unit, AULSS2 Marca Trevigiana, Conegliano Veneto (TV); 25General Surgery Unit, “E. Agnelli” Hospital, Pinerolo (TO); 26Department of Surgery, Marche Nord Hospital, Pesaro e Fano (PU); 27General Surgery Unit, “Ceccarini” Hospital, Riccione (RN); 28General Surgery Unit, University Hospital, L’Aquila; 29General Surgery Unit, Policlinico Casilino, Roma; 30General Surgery Unit, Spedali Civili of Brescia, Montichiari (BS); 31General Surgery Unit, San Giovanni di Dio Hospital, Crotone; 32General Surgery Unit, ASL 5 Liguria POLL, La Spezia; 33General & Laparoscopic Surgery Unit, University Hospital, Ferrara; 34General Surgery Unit, Regional Hospital, Macerata; 35General & Upper GI Surgery Unit, University Hospital, Verona; 36General Surgery Unit, ASST Valcamonica, Esine (BS); 37General and Minimally Invasive Surgery Unit, San Camillo Hospital, Trento; 38General Surgery Unit, “U. Parini” Regional Hospital, Aosta; 39 Clinical Trial Center, Biostatistics and Bioinformatics, Regina Elena National Cancer Institute IRCCS, Roma; 40 General Surgery Unit, Sandro Pertini Hospital, ASL Roma 2, Italy; α Study coordinator.

Funding

This research received no specific Grant from any funding agency in the public, commercial or not-for-profit sectors. Medtronic SI® Italy gave liberal and unconditioned support for several investigator meetings, held in Rome, Italy, on October 2018, in Matera, Italy, on June 2019 and in Bologna, Italy, on October 2019.

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Author notes

  1. Marco Catarci—Study coordinator.

Authors and Affiliations

  1. General Surgery Unit, “C. E G. Mazzoni” Hospital, Ascoli Piceno, Italy

    Marco Catarci, Gianluca Guercioni, Paolo Ciano, Michele Benedetti, Simone Cicconi & Irene Marziali

  2. General Surgery Unit, IRCCS Sacro Cuore Don Calabria Hospital, Negrar Di Valpolicella, VR, Italy

    Giacomo Ruffo & Elisa Bertocchi

  3. General Surgery Unit, Cardinale G. Panico Hospital, Tricase, LE, Italy

    Massimo Giuseppe Viola, Amedeo Altamura & Francesco Rubichi

  4. General Surgery Unit, ASL Napoli 2 Nord, Pozzuoli, NA, Italy

    Felice Pirozzi & Antonio Sciuto

  5. Colorectal Surgical Oncology, Istituto Nazionale per lo Studio e la Cura dei Tumori, “Fondazione Giovanni Pascale IRCCS-Italia”, Naples, Italy

    Paolo Delrio, Ugo Pace & Andrea Fares Bucci

  6. General & Oncologic Surgery Unit, Department of Surgery, Santa Croce e Carle Hospital, Cuneo, Italy

    Felice Borghi, Desirée Cianflocca & Marco Migliore

  7. General Surgery Unit, Infermi Hospital, Rimini, Italy

    Gianluca Garulli, Basilio Pirrera & Vincenzo Alagna

  8. General Surgery Unit, ASST Nord Milano, Sesto San Giovanni, MI, Italy

    Gianandrea Baldazzi & Diletta Cassini

  9. General Surgery Unit, San Camillo-Forlanini Hospital, Rome, Italy

    Pierluigi Marini & Grazia Maria Attinà

  10. Minimally Invasive Surgery Unit, Policlinico tor Vergata University Hospital, Rome, Italy

    Giuseppe Sica, Claudio Arcudi & Bruno Sensi

  11. General Surgery Unit, Sandro Pertini Hospital, ASL Roma 2, Via dei Monti Tiburtini, 385, 00157, Rome, Italy

    Marco Catarci

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Consortia

The Italian ColoRectal Anastomotic Leakage (iCral) study group

  • Gianluca Guercioni
  • , Paolo Ciano
  • , Michele Benedetti
  • , Simone Cicconi
  • , Irene Marziali
  • , Elisa Bertocchi
  • , Amedeo Altamura
  • , Francesco Rubichi
  • , Antonio Sciuto
  • , Ugo Pace
  • , Andrea Fares Bucci
  • , Desirée Cianflocca
  • , Marco Migliore
  • , Basilio Pirrera
  • , Vincenzo Alagna
  • , Diletta Cassini
  • , Grazia Maria Attinà
  • , Claudio Arcudi
  • , Bruno Sensi
  • , Roberto Campagnacci
  • , Angela Maurizi
  • , Massimo Basti
  • , Diletta Frazzini
  • , Valerio Caracino
  • , Corrado Pedrazzani
  • , Giulia Turri
  • , Stefano Mancini
  • , Andrea Sagnotta
  • , Marco Scatizzi
  • , Lorenzo Pandolfini
  • , Alessandro Falsetto
  • , Gian Luca Baiocchi
  • , Sarah Molfino
  • , Mauro Totis
  • , Marco Braga
  • , Andrea Liverani
  • , Tatiana Di Cesare
  • , Stefano Scabini
  • , Antonio Martino
  • , Raffaele De Luca
  • , Michele Simone
  • , Alessandro Carrara
  • , Giuseppe Tirone
  • , Michele Motter
  • , Marco Caricato
  • , Gabriella Teresa Capolupo
  • , Pietro Amodio
  • , Raffaele Macarone Palmieri
  • , Maurizio Pavanello
  • , Carlo Di Marco
  • , Andrea Muratore
  • , Patrizia Marsanic
  • , Alberto Patriti
  • , Valerio Sisti
  • , Andrea Lucchi
  • , Giacomo Martorelli
  • , Marco Clementi
  • , Stefano Guadagni
  • , Graziano Longo
  • , Federico Tomassini
  • , Simone Santoni
  • , Nereo Vettoretto
  • , Emanuele Botteri
  • , Andrea Armellini
  • , Giuseppe Brisinda
  • , Maria Michela Chiarello
  • , Maria Cariati
  • , Stefano Berti
  • , Andrea Gennai
  • , Gabriele Anania
  • , Serena Rubino
  • , Walter Siquini
  • , Alessandro Cardinali
  • , Mariantonietta Di Cosmo
  • , Daniele Zigiotto
  • , Lucio Taglietti
  • , Silvia Ruggiero
  • , Alberto Di Leo
  • , Jacopo Andreuccetti
  • , Paolo Millo
  • , Manuela Grivon
  •  & Diana Giannarelli

Corresponding author

Correspondence to Marco Catarci.

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Disclosures

Drs. Catarci, Ruffo, Viola, Pirozzi, Delrio, Borghi, Garulli, Baldazzi, Marini, Sica, Guercioni, Ciano, Benedetti, Cicconi, Marziali, Bertocchi, Altamura, Rubichi, Sciuto, Pace, Fares Bucci, Cianflocca, Migliore, Pirrera, Alagna, Cassini, Attinà, Arcudi, Sensi, Campagnacci, Maurizi, Basti, Frazzini, Caracino, Pedrazzani, Turri, Mancini, Sagnotta, Scatizzi, Pandolfini, Falsetto, Baiocchi, Molfino, Totis, Braga, Liverani, Di Cesare, Scabini, Martino, De Luca, Simone, Carrara, Tirone, Motter, Caricato, Capolupo, Amodio, Macarone Palmieri, Pavanello, Di Marco, Muratore, Marsanic, Patriti, Sisti, Lucchi, Martorelli, Clementi, Guadagni, Longo, Tomassini, Santoni, Vettoretto, Botteri, Armellini, Brisinda, Chiarello, Cariati, Berti, Gennai, Anania, Rubino, Siquini, Cardinali, Di Cosmo, Zigiotto, Taglietti, Ruggiero, Di Leo, Andreuccetti, Millo, Grivon, and Giannarelli have no competing interests to declare.

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Catarci, M., Ruffo, G., Viola, M.G. et al. ERAS program adherence-institutionalization, major morbidity and anastomotic leakage after elective colorectal surgery: the iCral2 multicenter prospective study. Surg Endosc 36, 3965–3984 (2022). https://doi.org/10.1007/s00464-021-08717-2

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