Gastrointestinal Surgery| Volume 286, P74-84, June 2023

Outcomes of a Colorectal Enhanced Recovery After Surgery Protocol Modified for a Diverse and Urban Community

Published:February 10, 2023DOI:



      Enhanced recovery after surgery (ERAS) colorectal programs have been shown to improve the length of stay (LOS) without increasing hospital resource utilization at academic centers worldwide. A multidisciplinary ERAS protocol that includes preoperative, intraoperative, and postoperative management guidelines was recently implemented at our urban, racially diverse, and academically affiliated community hospital. A delivery option was provided to reduce barriers to care. Given our unique patient population, the objective of our study was to determine if improvements in outcomes were reproducible in our hospital.


      This is a retrospective study of patients undergoing elective colectomy at New York-Presbyterian Queens Hospital between January 1, 2015, and December 31, 2020. Patient outcomes were compared between surgeries performed under standard practice (all colectomies prior to April 2017) and those performed after the implementation of the ERAS protocol. Demographic and perioperative data were abstracted from a prospectively derived database used to submit data to the National Surgical Quality Improvement Program. Additional data were obtained from chart review.


      Six hundred five elective colectomies were performed by 12 surgeons (range 1-228 cases) during the study period. Of these, 22 were performed open (41% followed ERAS), 467 were performed laparoscopically (57% followed ERAS), and 116 were performed robotically (74% followed ERAS). The average patient age was 64 y. Of which, 55% were male; 34% were Asian, 27% were non-Hispanic Caucasian, 27% were Hispanic, and 11% were Black or African American (all P-values > 0.05 for ERAS versus non-ERAS). Average duration of procedure was longer in the ERAS group (262 min versus 243 min, P = 0.04), although when stratified by procedure type, this relationship held true only for laparoscopic procedures. Hospital LOS was significantly shorter in the ERAS group (4.3 versus 5.4 d, P < 0.001) and this relationship held true for procedures performed both laparoscopically (4.2 versus 5.3 d, P = 0.01) and robotically (4.1 versus 5.1 d, P = 0.04). Of the ERAS group, patients who opted for delivery of ERAS components (n = 205) had the shortest LOS when compared to patients who picked up components (n = 91) or opted out of ERAS (n = 309) (4.1 versus 4.4 versus 5.2 d, P = 0.003). No significant differences were found for 30-d mortality, 30-d readmission, wound infection, or other postoperative complications (all P-values > 0.05).


      Implementation of an ERAS protocol in an urban, diverse, academically affiliated community hospital is associated with reductions in LOS for colectomies performed both laparoscopically and robotically. Facilitating ERAS compliance with a delivery option was also associated with improvements in hospital LOS. Preoperative nutrition supplementation was not associated with outcomes. No differences in mortality, readmission rates, or rates of postoperative complications were found.

      Graphical abstract


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        • Weiss A.J.
        • Elixhauser A.
        Trends in operating room procedures in U.S. Hospitals, 2001–2011.
        (Available at:)
        Date: 2014
        Date accessed: October 2, 2022
        • Cousin-Peterson E.
        • Janjua H.M.
        • Barry T.M.
        • Baker M.S.
        • Kuo P.C.
        Discharge timing: does targeting an ideal length of stay for patients undergoing colectomy impact readmissions and costs of care?.
        Am J Surg. 2021; 221: 570-574
        • Henning R.E.
        • Hu K.Y.
        • Rein L.E.
        • et al.
        Alvimopan is associated with decreased length of stay for both open and laparoscopic segmental colectomy.
        Surgery. 2019; 166: 483-488
        • De Roo A.C.
        • Vu J.V.
        • Regenbogen S.E.
        Statewide utilization of multimodal analgesia and length of stay after colectomy.
        J Surg Res. 2020; 247: 264-270
        • Pisarska M.
        • Pędziwiatr M.
        • Małczak P.
        • et al.
        Do we really need the full compliance with ERAS protocol in laparoscopic colorectal surgery? A prospective cohort study.
        Int J Surg. 2016; 36: 377-382
        • Pang Q.
        • Duan L.
        • Jiang Y.
        • Liu H.
        Oncologic and long-term outcomes of enhanced recovery after surgery in cancer surgeries - a systematic review.
        World J Surg Oncol. 2021; 19: 191
        • Ljungqvist O.
        • Thanh N.X.
        • Nelson G.
        ERAS—value based surgery.
        J Surg Oncol. 2017; 116: 608-612
        • Lemanu D.P.
        • Singh P.P.
        • Stowers M.D.J.
        • Hill A.G.
        A systematic review to assess cost effectiveness of enhanced recovery after surgery programmes in colorectal surgery.
        Colorectal Dis. 2014; 16: 338-346
        • Stone A.B.
        • Grant M.C.
        • Pio Roda C.
        • et al.
        Implementation costs of an enhanced recovery after surgery program in the United States: a financial model and sensitivity analysis based on experiences at a quaternary academic medical center.
        J Am Coll Surg. 2016; 222: 219-225
        • Matias De Sousa I.
        • Moraes F.
        • Rd S.
        • et al.
        Accuracy of isolated nutrition indicators in diagnosing malnutrition and their prognostic value to predict death in patients with gastric and colorectal cancer: a prospective study.
        JPEN J Parenter Enteral Nutr. 2021; 46: 508-516
        • Barao K.
        • Abe Vicente Cavagnari M.
        • Silva Fucuta P.
        • Manoukian Forones N.
        Association between nutrition status and survival in elderly patients with colorectal cancer.
        Nutr Clin Pract. 2017; 32: 658-663
        • Sasaki M.
        • Miyoshi N.
        • Fujino S.
        • et al.
        The Geriatric Nutritional Risk Index predicts postoperative complications and prognosis in elderly patients with colorectal cancer after curative surgery.
        Sci Rep. 2020; 10: 1-9
      1. Strong for surgery.
        (Available at:)
        • Wahl T.S.
        • Goss L.E.
        • Morris M.S.
        • et al.
        Enhanced recovery after surgery (ERAS) eliminates racial disparities in postoperative length of stay after colorectal surgery.
        Ann Surg. 2017; 268: 1026-1035
        • Yu X.Q.
        • Goldsbury D.
        • Feletto E.
        • Koh C.E.
        • Canfell K.
        • O’Connell D.L.
        Socioeconomic disparities in colorectal cancer survival: contributions of prognostic factors in a large Australian cohort.
        J Cancer Res Clin Oncol. 2021; 148: 2971-2984
        • González-Rivera C.
        • Bowles J.
        New York’s older adult population is booming statewide. Center for an urban future (CUF).
        (Available at:)
      2. NYC-queens community district 7--flushing, Murray Hill & Whitestone PUMA, NY - Profile data - Census Reporter.
        (Available at:)
        • Chau P.H.
        • Gusmano M.K.
        • Cheng J.O.Y.
        • Cheung S.H.
        • Woo J.
        Social vulnerability index for the older people—Hong Kong and New York City as examples.
        J Urban Health. 2014; 91: 1048-1064
        • Currie A.
        • Burch J.
        • Jenkins J.T.
        • et al.
        The impact of enhanced recovery protocol compliance on elective colorectal cancer resection: results from an international registry.
        Ann Surg. 2015; 261: 1153-1159
        • Aarts M.A.
        • Rotstein O.D.
        • Pearsall E.A.
        • et al.
        Postoperative ERAS interventions have the greatest impact on optimal recovery.
        Ann Surg. 2018; 267: 992-997
        • Ripollés-Melchor J.
        • Ramírez-Rodríguez J.M.
        • Casans-Francés R.
        • et al.
        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. 2019; 154: 725-736
        • Viramontes O.
        • Bastani R.
        • Yang L.
        • Glenn B.A.
        • Herrmann A.K.
        • May F.P.
        Colorectal cancer screening among Hispanics in the United States: disparities, modalities, predictors, and regional variation.
        Prev Med. 2020; 138: 106146
        • Raber M.
        • Huynh T.N.
        • Crawford K.
        • Kim S.
        • Chandra J.
        Development and feasibility of a community-based, culturally flexible colorectal cancer prevention program.
        J Community Health. 2018; 43: 882-885
        • Gustafsson U.O.
        • Scott M.J.
        • Hubner M.
        • et al.
        Guidelines for perioperative care in elective colorectal surgery: enhanced recovery after surgery (ERAS®) society recommendations: 2018.
        World J Surg. 2018; 43: 659-695
        • Forsmo H.M.
        • Erichsen C.
        • Rasdal A.
        • Körner H.
        • Pfeffer F.
        Enhanced recovery after colorectal surgery (ERAS) in elderly patients is feasible and achieves similar results as in younger patients.
        Gerontol Geriatr Med. 2017; 3 (2333721417706299)
        • Pedrazzani C.
        • Conti C.
        • Turri G.
        • et al.
        Impact of age on feasibility and short-term outcomes of ERAS after laparoscopic colorectal resection.
        World J Gastrointest Surg. 2019; 11: 395
        • Chan D.K.H.
        • Ang J.J.
        • Tan J.K.H.
        • Chia D.K.A.
        Age is an independent risk factor for increased morbidity in elective colorectal cancer surgery despite an ERAS protocol.
        Langenbecks Arch Surg. 2020; 405: 673-689
        • Slieker J.
        • Frauche P.
        • Jurt J.
        • et al.
        Enhanced recovery ERAS for elderly: a safe and beneficial pathway in colorectal surgery.
        Int J Colorectal Dis. 2017; 32: 215-221
        • Simon A.E.
        • Wardle J.
        Socioeconomic disparities in psychosocial wellbeing in cancer patients.
        Eur J Cancer. 2008; 44: 572-578
        • Kenton K.
        • Pham T.
        • Mueller E.
        • Brubaker L.
        Patient preparedness: an important predictor of surgical outcome.
        Am J Obstet Gynecol. 2007; 197: 654.e1
        • Hong J.
        • De Roulet A.
        • Chao S.
        Equity in postoperative outcomes in geriatric patients requiring non-elective colectomy in a high-density, multilingual hospital setting.
        J Am Coll Surg. 2021; 233: e29
        • Brach C.
        • Fraserirector I.
        Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model.
        Med Care Res Rev. 2000; 57: 181-217
        • Jacobs E.A.
        • Shepard D.S.
        • Suaya J.A.
        • Stone E.L.
        Overcoming Language barriers in health care: costs and benefits of interpreter services.
        Am J Public Health. 2011; 94: 866-869
        • Leeds I.L.
        • Alimi Y.
        • Hobson D.R.
        • et al.
        Racial and socioeconomic differences manifest in process measure adherence for enhanced recovery after surgery pathway.
        Dis Colon Rectum. 2017; 60: 1092
        • Cohen N.
        SNAP at the community scale: how neighborhood characteristics affect participation and food access.
        Am J Public Health. 2019; 109: 1646-1651
        • Ghosh A.K.
        • Venkatraman S.
        • Soroka O.
        • et al.
        Association between overcrowded households, multigenerational households, and COVID-19: a cohort study.
        Public Health. 2021; 198: 273
        • Truong A.
        • Hanna M.H.
        • Moghadamyeghaneh Z.
        • Stamos M.J.
        Implications of preoperative hypoalbuminemia in colorectal surgery.
        World J Gastrointest Surg. 2016; 8: 353
        • Ge X.
        • Dai X.
        • Ding C.
        • et al.
        Early postoperative decrease of serum albumin predicts surgical outcome in patients undergoing colorectal resection.
        Dis Colon Rectum. 2017; 60: 326-334