ERAS failure and major complications in elective colon surgery: Common risk factors

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• Male sex, ASA IV, open surgery, and low albumin level predict ERAS failure in colon surgery. • 70% ERAS compliance associates with fewer complications and shorter stay after colon surgery. • Open surgery and failure to mobilize postoperatively predict increased risk of major complications. • Adequate ERAS compliance correlates with decreased mortality. Proper implementation and practice of an Enhanced Recovery After Surgery (ERAS) protocol streamlines perioperative management to its optimum, resulting in fewer complications and lower costs. This study aims to identify potential risk factors for the failure of ERAS and for major postoperative complications in patients with elective colon resection. This was a single center retrospective analysis including all consecutive patients for elective colon resection during June 2017 - June 2019. All patients were treated within an upgraded ERAS program. 908 patients were included. Median ERAS compliance was 67%. Over 70% compliance was associated with a significantly lower median complication index and a shorter median hospital stay and was set as threshold in further analyses. In a multivariate regression analysis, male gender, American Society of Anesthesiologists Physical Status (ASA PS) Classification IV, open surgery, and albumin level < 34 independently predicted increased risk for failure of ERAS. Furthermore, multivariate analyses revealed that male gender, cancer in the right hemicolon/transverse colon/splenic flexure, open surgery, failure to mobilize postoperatively, and administration of > 60 mg oxycodone postoperatively, independently predicted increased risk of postoperative ileus. Volvulus as primary diagnosis, conversion of laparoscopy to open surgery, failure to mobilize postoperatively, and preoperative hemoglobin < 100 g/l were found to independently predict increased risk of anastomotic dehiscence. We suggest that patients of male gender, high ASA class, challenged mobility, and higher risk in open surgery, be managed with powered preoperative counseling, including rigorous physiotherapy, and operated on by two senior colorectal surgeons, in order to diminish the risk of conversion to open surgery and of postoperative complications.