Background: The ERAS (enhanced recovery after surgery) care has been shown to improve outcome after colorectal surgery compared to traditional care. Audit of process compliance and patient outcomes are important features to assess the impact of a predefined protocol. We did a study to determine the influence of the ERAS protocols in patients undergoing elective colorectal surgery Methods: We did a multicenter, prospective cohort study at 80 Spanish hospitals. We recruited adults scheduled for elective colorectal surgery and deemed to have an ERAS protocol. 22 individual ERAS items were assessed in all included patients. The primary outcome was moderate to severe postoperative complications within 30 days after surgery. Secondary outcomes included ERAS compliance, readmissions, reinterventions, length of stay and mortality. Findings: Between September 15, 2017, and December 15, 2017, 2084 patients were included. 879 (42·1%) presented postoperative complications; 566 (27·1%) presented moderate-severe complications. The number of patients with moderate or severe complication was lower in the ERAS group, 25·2% vs. 30·3%, p=0·011, but not in terms of overall complications, readmission, reintervention or mortality rate. The overall compliance rate with the ERAS protocol was 63·6% [54·5%-77·3%], with the rate for patients declared as ERAS being 72·7% [59·1%-81·8%] vs Non-ERAS 59·1% [50%-63·6%], p<0·001. The study among the highest and lowest ERAS compliance quartiles showed that the patients with the highest compliance had less moderate to severe complications (OR 0·34, 95% CI 0·25-0·46; p<0·001), overall complications, and mortality compared to the lowest. Interpretation: Simply having a protocol was not enough to improve outcomes, while an increase in the ERAS compliance was associated with a decrease in postoperative complications. Funding Statement: Perioperative Audit and Research Network (RedGERM). Grupo Espanol de Rehabilitacion Multimodal (GERM)/ ERAS Spain Chapter. Declaration of Interests: JRM reports personal fees from Edwards Lifesciences, and personal fees from Fresenius Kabi, outside the submitted work; JAGE reports personal fees from Alexion, Amgen, Braun, Celgene, Ferrer, GSK, Inmucor, Jansen, Novartis, Octapharma, Sanofi, Sandoz, Terumo and Zambon, personal fees and nonfinancial support from Vifor Pharma, outside the submitted work; ASR reports personal fees from Baxter outside the submitted work; JMRR, RCF, CA, AAM, MLE, ACC, CFO, ACM, SMM, AAG and JMCV have nothing to disclose. Ethics Approval Statement: The study was approved by the Instituto Aragones de Ciencias de la Salud Ethics Committee (Zaragoza, Spain) (C.P.-C.I. P117/017) and by the Spanish Medical Agency. Ethics committees or institutional review boards at each site reviewed and approved the protocol, and the research was consistent with the principles of the declaration of Helsinki. All participants or their designates provided written informed consent to take part in the study.
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