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Background: Patient and case complexity influence colorectal surgery outcomes. Success using enhanced recovery pathways (ERP) after surgery requires assessing both patient-factors risk adjustment as well as compliance with pathway elements.

Methods: During 2011, 535 minimally invasive colorectal surgery patients enrolled in an ERP protocol at a single institution were reviewed. Patient comorbidities at admission and compliance with key ERP elements were captured using billing data and prospectively-collected data, respectively. The association of American
Society of Anaesthesiologists Physical Status classification (ASA), comorbidities, and ERP element compliance were considered in logistic regression models to predict length of stay (LOS). A prolonged LOS was defined as 9 days or longer. Competing risk models were used to examine the impact of factors on in-hospital outcomes. Surgery was the initial state, discharge the endpoint, and occurrence of complications a time-dependent intermediate state.

Results:
Compliance with the ERP protocol diet and fluid management was 76%. Surgical complications occurred in 16% of the patients, with Ileus being the most common (12%), and 9% of the patients had a prolonged LOS. The majority of patients had at least one comorbidity, including inflammatory bowel diseases (IBD, 36%), chronic renal insufficiency (5%) heart disease (9%), diabetes (9%), or COPD (11%). An ASA score 3 or 4 was present in in 19%. Chronic renal insufficiency, IBD, conversion to open, and non-compliance with ERP diet/fluid protocol were risk factors for occurrence of complications (c-index=0.74) and prolonged length of stay (c-index=0.78). Using ASA in place of other comorbidities or excluding diet/fluid compliance reduced the predictive value of the models (c-index 0.67 for complications and 0.70 for prolonged LOS). In a competing risk model chronic renal insufficiency, IBD, non-compliance with diet/fluid ERP protocol were predictors of a longer LOS.

Conclusion: In the era of ERP diet/fluid management compliance leads to predictably earlier recognition and treatment of complications and thus shorter LOS. Preexisting comorbidities such as chronic renal insufficiency and inflammatory bowel need to be considered in predicting adverse outcomes after minimally invasive colorectal surgery, while ASA was not sufficient as a risk-adjustment factor.