Effect of enhanced recovery after surgery protocols on postoperative length of stay and complication rates in elective colorectal surgery: a systematic review and meta-analysis of randomized controlled trials

Enhanced recovery after surgery (ERAS) protocols are standardized multimodal perioperative care pathways designed to reduce surgical stress, accelerate recovery, and improve outcomes. Originally developed for colorectal surgery, ERAS has been associated with shorter hospital stays and fewer complications, but evolving evidence and protocol variations warrant updated synthesis of high-quality randomized controlled trials. This systematic review and meta-analysis, conducted according to PRISMA guidelines and registered in PROSPERO (ID: 1038955), included randomized controlled trials published since 2010 comparing ERAS protocols (≥12 elements per ERAS® Society guidelines) with conventional care in elective colorectal surgery. The primary and secondary outcomes were postoperative length of stay and complications, respectively. Five trials met the eligibility criteria. Pooled analysis showed ERAS was associated with a non-significant reduction in length of stay (mean difference= –2.68 days; 95% CI: –5.70 to 0.34; p=0.082; I²=96.66%), with sensitivity analysis excluding estimated data yielding a similar non-significant effect (mean difference = –3.89 days; 95% CI: –8.54 to 0.77; p=0.102). For complications, the pooled log odds ratio was –0.58 (95% CI: –1.22 to 0.06; p=0.078; I² = 86.63%), and sensitivity analysis restricted to low risk of bias studies also showed no significant difference (log OR= –0.56; 95% CI: –1.56 to 0.43; p=0.264). In conclusion, ERAS protocols showed trends toward reducing hospital stay and complications after elective colorectal surgery, but the results were not statistically significant, highlighting the need for further high-quality RCTs with standardized implementation.