Letter to the editor: outcomes of enhanced recovery after surgery in laparoscopic colorectal surgery: a systematic outcome mapping study and descriptive analysis to inform a core outcome set

Dear Editor, We recently read the paper by Jiang et al[1] published in the International Journal of Surgery titled “Outcomes of enhanced recovery after surgery in laparoscopic colorectal surgery: a systematic outcome mapping study and descriptive analysis to inform a core outcome set.” This study categorized the outcomes reported in randomized controlled trials evaluating enhanced recovery after surgery (ERAS) in laparoscopic colorectal surgery. By constructing a comprehensive list of outcome measures and highlighting the differences in definitions and measurement methods across different indicators, the authors provide valuable insights for improving comparability between trials and informing the development of a future core outcome set (COS). We believe that since outcome mapping is an early step in COS development, carefully distinguishing between “candidate outcome domains” and the finally determined “core” set of indicators will help avoid unnecessary overinterpretation. Briefly and clearly stating that the mapped domains are provisional, and supplementing this with clear criteria for domain boundary delineation (e.g. how to determine overlapping concepts such as “readiness for discharge,” “functional recovery,” and “quality of recovery”), can improve reproducibility and support consistent adoption of these domains by other research teams. Secondly, the most practical value of outcome mapping lies in not only documenting “what has been reported,” but also the key characteristics that determine whether outcomes can be combined or compared. The study’s observation of underrepresentation of patient-reported outcome measures (PROMs) and economic endpoints is crucial and may warrant more guided discussion on how to integrate these domains into an ERAS-specific COS while avoiding increased burden. A pragmatic approach would be to adopt a tiered COS structure: (1) a minimum mandatory core set of indicators, for example, complications, length of hospital stay, and patient-centered recovery indicators; (2) additional indicators specific to the disease or surgery (colon vs. rectal cancer; cancer vs. benign tumors; stoma vs. non-stoma); (3) optional mechanistic modules for explanatory trials (e.g. inflammatory biomarkers). This structure ensures feasibility while guaranteeing that patient experience and value-based endpoints are not systematically overlooked. Finally, the choice of measurement tools will determine whether the COS is truly usable. We recommend that future research explicitly apply measurement selection methods, including validity, feasibility, and cross-cultural applicability, and pre-specify time points reflecting the ERAS recovery trajectory. Innovative measurement methods are now achievable at low incremental cost: brief electronic PROMs, passive activity metrics from wearable devices or smartphones, and standardized composite recovery endpoints, which collectively reflect complications, length of stay, and readmissions. These methods can significantly improve sensitivity to differences in recovery while reducing reliance on single, inconsistently defined event-time metrics. In summary, Jiang et al[1] make a timely contribution by quantifying outcome heterogeneity and advancing the development of a COS for ERAS focused on laparoscopic colorectal surgery. With further emphasis on reproducible classifications, structured outcome dictionaries, and prospective measurement strategies incorporating patient-centered and implementation outcomes, this work has the potential to accelerate evidence synthesis and the optimization of ERAS in real-world settings.