Role and importance of quality control in improving compliance of enhanced recovery after surgery to overcome postoperative complications

Enhanced recovery after surgery (ERAS) has been proven to reduce postoperative complication and length of hospital stay. However, implementation varies among centers, and not all protocols can be applied uniformly in clinical practice. We aimed to evaluate the role and importance of overall ERAS compliance through quality control rather than assessing the appropriateness of individual components. Patients who underwent colon cancer surgery were stratified into two phases based on quality control implementation: Phase I (January 2017 to November 2019) and Phase II (December 2019 to December 2022). More stringent compliance criteria were implemented in Phase II. We performed propensity score matching by age, ASA score, and tumor location to reduce the selection bias. Mean ERAS compliance showed no significant difference between phases (phase I vs. II, 77.28 ± 11.66 vs. 77.79 ± 11.99, P = 0.498). Total complications significantly decreased (phase I vs. II, 78 (16.1%) vs. 48 (9.9%), p = 0.005), with non-surgical complications such as postoperative ileus, respiratory complications significantly lower in Phase II. However, major complication showed no significant difference between phases. Multivariate analysis revealed that high compliance (≥ 70%) and Phase II were associated with lower complications and significantly reduced lengths of stay. Several surgical stress-related inflammatory markers showed significantly reduced changes from Phase I to Phase II, suggesting that the postoperative stress response can be attenuated through ERAS implementation and reinforcement. Although ERAS protocol compliance cannot prevent major surgery-related complications, high compliance through overall application enables earlier recovery and shorter hospital stays for patients with major complications by reducing surgical stress-related inflammatory responses.