Enhanced Recovery Pathway and Postoperative Ileus After Elective Minimally Invasive Colorectal Surgery

Background: Postoperative ileus (POI) remains a leading driver of delayed recovery and prolonged length of stay (LOS) after colorectal surgery. Although ERAS is well established, less is known about how pathway adherence and implementation fidelity relate to bowel recovery in pragmatic minimally invasive practice. Objectives: To evaluate whether a structured ERAS pathway, delivered in routine care, was associated with lower POI and improved early recovery compared with contemporaneous standard care after elective minimally invasive colorectal surgery. Methods: In a prospective, non-randomized pragmatic comparative study conducted from January 2022 to September 2024, 123 adults undergoing elective laparoscopic colorectal resection were managed with either an ERAS pathway (n = 62) or standard care (n = 61). POI was operationalized prospectively using predefined clinical criteria and daily team assessment. Primary outcome was POI. Secondary outcomes included time to flatus, LOS, 48 h opioid use (morphine milligram equivalents, MME), complications (Clavien–Dindo), 30-day readmission, and Quality of Recovery (QoR-15). Multivariable logistic regression and propensity score–adjusted sensitivity analyses were performed to address baseline imbalance. Results: POI occurred in 7/62 (11.3%) in ERAS vs. 22/61 (36.1%) in standard care (p = 0.002). ERAS patients had earlier flatus (38.6 ± 15.2 h vs. 60.0 ± 20.1 h, p < 0.001), shorter LOS (4.2 [3.4–5.0] vs. 5.4 [4.5–6.8] days, p < 0.001), lower 48 h opioids (35.4 [25.2–47.8] vs. 61.1 [41.5–88.6] MME, p < 0.001), and higher QoR-15 at POD2 (113.9 ± 14.9 vs. 104.8 ± 15.5, p = 0.001). In the primary multivariable model, ERAS was independently associated with lower POI odds (adjusted OR 0.2; 95% CI 0.1–0.7; p = 0.013); the association remained directionally similar in propensity-adjusted sensitivity analysis (adjusted OR 0.31; 95% CI 0.12–0.79; p = 0.015). Higher adherence was associated with lower POI and lower opioid exposure. Conclusions: In this prospective cohort, ERAS implementation was associated with lower POI incidence and faster early recovery; however, findings should be interpreted as observational and hypothesis-generating rather than causal.