Impact of ERAS on morbidity and length of stay in elderly patients undergoing elective laparoscopic colorectal cancer surgery: a two-center comparative study

BACKGROUND: Enhanced Recovery After Surgery (ERAS) protocols are widely implemented in colorectal surgery to improve postoperative recovery and reduce hospital stay. However, their impact on postoperative morbidity in elderly and clinically complex populations remains debated. AIM: To evaluate the impact of ERAS implementation on postoperative morbidity and hospital length of stay in an elderly and oncologically complex population undergoing elective laparoscopic colorectal cancer surgery. METHODS: We conducted a retrospective comparative study including patients undergoing elective laparoscopic colorectal cancer resection. Patients treated between January 2016 and December 2018 received standard perioperative care, whereas those treated between January 2022 and December 2025 were managed according to a structured ERAS protocol. All procedures were performed laparoscopically by the same surgical team. To reduce selection bias and improve comparability between cohorts, propensity score matching was performed using age, sex, tumour location, T stage, N stage, and preoperative metastatic disease. The primary endpoint was the incidence of major postoperative complications (Clavien-Dindo grade ≥ III). Secondary endpoints included overall postoperative complications, in-hospital/30-day mortality, and length of hospital stay. RESULTS: A total of 209 patients were included (ERAS: 83; non-ERAS: 126). Propensity score matching generated 68 matched pairs, achieving adequate covariate balance (all standardized mean differences < 0.10). In the overall cohort, major complication rates were similar between groups (22.9% vs. 23.8%, p = 1.000), as were overall complication rates (59.0% vs. 61.1%, p = 0.876). Mortality did not differ significantly (6.0% vs. 2.4%, p = 0.270). Length of hospital stay was significantly shorter in the ERAS group (6.2 ± 2.8 vs. 7.9 ± 5.7 days, p = 0.004). CONCLUSIONS: In an elderly and clinically complex population undergoing elective laparoscopic colorectal cancer surgery, ERAS implementation was associated with a significant reduction in hospital length of stay without evidence of increased major postoperative morbidity or mortality. Propensity score matching improved baseline comparability between cohorts. Given the retrospective design and non-contemporaneous study periods, these findings should be interpreted with caution but support the feasibility and safety of ERAS in real-world colorectal surgical practice.