Objectives
This is a protocol for a Cochrane review (intervention). The objectives are as follows:
To assess the effects of ERAS pathways compared with conventional perioperative care in people undergoing colorectal resection for malignant or benign conditions.
Background
Description of the condition
Colorectal cancer is one of the most commonly diagnosed malignancies worldwide, and curative resection remains the mainstay of treatment for localized disease [1]. In addition to malignancy, several benign colorectal conditions, such as diverticulitis, inflammatory bowel disease, and other causes of colonic obstruction (e.g. volvulus), may also require surgical intervention. Colorectal resection is therefore one of the most frequently performed major abdominal operations [2], and minimally invasive approaches, including laparoscopic and robotic surgery, are increasingly used in current practice [3].
Despite advances in surgical techniques and perioperative care, postoperative morbidity remains relatively common, with overall complication rates reported to be around 20% to 30% and surgical site infections occurring in approximately 15% to 30% of patients, which is higher than that reported for other abdominal surgeries [4, 5]. Postoperative hospital stay usually ranges from five to eight days [6]. Perioperative morbidity is clinically important because postoperative complications may adversely affect recovery and influence long‐term oncologic outcomes in patients with colorectal cancer [7, 8]. Consequently, improving postoperative recovery and reducing complications after colorectal surgery have become important goals in perioperative care.
Description of the intervention and how it might work
The group that established the Enhanced Recovery After Surgery (ERAS) Society in 2010 first introduced a consensus guideline in 2005 to improve perioperative care for people undergoing major colorectal surgery [9]. Since the publication of the first ERAS guideline for colorectal surgery, four updates have been published [10, 11, 12, 13], with the most recent update being released in 2025 [14]. Although some modifications have been made with each revision, the core principles of ERAS have remained largely consistent over time. ERAS is a multimodal perioperative care pathway that integrates evidence‐based interventions across the preoperative, intraoperative, and postoperative phases of surgical care. ERAS emphasizes the coordinated implementation of multiple perioperative strategies, and adherence to the pathway is considered an important determinant of clinical outcomes. According to the most recent ERAS guidelines (2025) [14], the pathway includes interventions such as patient education and preoperative optimization, shortened fasting with carbohydrate loading, multimodal anesthesia and goal‐directed fluid therapy, minimally invasive surgical approaches where feasible, and postoperative strategies, including early enteral nutrition and early mobilization.
ERAS is designed to reduce surgical trauma and the associated physiological stress response [15]. Through coordinated perioperative strategies that maintain physiological stability and promote early restoration of organ function, ERAS may facilitate earlier functional recovery, reduce postoperative morbidity and mortality, shorten hospital stay, and improve postoperative quality of life.
However, the effects of ERAS may vary according to patient and surgical characteristics. Older persons may have reduced physiological reserves, different comorbidity profiles, and distinct recovery patterns, which may influence the effectiveness of ERAS pathways [16]. Differences in surgical complexity, perioperative stress responses, and recovery trajectories between benign and malignant colorectal conditions may also modify the effects of ERAS [17]. In addition, minimally invasive surgery is associated with reduced surgical stress and faster postoperative recovery compared with open surgery and may therefore attenuate or amplify the incremental benefits of ERAS pathways [18]. We therefore considered age, disease type, and surgical approach to be clinically plausible effect modifiers and prespecified that we would undertake subgroup analyses according to these characteristics.
Why it is important to do this review
This review is an update of a Cochrane review first published in 2011 that evaluated the effects of ERAS pathways in colorectal surgery [19].
Since the publication of that review, ERAS pathways in colorectal surgery have been extensively studied in randomized controlled trials and systematic reviews. As mentioned above, during the same period, ERAS guidelines for colorectal surgery have undergone several updates. Consequently, ERAS pathways used in clinical trials may vary depending on the guideline version available at the time the study was conducted.
A key challenge in interpreting the existing evidence is the variability in how ERAS interventions are defined and implemented across studies. Trials labeled as ERAS pathways may differ substantially in the perioperative components actually applied [20, 21], and previous systematic reviews have often classified interventions as ERAS without explicitly evaluating whether key ERAS elements were implemented [22, 23]. Among the many published systematic reviews, only a limited number have clearly defined the criteria for considering an intervention as ERAS based on the number of recommended ERAS components actually implemented in the intervention group [24, 25]. Such variability in the fidelity of ERAS implementation may contribute to heterogeneity in outcomes and limit the interpretability of existing meta‐analyses.
Therefore, this review aims to provide a more rigorous evaluation of ERAS pathways in colorectal surgery by explicitly assessing ERAS interventions according to the implementation of key ERAS components recommended across successive updates of the colorectal ERAS guidelines. By clarifying whether trials incorporated these essential elements of ERAS care, this review seeks to better distinguish ERAS pathways from conventional perioperative care and to provide more reliable evidence regarding the effectiveness of ERAS pathways.
Objectives
To assess the effects of ERAS pathways compared with conventional perioperative care in people undergoing colorectal resection for malignant or benign conditions.
Methods
We will follow the Methodological Expectations for Cochrane Intervention Reviews (MECIR) standards when conducting this review [26], and the PRISMA 2020 statement for reporting [27].
Criteria for considering studies for this review
Types of studies
We will include parallel randomized controlled trials (RCTs) regardless of their publication status or language of publication. We will also include cluster‐RCTs.
We will exclude cross‐over trials because the intervention cannot be reversed after surgery. We will exclude quasi‐randomized trials (e.g. allocation by date of birth, medical record number, or alternation) because these methods are associated with a higher risk of selection bias.
Types of participants
We will include adult participants (aged 18 years or older) undergoing elective colorectal resection for malignant or benign conditions. We will exclude studies exclusively involving emergency colorectal surgery. We will include studies involving both elective and emergency colorectal surgery if data for elective colorectal surgery can be extracted separately or if at least 80% of participants underwent elective colorectal resection. We will include studies involving both colorectal resection and other types of surgery if data for participants undergoing colorectal resection can be extracted separately or if at least 80% of participants underwent colorectal resection.
Types of interventions
In this review, we will compare any type of ERAS pathway with conventional perioperative care in participants undergoing colorectal resection. ERAS pathways are multimodal perioperative care pathways designed to reduce surgical stress and facilitate postoperative recovery. Typical ERAS components include preoperative counseling and optimization, minimization of preoperative fasting with carbohydrate loading, multimodal opioid‐sparing analgesia, early postoperative mobilization, early oral or enteral nutrition, and goal‐directed perioperative fluid management, among others.
A key methodological challenge in evaluating ERAS interventions is that the pathways used in clinical trials are not always clearly described, making it difficult to determine whether ERAS was truly implemented as intended. Furthermore, ERAS guidelines have undergone several revisions over time, and both the number and composition of recommended ERAS components have changed across guideline versions. Consequently, defining ERAS solely on the basis of the total number of components implemented may not adequately capture whether the core principles of the ERAS pathway were applied in a given study.
To address this limitation, we will define ERAS implementation based on the presence of selected key ERAS components representing the fundamental principles of ERAS pathways. These components were identified a priori based on the results of a structured survey of experts, informed by the recommendations of the most recent ERAS Society guidelines for colorectal surgery and earlier guideline versions. Detailed results of the survey are provided in Supplementary material 2. We consider the following six components to be critical ERAS elements.
Minimization of preoperative fasting with carbohydrate loading
Fluid therapy, particularly appropriate postoperative fluid management
Surgical approach using minimally invasive techniques when feasible, or a short‐incision approach reflecting earlier ERAS recommendations
Multimodal postoperative opioid‐sparing analgesia
Early postoperative nutritional care with early oral or enteral feeding
Early mobilization
We selected these components because they represent key perioperative strategies consistently recommended in ERAS guidelines and are considered major drivers of postoperative recovery. To ensure that the ERAS pathway is fully implemented, we will classify a study as an ERAS intervention only if all six of these critical components are reported in the intervention group. We will define conventional perioperative care as usual care that does not involve the implementation of a standardized ERAS pathway. This may include both open and minimally invasive (laparoscopic or robotic) surgical approaches, provided that perioperative care is not delivered within a structured ERAS pathway. Therefore, in studies involving participants undergoing minimally invasive surgery, we will classify interventions as conventional perioperative care if the remaining perioperative components, apart from the surgical approach, do not meet the predefined criteria for ERAS implementation. Conventional perioperative care typically consists of non‐protocolized perioperative management, which may include practices such as prolonged fasting, delayed postoperative feeding, liberal use of tubes and drains, and variable analgesic strategies, depending on institutional or clinician preferences.
Outcome measures
We will not use the measurement of the outcomes assessed in this review as an eligibility criterion.
The COMET Initiative [28] identified a relevant study [29] regarding core outcomes in ERAS‐related research. From the outcomes reported as core outcomes in that study (e.g. gastrointestinal recovery, postoperative pain, length of hospital stay, postoperative complications, physical function, immune and inflammatory response, patient‐reported outcomes, and postoperative nausea and vomiting (PONV)), the review authors selected the critical and important outcomes for this review through discussion and consensus.
Critical outcomes
Serious complications
Quality of life
Length of hospital stay
Method and timing of outcome measurement
See below, under Important outcomes, for our plan for all outcomes.
Important outcomes
Overall complications
Postoperative pain
Gastrointestinal function recovery
Physical function recovery
Postoperative nausea and vomiting (PONV)
Hospital readmission
Method and timing of outcome measurement
Serious complications (dichotomous outcome): number of participants who developed at least one complication classified as Clavien–Dindo grade III or higher [30] within 30 days of surgery, such as anastomotic leakage or intra‐abdominal abscess requiring surgical, endoscopic, or radiological intervention; reoperation for a postoperative complication; and life‐threatening organ dysfunction requiring intensive care. If Clavien–Dindo classification [30] is not reported, we will use the study authors’ definitions of serious or major complications where appropriate.
Quality of life (continuous outcome): patient‐reported quality of life measured using validated patient‐reported outcome measures (PROMs), including recovery‐specific tools (e.g. QoR‐15 [31] and QoR‐40 [32]), during the specified follow‐up period
Length of hospital stay (continuous outcome): number of days of the index hospitalization, calculated from the date of surgery to the date of discharge
Overall complications (dichotomous outcome): number of participants who developed at least one complication of any cause within the defined follow‐up period
Postoperative pain (continuous outcome): patient‐reported postoperative pain intensity measured during the first postoperative week using validated pain assessment tools, including visual analogue scales (VAS), numeric rating scales (NRS), or any categorical pain rating scales
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Gastrointestinal function recovery (time‐to‐event outcome):
Time to first flatus: time from surgery to the first passage of flatus
Time to first defecation: time from surgery to the first passage of stool
Physical function recovery (time‐to‐event outcome): time to first ambulation, defined as the time from surgery to the first instance of the participant standing and walking with or without assistance, measured in hours or days
PONV (dichotomous outcome): number of participants who experienced at least one episode of nausea and/or vomiting within the defined postoperative follow‐up period
Hospital readmission (dichotomous outcome): number of participants who experienced at least one unplanned hospital readmission after discharge from the index colorectal surgery
We will analyze outcomes according to the following time points.
Short term: up to 30 days after surgery
Intermediate term: more than 30 days to 3 months after surgery
Long term: more than 3 months to 1 year after surgery
If an outcome is reported at multiple time points within a defined category, we will use the latest available time point within that category.
We will consider clinically important differences as the basis for rating the certainty of the evidence (for 'imprecision') for key outcomes that we will present in summary of findings tables (see Certainty of the evidence assessment) [33, 34]. Where available, we will use published minimal clinically important differences (MCIDs) established through previous research or established consensus or both. Where no established MCID is available, we will use prespecified thresholds based on clinical judgment and consensus among the review authors.
We will consider absolute risk differences of 3% for serious complications and 5% for overall complications, PONV, and readmission as clinically important. We have prespecified these thresholds based on clinical judgment and consensus among the review authors. For quality of life outcomes, we expect clinically important differences to vary depending on the measurement instrument used. When established reference values are available, we will apply published MCIDs derived from previous research (e.g., an 8‐point difference for the QoR‐15 and a 6.3‐point difference for the QoR‐40 [35]). In the absence of established MCIDs, we will consider a 25% improvement from baseline to be clinically important [36]. In terms of the length of hospital stay, we will consider a difference of 2 days to be clinically important. We have prespecified this threshold based on discussion and consensus among the review authors. For postoperative pain, we will apply published MCIDs established through previous research: a difference of 10 points on the VAS or 1 point on the NRS [37]. For gastrointestinal function recovery (time to first flatus and time to first defecation), we will consider a reduction of at least 24 hours to be clinically meaningful. For physical function recovery (time to first ambulation), we will consider a reduction of at least 12 hours to be clinically meaningful. In the absence of established MCIDs for these outcomes, we have prespecified these thresholds based on clinical judgment and consensus among the review authors, taking into account typical perioperative recovery patterns.
Search methods for identification of studies
We have presented all search methods and search strategies in Supplementary material 1. As this review is an update of a previously published Cochrane review, we built on the search strategy used in the original review and adapted it where necessary to reflect current indexing terms and database structures. The search strategy development and adaptation were led by a review author (MHK) who is an information specialist with expertise in systematic review searching.
Electronic searches
We will search the following electronic databases from the inception of each database.
Cochrane Library via Wiley (from 1991) Cochrane Database of Systematic Reviews (CDSR) and Cochrane Central Register of Controlled Trials (CENTRAL)
MEDLINE via Ovid (from 1946)
EMBASE via Elsevier (from 1947)
Scopus (from 1966)
Web of Science Core Collection (from 1900)
We will also search the following sources.
ClinicalTrials.gov (https://www.clinicaltrials.gov/)
World Health Organization International Clinical Trials Registry Platform search portal (http://www.who.int/clinical-trials-registry-platform)
Grey literature repositories including ERAS Society Guidelines/ Expert Reviews (https://erassociety.org/guidelines/)
We will not apply any language or publication status restrictions.
Searching other resources
We will screen the reference lists of included trials and relevant reviews, meta‐analyses, and health technology assessment reports in order to identify additional potentially eligible studies or related publications. We will also contact the authors of included trials for information on additional published or unpublished studies that may have been missed.
We will conduct a retraction search using the Retraction Watch Database (http://retractiondatabase.org/) and check for any post‐publication amendments related to included or otherwise eligible studies, including expressions of concern, errata, corrigenda, and retractions.
Data collection and analysis
Selection of studies
We will remove duplicate records identified through database searches using EndNote reference management software (Clarivate Analytics) [38]. We will screen the remaining records in two stages. First, titles and abstracts will be independently screened using Covidence [39] by three pairs of review authors (SA and IS; JHJ and WYK; and KK and WSW) to identify potentially relevant studies. The records identified for title and abstract screening will be divided into three equal parts and allocated to each review author pair. In the second stage, the full texts of all records considered potentially relevant will also be divided into three equal parts and independently assessed by the same pairs of review authors in the same manner. We will consolidate multiple reports referring to the same study. We will then categorize each study as included, excluded, awaiting classification, or ongoing, in accordance with the guidance in the Cochrane Handbook for Systematic Reviews of Interventions [40]. We will resolve any disagreements between review authors through discussion. Where disagreements cannot be resolved, we will classify the study as ‘awaiting classification’, and we will contact the study authors for clarification. We will not exclude studies solely on the basis of unavailable or non‐usable outcome data. We will document reasons for exclusion for studies that initially appear to meet the inclusion criteria. We will illustrate the study selection process using an adapted PRISMA flow diagram.
Data extraction and management
We will design a standardized data extraction form and pilot‐test it prior to use. For studies meeting the inclusion criteria, two review authors (SA and KK) will independently extract the following information.
Study design
Study dates
Study settings and countries
Participant inclusion and exclusion criteria
Participant details, baseline demographics (e.g. age, reason for surgery)
Numbers of participants by study and study arm
Details of experimental and comparator interventions (e.g. number of ERAS items used, ERAS components implemented in each study arm)
Description of co‐interventions (if possible)
Definitions of relevant outcomes, methods, and timing of outcome measurements, as well as any relevant subgroups
Study funding sources
Declarations of conflicts of interest by primary investigators
We will extract outcome data relevant to this review as required for the calculation of summary effect estimates and measures of variability. For dichotomous outcomes, we will collect the number of events and the number of participants in each study arm, along with reported effect estimates and corresponding measures of variance where available. For continuous outcomes, we will extract means and standard deviations (SDs), or other information necessary to calculate these statistics. For time‐to‐event outcomes, we will extract hazard ratios (HRs) with corresponding confidence intervals (CIs) when reported. If HRs are not directly available, we will estimate HRs using available data in accordance with the methods described by Tierney and colleagues [41]. We will resolve any disagreements between review authors through discussion. In studies with more than two intervention arms, we will include only data from arms meeting the eligibility criteria in the review and meta‐analysis.
We will provide information, including trial identifiers, about potentially relevant ongoing studies. We will contact the authors of the included studies to obtain key missing data as needed. We will also check included studies for retractions or corrections using the Retraction Watch Database (http://retractiondatabase.org/) and relevant journal websites, where applicable.
Dealing with duplicate and companion publications
When we identify duplicate publications, companion papers, or multiple reports of the same study, we will link all related reports to a single study and consolidate the available information to ensure comprehensive data capture. We will use the most complete dataset compiled from all relevant publications. If uncertainty arises, we will give priority to the report providing the longest follow‐up relevant to the primary or secondary outcomes.
Risk of bias assessment in included studies
Two review authors (SA and KK) will independently assess the risk of bias in the specific results from each included study that contribute to the outcomes prioritized for the summary of findings tables, using the revised Cochrane risk of bias tool for randomized trials (RoB 2) [42]. We will resolve any disagreements through discussion and consensus, with consultation with a third review author (JHJ) if necessary.
We will assess the following domains.
Bias arising from the randomization process
Bias due to deviations from intended interventions
Bias due to missing outcome data
Bias in measurement of the outcome
Bias in selection of the reported result
Overall risk of bias judgment
Each domain will be judged as ‘low risk of bias’, ‘some concerns’, or ‘high risk of bias’.
We will perform separate RoB 2 assessments, where the relevant outcome is reported, for the following specific results.
Serious complications, defined as the number of participants with at least one Clavien–Dindo grade III or higher complication within 30 days of surgery
Quality of life measured using validated patient‐reported outcome measures
Length of hospital stay, measured in days from surgery to discharge
Overall complications, defined as the number of participants with at least one complication of any cause
Postoperative pain measured using validated pain assessment tools during the first postoperative week
Gastrointestinal function recovery, measured as the time from surgery to first flatus and the time from surgery to first defecation
Physical function recovery, measured as the time from surgery to first ambulation
We will assess serious complications within 30 days of surgery, and postoperative pain during the first postoperative week. For the remaining outcomes, we will assess results at the prespecified short‐term, intermediate‐term, and long‐term timeframes, where applicable and reported.
Where risk of bias assessments are identical across outcomes, we will consolidate results to avoid redundant reporting. We will present the results of the risk of bias assessments in risk of bias tables and summary figures. This process will follow the guidance in the Cochrane Handbook for Systematic Reviews of Interventions [40]. We will also consider funding sources and investigator conflicts of interest in included studies and reflect on their potential impact on study design, risk of bias in individual study results, and the overall synthesis results.
For the domain assessing bias due to deviations from intended interventions, we will evaluate the effect of assignment to the intervention groups at baseline, irrespective of whether participants adhered to the assigned interventions during follow‐up, consistent with the intention‐to‐treat effect.
For cluster‐randomized trials, we will assess the risk of bias using the RoB 2 tool with extensions for cluster‐randomized trials, in accordance with the guidance in the Cochrane Handbook for Systematic Reviews of Interventions [43].
Measures of treatment effect
We will express dichotomous outcomes as risk ratios (RRs) with 95% confidence intervals (CIs). For continuous outcomes, we will express results as mean differences (MDs) with 95% CIs. When different studies use different measurement scales for the same outcome, we will express results as standardized mean differences (SMDs) with 95% CIs. For time‐to‐event outcomes, we will express results as hazard ratios (HRs) with 95% CIs.
Unit of analysis issues
The unit of analysis will be the individual participant in each study arm. If we identify cluster‐RCTs or studies with more than two intervention arms, we will manage these in accordance with the guidance provided in the Cochrane Handbook for Systematic Reviews of Interventions [40].
For studies with multiple intervention groups, we will combine all relevant experimental groups into a single intervention group and all relevant control groups into a single comparator group to avoid double‐counting of participants. If combining groups is not appropriate due to clinical heterogeneity, we will include each relevant pairwise comparison separately whilst accounting for any shared comparator group, for example, by dividing the shared comparator group approximately evenly among the comparisons. For dichotomous outcomes, we will divide both the number of participants and the number of events in the shared comparator group; for continuous outcomes, we will divide only the number of participants, leaving the means and standard deviations unchanged [40].
For cluster‐RCTs, we will use effect estimates and corresponding standard errors that appropriately account for clustering. If clustering has not been accounted for in the reported analysis, we will adjust the effective sample size using the design effect, calculated as 1+(M−1)×ICC, where M is the mean cluster size and ICC is the intracluster correlation coefficient. We will obtain the ICC from the included study or by contacting the study authors. If an ICC is unavailable, we will use an estimate from a similar study or population and examine the impact of the imputed ICC in sensitivity analyses. For dichotomous outcomes, we will divide both the number of participants and the number of events by the design effect; for continuous outcomes, we will divide only the number of participants, leaving the means and standard deviations unchanged. If clustering cannot be appropriately accounted for using the available information, we will not include the study in the meta‐analysis and will report its findings narratively [40].
Dealing with missing data
We will conduct available‐case analyses using outcome data as reported by the original studies. We will record whether each study used an intention‐to‐treat approach. Where both intention‐to‐treat and other analyses are reported, we will preferentially use the intention‐to‐treat results reported by the original study.
When outcome data are missing, we will attempt to contact study authors to obtain the missing information whenever possible. We will not impute missing outcome data. We will examine attrition rates, including dropouts, losses to follow‐up, and withdrawals, and will critically assess the potential impact of missing data on study findings. When feasible, we will derive missing standard deviations (SDs) from available statistical information, such as standard errors, exact P values, or confidence intervals. If necessary, we will estimate means and measures of dispersion from graphical data presented in study reports using GetData Graph Digitizer [44].
Reporting bias assessment
We will seek study protocols, where available, to assess the potential for selective outcome reporting. If more than 10 studies are included in a meta‐analysis, we will construct funnel plots and apply linear regression tests to evaluate the presence of reporting bias [45]. Funnel plot asymmetry may arise from several factors, including genuine heterogeneity related to study size, methodological limitations of smaller studies, or publication bias. Therefore, we will interpret findings from these assessments with caution. Two review authors (SA and KK) will independently assess the risk of bias due to missing results. We will resolve disagreements through discussion or, if necessary, consultation with a third review author (JHJ). When required, we will contact study authors to obtain or verify relevant information. We do not plan to use automation tools for the assessment of reporting bias.
Synthesis methods
For the primary analyses, we will include all studies that meet the eligibility criteria. We will use the random‐effects model for meta‐analysis because we expect clinical and methodological heterogeneity across studies [46], and will interpret the results while considering the distribution of effect estimates. We will use the restricted maximum likelihood (REML) estimator to estimate the between‐study variance. We will use the Hartung–Knapp–Sidik–Jonkman (HKSJ) method to calculate confidence intervals for the summary effect when at least three studies are included and the estimate of the between‐study variance is greater than zero. When only two studies are included or the estimated between‐study variance is zero, we will use the Wald‐type method [47].
We will conduct statistical analyses in accordance with the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions [40]. For dichotomous outcomes, we will apply the Mantel–Haenszel method; for continuous outcomes, the inverse variance method; and for time‐to‐event outcomes, the generic inverse variance method. We will consider the possibility of skewed data when analyzing continuous outcomes, particularly for outcomes such as quality of life scores and length of hospital stay. We will perform analyses using Review Manager (RevMan) [48]. Where meta‐analysis is not feasible, we will follow the guidance provided in the SWiM (synthesis without meta‐analysis) reporting guideline [49].
Where meta‐analysis may be feasible, but we consider it inappropriate, for example, due to substantial clinical or statistical heterogeneity, we will apply alternative synthesis methods recommended in the Cochrane Handbook for Systematic Reviews of Interventions and present study findings individually [50]. We will assess heterogeneity by visually inspecting forest plots to evaluate the degree of confidence interval overlap and by calculating the I² statistic to quantify inconsistency across studies and its potential influence on meta‐analysis results [51, 52]. We will interpret I² values according to the following thresholds [47].
0% to 40%: may not be important
30% to 60%: may indicate moderate heterogeneity
50% to 90%: may indicate substantial heterogeneity
75% to 100%: considerable heterogeneity
We will attempt to determine potential reasons for any heterogeneity by examining individual study and subgroup characteristics.
Investigation of heterogeneity and subgroup analysis
We will explore potential sources of heterogeneity arising from clinical and methodological diversity across included studies. Where sufficient data are available, we will perform subgroup analyses to investigate whether the effects of ERAS pathways differ according to clinically relevant factors.
We prespecified the following subgroup analyses based on clinical plausibility and their potential role as effect modifiers.
Age: participants aged ≥ 65 years versus < 65 years
Disease type: benign versus malignant colorectal conditions
Surgical approach: open surgery versus minimally invasive surgery (laparoscopic or robotic approaches)
Older persons may have different physiological reserves, comorbidity profiles, and recovery patterns, which may influence the effectiveness of ERAS pathways [16]. Surgical complexity, perioperative stress response, and recovery trajectories may differ between benign and malignant diseases, potentially modifying the effects of ERAS [17]. Surgical approach may modify the effectiveness of ERAS pathways, as minimally invasive surgery is associated with reduced surgical stress and faster postoperative recovery, potentially attenuating or amplifying the incremental benefits of ERAS pathways [18].
When subgroup‐specific data are available within studies, we will perform within‐study subgroup analyses. If only study‐level characteristics are available, we will conduct subgroup analyses using study‐level variables. We will assess differences between subgroups using tests for interaction. If subgroup analyses cannot be performed due to an insufficient number of studies or limited reporting of subgroup data, we will state this and undertake a narrative exploration of heterogeneity.
Sensitivity analysis
We will perform sensitivity analyses to explore the influence of the following factor (when applicable) on effect sizes.
Restricting the analysis to studies at low risk of bias or with some concerns, excluding studies we have judged to be at high risk of bias.
Certainty of the evidence assessment
We will assess the overall certainty of the evidence for each outcome according to the GRADE approach, following the guidance in the GRADE Handbook [53], which takes into account five domains: overall risk of bias, inconsistency, indirectness, imprecision, and publication bias [54]. We will downgrade the certainty of the evidence by one or two levels depending on the seriousness of concerns in these domains. We will evaluate the certainty of the evidence for the comparison of ERAS pathways versus conventional perioperative care in colorectal surgery. Two review authors (SA and KK) will independently rate the certainty of the evidence for each outcome as high, moderate, low, or very low using GRADEpro GDT software [36, 55]. We will resolve any disagreements through discussion or, if necessary, by consultation with a third review author (JHJ).
For this comparison, we will present the main outcomes in a summary of findings table. This table will summarize key information, including the magnitude of the intervention effect, the number of participants and studies contributing data, and the overall certainty of the evidence for each outcome [56, 57]. If meta‐analysis is not possible, we will present the results in a narrative summary of findings table.
Main outcomes for summary of findings table
We will present a summary of findings table reporting the following outcomes and measurements, listed according to priority.
Serious complications, defined as the number of participants with at least one Clavien–Dindo grade III or higher complication within 30 days of surgery
Quality of life, measured using validated patient‐reported outcome measures
Length of hospital stay, measured in days from surgery to discharge
Overall complications, defined as the number of participants with at least one complication of any cause
Postoperative pain, measured using validated pain assessment tools during the first postoperative week
Gastrointestinal function recovery, measured as the time from surgery to first flatus and the time from surgery to first defecation
Physical function recovery, measured as the time from surgery to first ambulation
As described in Outcome measures and Risk of bias assessment in included studies, we will assess serious complications within 30 days of surgery, and postoperative pain during the first postoperative week. For the remaining outcomes, we will present results at the prespecified short‐term, intermediate‐term, and long‐term timeframes, where applicable and reported.
Equity considerations
Although the primary objective of this review is to evaluate the effectiveness of ERAS pathways compared with conventional perioperative care in colorectal surgery, we will consider potential equity issues when interpreting the findings and assessing the applicability of the evidence. Where reported, we will summarize relevant participant and study characteristics, including age, study setting, and country, and discuss limitations arising from inadequate reporting or under‐representation of particular populations or settings.
Consumer involvement
Consumers were not involved in the development of this pathway. At the review stage, we will seek consumer input to assess the clarity and readability of the plain language summary. We will consider any feedback received and will document any involvement of consumers in the completed review.
Supporting Information
Supplementary materials are available with the online version of this article: 10.1002/14651858.CD016406.
Supplementary materials are published alongside the article and contain additional data and information that support or enhance the article. Supplementary materials may not be subject to the same editorial scrutiny as the content of the article and Cochrane has not copyedited, typeset or proofread these materials. The material in these sections has been supplied by the author(s) for publication under a Licence for Publication and the author(s) are solely responsible for the material. Cochrane accordingly gives no representations or warranties of any kind in relation to, and accepts no liability for any reliance on or use of, such material.
Supplementary material 1 Search strategies
Supplementary material 2 Results of the expert survey used to identify critical ERAS components for defining ERAS interventions
a.
These authors should be considered joint first author.
New
Declarations and contributions
Acknowledgements
This review is an update of a Cochrane review first published in 2011 that evaluated enhanced recovery after surgery (ERAS) pathways in colorectal surgery. We are grateful to all authors who developed the protocol for the previous review version [58] and contributed to the 2011 review [19].
Editorial and peer‐reviewer contributions
Cochrane Colorectal supported the authors in the development of this protocol.
The following people conducted the editorial process for this article.
Sign‐off Editors (final editorial decision): Rupa Sarkar, Cochrane Editor in Chief; Toby Lasserson, Cochrane Deputy Editor in Chief
Managing Editor (selected peer reviewers, provided editorial guidance to authors, edited the article): Hannah Payne, Cochrane Central Editorial Service
Editorial Assistant (conducted editorial policy checks, selected peer reviewers, collated peer‐reviewer comments, and supported editorial team): Cynthia Stafford, Cochrane Central Editorial Service
Copy Editor (copy editing and production): Laura MacDonald, Cochrane Central Production Service
Peer reviewers (provided comments and recommended an editorial decision): Clare Miles, Evidence Production and Methods Directorate (methods review); Jo Platt, Central Editorial information Specialist (search review)
Contributions of authors
SA, JHJ, and KK conceived the review.
SA, JHJ, IS, WYK, WSW, MHK, and KK designed the review.
SA, JHJ, WYK, WSW, and KK drafted the protocol with input from IS and MHK. SA, JHJ, IS, MHK, and KK critically revised the protocol for important intellectual content.
SA, JHJ, IS, WYK, WSW, and KK will independently screen studies for inclusion.
SA and KK will independently extract data and assess the risk of bias of included studies.
SA and KK will perform the data analyses and assess the certainty of the evidence using the GRADE approach.
MHK (information specialist) developed the search strategies and will conduct the literature searches.
JHJ will act as a third reviewer to resolve disagreements when necessary and provide methodological guidance.
All authors reviewed and approved the final version of the protocol.
Declarations of interest
Sanghyun An (SA), Jae Hung Jung (JHJ), Insik Shin (IS), and Kwangmin Kim (KK): healthcare professionals at university hospitals; no financial or non‐financial conflicts of interest relevant to this review.
Won Yeol Kim (WYK), Woo Seong Won (WSW), and Myung Ha Kim (MHK): no financial or non‐financial conflicts of interest relevant to this review.
Jae Hung Jung (JHJ): editor for Cochrane Urology; JHJ had no involvement in the editorial process for this review.
Sources of support
Internal sources
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Yonsei University Wonju College of Medicine, Wonju, Korea, South
Salary support for Sanghyun An, Jae Hung Jung, In Sik Shin, Myung Ha Kim, and Kwangmin Kim
External sources
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None, Other
None
Registration and protocol
Cochrane approved the proposal for this review in February 2026.
Data, code and other materials
Data sharing is not applicable to this article as it is a protocol, and no datasets will be generated or analyzed.
Disclosure of artificial intelligence use
We did not use AI platforms, systems, or tools in the preparation of this protocol.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplementary material 1 Search strategies
Supplementary material 2 Results of the expert survey used to identify critical ERAS components for defining ERAS interventions
Data Availability Statement
Data sharing is not applicable to this article as it is a protocol, and no datasets will be generated or analyzed.