ERas and COLorectal endoscopic surgery: an Italian society for endoscopic surgery and new technologies (SICE) national report
Authors: Milone Marco , Elmore Ugo , Manigrasso Michele , Ortenzi Monica , Botteri Emanuele , Arezzo Alberto , Silecchia Gianfranco , Guerrieri Mario , De Palma Giovanni Domenico , Agresta Ferdinando ,   ERCOLE Study Group, Agresta Ferdinando , Pizza Francesco , D’Antonio Dario , Amalfitano Francesco , Selvaggi Francesco , Sciaudone Guido , Selvaggi Lucio , Prando Daniela , Cavallo Fabio , Guerrieri Mario , Ortenzi Monica , Lezoche Giovanni , Cuccurullo Diego , Tartaglia Ernesto , Sagnelli Carlo , Coratti Andrea , Tribuzi Angela , Di Marino Michele , Anania Gabriele , Bombardini Cristina , Zago Mauro Pietro , Tagliabue Fulvio , Burati Morena , Di Saverio Salomone , Colombo Samuele , Adla Sara El , De Luca Maurizio , Zese Monica , Parini Dario , Prosperi Paolo , Alemanno Giovanni , Martellucci Jacopo , Olmi Stefano , Oldani Alberto , Uccelli Matteo , Bono Dario , Scaglione Donatella , Saracco Roberto , Podda Mauro , Pisanu Adolfo , Murzi Valentina , Agrusa Antonino , Buscemi Salvatore , Muttillo Irnerio Angelo , Picardi Biagio , Muttillo Edoardo Maria , Solaini Leonardo , Cavaliere Davide , Ercolani Giorgio , Corcione Francesco , Peltrini Roberto , Bracale Umberto , Lucchi Andrea , Vittori Laura , Grassia Michele , Porcu Alberto , Perra Teresa , Feo Claudio , Angelini Pierluigi , Izzo Domenico , Ricciardelli Luigi , Trompetto Mario , Gallo Gaetano , Luc Alberto Realis , Muratore Andrea , Calabrò Marcello , Cuzzola Bruno , Barberis Andrea , Costanzo Federico , Angelini Giulio , Ceccarelli Graziano , Rondelli Fabio , De Rosa Michele , Cassinotti Elisa , Boni Luigi , Baldari Ludovica , Bianchi Paolo Pietro , Formisano Giampaolo , Giuliani Giuseppe , Ceretti Andrea Alessandro Pisani , Mariani Nicolò Maria , Giovenzana Marco , Farfaglia Roberto , Marcianò Paolo , Arizzi Valeria , Piccoli Micaela , Pecchini Francesca , Pattacini Gianmaria Casoni , Botteri Emanuele , Vettoretto Nereo , Guarnieri Claudio , Laface Letizia , Abate Emmanuele , Casati Massimiliano , Feo Carlo , Fabri Nicolò , Pesce Antonio , Maida Piero , Marte Giampaolo , Abete Roberta , Casali Lorenzo , Marchignoli Alessandro , Dall’Aglio Matteo , Scabini Stefano , Pertile Davide , Aprile Alessandra , Andreuccetti Jacopo , Di Leo Alberto , Crepaz Lorenzo , Maione Francesco , Vertaldi Sara , Chini Alessia , Rosati Riccardo , Puccetti Francesco , Maggi Giulia , Cossu Andrea , Sartori Alberto , De Luca Maurizio , Piatto Giacomo , Perrotta Nicola , Celiento Marta , Scorzelli Marco , Pilone Vincenzo , Tramontano Salvatore , Calabrese Pietro , Sechi Raffaele , Cillara Nicola , Putzu Giaime , Podda Michele Guido , Montuori Mauro , Pinotti Enrico , Sica Giuseppe , Franceschilli Marzia , Sensi Bruno , Degiuli Maurizio , Reddavid Rossella , Puca Lucia , Farsi Marco , Minuzzo Alessio , Gia Elena , Baiocchi Gian Luca , Ranieri Valerio , Celotti Andrea , Bianco Francesco , Grassia Sebastiano , Novi Alessandra 
Published: May 2022

Abstract
Background
Several reports demonstrated a strong association between the level of adherence to the protocol and improved clinical outcomes after surgery. However, it is difficult to obtain full adherence to the protocol into clinical practice and has still not been identified the threshold beyond which improved functional results can be reached.

Methods
The ERCOLE (ERas and COLorectal Endoscopic surgery) study was as a cohort, prospective, multi-centre national study evaluating the association between adherence to ERAS items and clinical outcomes after minimally invasive colorectal surgery. The primary endpoint was to associate the percentage of ERAS adherence to functional recovery after minimally invasive colorectal cancer surgery. The secondary endpoints of the study was to validate safety of the ERAS programme evaluating complications’ occurrence according to Clavien-Dindo classification and to evaluate the compliance of the Italian surgeons to each ERAS item.

Results
1138 patients were included. Adherence to the ERAS protocol was full only in 101 patients (8.9%), > 75% of the ERAS items in 736 (64.7%) and > 50% in 1127 (99%). Adherence to > 75% was associated with a better functional recovery with 90.2 ± 98.8 vs 95.9 ± 33.4 h (p = 0.003). At difference, full adherence to the ERAS components 91.7 ± 22.1 vs 92.2 ± 31.6 h (p = 0.8) was not associated with better recovery.

Conclusions
Our results were encouraging to affirm that adherence to the ERAS program up to 75% could be considered satisfactory to get the goal. Our study could be considered a call to simplify the ERAS protocol facilitating its penetrance into clinical practice.