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Ding YB, Yu H, Zhan XL. Enhanced recovery after surgery in colorectal surgery: Do average benefits mask heterogeneous effects in patients underrepresented in trials? World J Gastrointest Surg 2026; 18(11): 125939 [DOI: 10.4240/wjgs.125939]
World J Gastrointest Surg. Nov 27, 2026; 18(11): 125939 Published online Nov 27, 2026. doi: 10.4240/wjgs.125939
Enhanced recovery after surgery in colorectal surgery: Do average benefits mask heterogeneous effects in patients underrepresented in trials?
Ying-Bin Ding, Hang Yu, Xue-Lei Zhan
Ying-Bin Ding, Department of Ultrasound Medicine, Harbin Hospital of Traditional Chinese Medicine, Harbin 150076, Heilongjiang Province, China
Hang Yu, Xue-Lei Zhan, Department of General Surgery, The First Hospital of Harbin, Harbin 150000, Heilongjiang Province, China
Co-first authors: Ying-Bin Ding and Hang Yu.
Author contributions: Ding YB conceived the review framework, executed database searches, completed primary literature screening, drafted the introduction and chapters 2 and 3, and performed quality appraisal of clinical cohort studies; Yu H collated cross-disciplinary evidence from human factors and safety science, synthesized registry data, and drafted chapters 4-6; Zhan XL supervised all research stages, standardized the narrative synthesis methodology, revised all chapters for logical consistency, checked all boundary compliance rules, and finalised the reference list; All authors read and approved the final submitted version. Ding YB and Yu H contributed equally as co-first authors.
AI contribution statement: The authors take full responsibility and accountability for all content of this manuscript, including any portions for which AI tools were used as assistive technologies. All AI-assisted outputs were carefully reviewed, validated, and approved by the authors. AI tools were not used to generate original scientific data, perform independent scientific analyses, or draw scientific conclusions.
Conflict-of-interest statement: The authors have no conflicts of interest to declare.
Corresponding author: Xue-Lei Zhan, PhD, Chief Physician, Department of General Surgery, The First Hospital of Harbin, No. 151 Diduan Street, Daoli District, Harbin 150000, Heilongjiang Province, China. zhanxuelei@126.com
Received: July 21, 2026 Revised: August 10, 2026 Accepted: September 18, 2026 Published online: November 27, 2026 Processing time: 114 Days and 20.2 Hours
Abstract
For elective colorectal surgery, enhanced recovery protocols are now standard practice, with convincing trial evidence showing fewer complications and shorter stays. What we know far less about is whether that same evidence reliably applies to the patients who were routinely excluded from those trials, older frail adults, those with severe obesity, and people carrying multiple chronic conditions. Three observations from the available data give reason for caution. First, baseline physiological vulnerability predicts complications irrespective of protocol fidelity, a finding that suggests the benefit of compliance is not uniform across patient groups. Second, patients least likely to meet trial eligibility complete fewer elements of the protocol; whether such shortfalls reflect sound clinical judgement or inadvertent undertreatment has not been established. Third, socioeconomic disadvantage and ethnic minority background are linked to wider adherence gaps and poorer outcomes, even where institutional compliance appears high. These signals converge on a single gap in measurement. Existing audit systems document whether a protocol step was carried out, but not why it was omitted. A framework that fails to account for why protocol steps are omitted cannot distinguish clinical adaptation from neglect. Building that distinction into perioperative audit may matter as much for the patients at the margins of evidence as achieving higher compliance scores does for the average patient.
Core Tip: Enhanced recovery after surgery audits capture whether a protocol element was actually carried out, not why it was omitted. The reasons for omitting a step are not all the same: Some deviations reflect clinical caution, others simple oversight. That distinction matters most when the patient in question does not resemble the trial populations on which the protocol was originally based. Audit systems that record the rationale for non-adherence, rather than merely its occurrence, have the potential to improve perioperative care, although this hypothesis requires prospective validation.
