Impact of Charlson Comorbidity Index (CCI) on Enhanced Recovery after Surgery (ERAS) in colorectal surgery Proposal of an algorithm to predict patients at risk for an inadequate ERAS score

Impact of Charlson Comorbidity Index (CCI) on Enhanced Recovery after Surgery (ERAS) in colorectal surgery Proposal of an algorithm to predict patients at risk for an inadequate ERAS score | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of Charlson Comorbidity Index (CCI) on Enhanced Recovery after Surgery (ERAS) in colorectal surgery Proposal of an algorithm to predict patients at risk for an inadequate ERAS score Marionna Cathomas, Anas Taha, Otto Kollmar, Nicole Kunst, Andres Heigl, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9149720/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 18 You are reading this latest preprint version Abstract Introduction: Enhanced recovery after surgery (ERAS) is a widely accepted program aimed at improving short-term outcomes in patients undergoing colorectal surgery. To achieve good postoperative outcomes, adherence of at least 75% to ERAS principles is required, which is particularly challenging during the postoperative period. Methods: Patients undergoing colorectal resection between May 2016 and October 2022 were prospectively enrolled in the ERAS protocol and stratified according to the retrospectively assessed CCI. Patients with ≥ 5% missing data were excluded. The primary outcome of this study was to evaluate the predictive value of patients’ comorbidities, summarized using the Charlson comorbidity index (CCI), with regard to postoperative ERAS adherence. Results: A total of 572 patients were included (CCI 0: 223 [39.0%], CCI 1: 41 [7.2%], CCI 2: 150 [26.2%], CCI 3: 71 [12.4%], CCI ≥ 4: 87 [15.2%]). Patients with a CCI score of 0 had a median postoperative ERAS adherence of 84.6% (range: 15.4-100) compared with 69.2% (range: 16.7-100) in patients with a CCI score of ≥ 4 (p<0.001). Increasing CCI was significantly associated with a higher complication index (p<0.001) and a longer length of hospitalization stay (p<0.001). In the multivariate analysis, CCI ≥2 was an independent predictor of low adherence to the ERAS protocol. Conclusion: In line with these findings, adaptation of ERAS protocols according to the preoperatively assessed CCI may improve short-term postoperative outcomes. Therefore, a CCI-based algorithm is proposed. Enhanced recovery after surgery (ERAS) colorectal surgery Charlson Comorbidity Index Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction The enhanced recovery after surgery (ERAS) program was developed to reduce patients’ recovery time after surgery by minimizing the perioperative stress response ( 1 ). Nowadays, ERAS is a widely accepted concept in the perioperative management of patients across various surgical fields and has been shown to improve short-term outcomes ( 2 ). Implementation of ERAS is associated with lower rates of postoperative complications and a shorter length of hospital stay (LOS) ( 2 – 4 ). The ERAS program divides the perioperative period into four phases, with specific principles recommended for each phase ( 5 ). Adherence to these principles is measured using a point-based system, with a maximum adherence score of 100% per phase. To achieve the full clinical benefit of ERAS, an adherence score of at least 75% is required ( 6 ). Previous studies have demonstrated that adherence to ERAS principles is lowest during the postoperative ERAS phase, mainly due to the high activity level required from both patients and healthcare professionals ( 7 , 8 ). However, the factors influencing adherence during the postoperative ERAS phase remain insufficiently understood, potentially leading to a suboptimal postoperative phase. In a previous study, we investigated the impact of patients´ age on the postoperative ERAS phase. Although older age was associated with a lower postoperative ERAS adherence, age was not identified as an independent predictor ( 9 ). This highlights the need to consider additional factors, such as comorbidities, which are well known to influence the postoperative clinical course ( 10 ). The aim of this study was to evaluate the predictive value of CCI with respect to postoperative ERAS adherence and its subsequent impact on the short-term clinical outcome ( 11 , 12 ). Based on the results presented, an algorithm is proposed to identify patients at increased risk of inadequate postoperative ERAS adherence. Methods 3.1. Study design This study is a retrospective analysis of prospectively collected ERAS data of patients undergoing colorectal resections in the Department of Surgery at Cantonal Hospital Baselland, Switzerland. Since the implementation of the ERAS program in 2016, the Department of Surgery at Cantonal Hospital Baselland has been a certified ERAS center and, since 2017, a certified colorectal cancer center. In accordance with the recommendations of the ERAS® Society, all ERAS-related data were prospectively recorded in an interactive ERAS audit system by a specially trained ERAS nurse. Demographic and clinical data were retrieved from the ERAS system and the patients’ medical records. All included patients provided written general consent. The study was approved by the Ethics Committee of Northwestern and Central Switzerland (KEK-Nr. 2023 − 01684). 3.2. Study population All adult patients (> 18 years old) undergoing colorectal resection between May 1, 2016 and October 31, 2022 at the Department of Surgery of the Cantonal Hospital Baselland, Switzerland, were eligible for inclusion. Colorectal resections were performed with primary anastomosis and/or definitive or temporary stoma. Inclusion required a postoperative ERAS dataset with less than 5% missing data. Further, no patients with chronic inflammatory bowel disease were included in the cohort. 3.3. ERAS program and perioperative management All patients were managed perioperatively according to an ERAS protocol adapted from the ERAS® Society guidelines ( 5 ). In this study, the postoperative ERAS phase comprised a total of 13 recommended principles (Supplementary Data Fig. 1 ). Full adherence to all recommended principles corresponded to an adherence score of 100%. An adherence score of ≥ 75%, which is recommended to achieve the full clinical benefit of ERAS, was therefore defined as sufficient adherence. During hospitalization, all patients received low-molecular-weight heparin in a prophylactic dose and those who required full anticoagulation were fully heparinized based on the indication for anticoagulation and the bleeding risk. To enhance intestinal motility, all patients initially received magnesium orally. Subsequently, medical therapy was extended to metoclopramide, gastrographin, or neostigmine if needed. All medications were prescribed following a thorough assessment of any contraindications. The standard basic analgetic regimen was acetaminophen combined with metamizole sodium monohydrate. Additionally, patients received either patient-controlled analgesia (PCA) pumps or epidural anesthesia (PDA). When pain control after the removal of PCA and PDA was inadequate, patients were administered oxycodone in combination with naloxone during hospitalization. Upon discharge, patients were typically prescribed basic analgesic therapy. No non-steroidal anti-inflammatory drugs (NSAIDs) were administered. 3.4. Charlson comorbidity index (CCI) The original CCI as described by Charlson et al., excluding age, was used in this study ( 13 ). This version includes 16 chronic diseases coded according to the International Classification of Diseases, 10th Revision (ICD-10) (Supplementary Data Fig. 2 ). CCI was assessed retrospectively for all included patients. Patients with a CCI score of ≥ 4 were grouped together for analysis. 3.5. Outcomes and variables The primary endpoint was the predictive value of CCI for adherence to the postoperative ERAS phase. Secondary endpoints included the association of CCI with postoperative complications and LOS. LOS was defined as the number of nights spent in hospital after surgery. Patients undergoing elective surgery were admitted one day before surgery, whereas emergency patients were admitted following presentation to the emergency department. Emergency surgery was defined according to ERAS® Society recommendations as surgery performed within 2 hours, within 2 to 48 hours, or more than 48 hours after emergency department assessment. These categories were summarized as emergency surgery. Emergency patients provided informed consent on postoperative day 1, while all other patients provided consent during the preoperative consultation. Conversions from minimally invasive to open procedures were classified as open surgery. Postoperative complications, defined as any medical or surgical deviation from the normal postoperative course, were classified according to the Clavien–Dindo classification and summarized as the complication index (IC) ( 14 , 15 ). Postoperative ileus was defined as impaired gastrointestinal motility requiring a nasogastric tube placement. Anastomotic leakage was either confirmed using reoperation or endoscopic intervention or diagnosed based on documented extraluminal air or contrast leakage adjacent to the anastomosis. All complications occurring within 30 days after operation were included. The American Society of Anesthesiologists (ASA) scores were grouped as I/II and III/IV. Furthermore, the predictive value of postoperative ERAS adherence was evaluated in a multivariate analysis including all patients. An ERAS adherence score of ≥ 75% was defined as sufficient. In addition, adherence to the individual postoperative ERAS items was analyzed. Poor adherence was defined as fulfillment of a given item in fewer than 75% of patients. 3.6. Statistical analysis Statistical analyses were performed using the statistical program R (version 4.1.2). Descriptive and univariate analyses were conducted using Student’s t test and the Mann–Whitney U test for normally and non-normally distributed continuous variables, respectively, and the results are presented as medians. Categorical variables were analyzed using the chi-square test, multivariable analysis was performed using binary regression, and the results are reported as odds ratios (ORs), with OR < 1 considered as an independent factor. Parameters identified as independent factors were additionally assessed for multicollinearity to statistically evaluate and exclude any potential correlations. Statistical significance was defined as p ≤ 0.05. Results 4.1. Patient characteristics During the 6-year study period, a total of 608 patients underwent colorectal surgery with perioperative care according to the ERAS protocol. During the exclusion process, 36 (5.9%) patients were excluded based on the predefined criteria (Figure 1). The remaining 572 (94.1%) were included in the final analysis and stratified into five groups according to their CCI score (CCI 0 n=223 [39.0%], CCI 1: n=41 [7.2%], CCI 2: n=150 [26.2%], CCI 3: n=71 [12.4%], CCI ≥ 4: n=87 [15.2%]; Figure 1). Patient characteristics are summarized in Table 1. The median age in the CCI ≥ 4 patient group was significantly higher than in the CCI 0 group (CCI 0: 61 [range 18-89] years vs. CCI ≥ 4: 74 [range 49-88] years). There were more male patients in the CCI ≥ 4 group with significantly higher ASA scores III/IV (CCI 0: 49 [22.0%] patients vs. CCI ≥ 4: 80 [92.0%] patients; p<0.001). Regarding the CCI score, patients received two points for localized solid tumors. Therefore, the patients in CCI groups 0 and 1 had only non-malignant underlying diseases. Consequently, the presence of malignancies differed significantly among the CCI groups (p<0.001). 4.2. Surgical data and clinical outcome In the CCI 0 patient group, significantly more patients underwent emergency intervention (p=0.04) and received minimally invasive treatments (p<0.001). Among patients with a CCI of 0, sigmoid resections were most commonly performed (n=192 [86.1%]), whereas anterior resections were the most frequent surgical procedures in patients with a CCI ≥ 4 (n=33 [37.9%]) (Table 2). The median blood loss and duration of surgery differed significantly among the groups (both p<0.001). The median LOS increased with higher CCI scores (6 days [range 3-21] in the CCI 0 group vs. 11 days [range 5-29] in the CCI ≥ 4 group; p < 0.001; Table 2). Significantly more patients with a CCI ≥ 4 were discharged to other healthcare facilities (p < 0.001). The overall complication rates increased with higher CCI scores (p 3a complications according to the Clavien–Dindo classification and, consequently, had a higher index of complication (p < 0.001 each, Table 3). 4.3. Adherence of the postoperative ERAS protocol In the univariate analysis of the study cohort, significantly fewer patients with a CCI ≥ 4 achieved the required postoperative ERAS adherence score of ≥ 75% necessary to obtain a clinical benefit (CCI 0: 162 patients [72.6%] vs. 37 patients [42.5%]; p<0.001; Table 4). The median postoperative ERAS adherence score, expressed as a percentage, decreased significantly with increasing CCI scores (84.6 % [range 23.1-100] in patients with CCI 0 vs. 69.2 % [range 16.7-100] in patients with CCI ≥ 4; p<0.001; Table 3). When comparing group medians, a marked decrease in adherence was observed between patients with CCI scores of 1 and 2, respectively (Figure 2). A detailed analysis identified seven items with particularly low adherence: mobilization on postoperative days 1 – 3, oral energy intake on day of surgery and postoperative day 1, duration of intravenous fluid infusion, and balanced fluid on the day of surgery (Supplementary Data Figure 3). All (n=572) CCI 0 (n=223) CCI 1 (n=41) CCI 2 (n=150) CCI 3 (n=71) CCI ≥ 4 (n=87) p-value Age 66.2 (18-93) 61 (18-89) 71 (37-87) 68 (24-92) 74 (46-93) 74 (49-88) <0.001 BMI 26.1 (12.1-45.1) 26.4 (16.6-45.1) 26.7 (18.6-40.8) 25.8 (17.8-39.4) 26.7 (12.1-38.3) 25 (17.3-40.3) 0.2 Gender (male) 289 (52.1%) 99 (44.4%) 16 (39.0%) 77 (51.3%) 50 (70.4%) 56 (64.4%) <0.001 ASA <0.001 1+2 227 (39.37%) 174 (78.0%) 20 (48.8%) 21 (14.0%) 5 (7.0%) 7 (8.0%) 3+4 345 (60.3%) 49 (22.0%) 21 (51.2%) 129 (86.0%) 66 (93.0%) 80 (92.0%) Tumor type <0.001 Benign 283 (49.5%) 223 (78.8%) 41 (14.5%) 11 (3.9%) 8 (2.8%) 0 Malignant 289 (50.5%) 0 0 139 (48.1%) 63 (21.8%) 87 (30.1%) Table 1: Patient characteristics of the study cohort in accordance with the CCI. Age, median; BMI, body mass index (kg/m2), median; ASA, American Society of Anesthesiologists score. All (n=572) CCI 0 (n=223) CCI 1 (n=41) CCI 2 (n=150) CCI 3 (n=71) CCI ≥ 4 (n=87) p-value Surgery scheduling type 0.04 Elective 509 (89.0%) 187 (83.9%) 37 (90.2%) 140 (93.3%) 65 (91.5%) 80 (92.0%) Emergency 63 (11.0%) 36 (16.1%) 4 (9.8%) 10 (6.7%) 6 (8.5%) 7 (8.0%) Surgical approach <0.001 Open 131 (22.9%) 23 (10.3%) 4 (9.8%) 40 (26.7%) 27 (38.0%) 37 (42.5%) Laparoscopic/robotic 441 (77.1%) 200 (89.7%) 37 (90.2%) 110 (73.3%) 44 (62.0%) 50 (57.5%) Surgical procedure <0.001 Right hemicolectomy/ileocecal 132 (23.1%) 16 (7.2%) 5 (12.2%) 54 (36.0%) 29 (40.8%) 28 (32.2%) Left hemicolectomy 35 (6.1%) 6 (2.7%) 1 (2.4%) 9 (6.0%) 8 (11.3%) 11 (12.6%) Sigmoid resection 289 (50.5%) 192 (86.1%) 34 (82.9%) 36 (24.0%) 15 (21.1%) 12 (13.8%) Anterior resection 101 (17.7%) 5 (2.2%) 1 (2.4%) 44 (29.3%) 18 (25.4%) 33 (37.9%) Abdominoperineal resection 5 (0.9%) 1 (0.4%) 0 3 (2.0%) 0 1 (1.1%) Total/subtotal colectomy 10 (1.7%) 3 (1.3%) 0 4 (2.7%) 1 (1.4%) 2 (2.3%) Blood loss (ml, median) 50 (0-3000) 20 (0-700) 50 (5-250) 37.5 (0-1800) 50 (0-800) 50 (0-3000) <0.001 Duration of the surgical procedure 200 (80-500) 180 (80-470) 185 (90-360) 211 (100-480) 225 (100-486) 240 (90-500) <0.001 Table 2: Surgical outcome in study cohort according to CCI. Open surgical approach including conversion from minimally invasive to open; CCI, Charlson comorbidity index. All (n=572) CCI 0 (n=223) CCI 1 (n=41) CCI 2 (n=150) CCI 3 (n=71) CCI ≥ 4 (n=87) p-value LOS 8.7 (3-42) 6 (3-21) 7 (5-28) 7.5 (3-27) 7 (5-42) 11 (5-29) <0.001 Discharge <0.001 Home 461 (80.0%) 207 (92.8%) 40 (97.6%) 116 (77.3%) 46 (64.8%) 52 (59.8%) Other institutions 111 (19.4%) 16 (7.2%) 1 (2.4%) 34 (22.7%) 25 (35.2%) 35 (40.2%) Overall complications* <0.001 No 370 (64.7%) 165 (74.0%) 27 (65.9%) 97 (64.7%) 41 (57.7%) 40 (46.0%) Yes 202 (35.3%) 58 (26.0%) 14 (34.1%) 53 (35.3%) 30 (42.3%) 47 (54.0%) Severity of complications° <0.001 1-3a 140 (24.5%) 39 (17.4%) 6 (14.6%) 44 (29.3%) 23 (32.4%) 28 (32.2%) 3b-4b 64 (11.2%) 19 (8.5%) 8 (19.5%) 9 (6.0%) 7 (9.9%) 19 (21.8%) Index of complications 10.6 (0-76.7) 7.2 (0-58.4) 11.2 (0-59.9) 10.3 (0-74.2) 11.8 (0-68.6) 18.4 (0-76.7) <0.001 Postoperative ileus <0.001 No 495 (86.5%) 210 (94.2%) 37 (90.2%) 126 (84.0%) 59 (83.1%) 63 (73.4%) Yes 77 (13.5%) 13 (5.8%) 4 (9.8%) 24 (16.0%) 12 (16.9%) 24 (27.6%) Anastomotic leakage 0.06 No 544 (96.5%) 219 (89.6%) 40 (97.6%) 142 (96.6%) 65 (92.9%) 78 (92.9%) Yes 20 (3.5%) 3 (1.4%) 1 (2.4%) 5 (3.4%) 5 (7.1%) 6 (7.1%) Table 3: Clinical outcome in study cohort according to CCI. LOS, length of hospitalization, median (in days); CCI, Charlson comorbidity index; ° according to Clavien–Dindo classification; * within 30 days after operation. All (n=572) CCI 0 (n=223) CCI 1 (n=41) CCI 2 (n=150) CCI 3 (n=71) CCI ≥ 4 (n=87) p-value Postop. ERAS adh.* 76.9 (15.4-100) 84.6 (23.1-100) 84.6 (25.0-100) 75.0 (15.4-100) 75.0 (23.1-100) 69.2 (16.7-100) <0.001 Postop. ERAS adh.° ≥75% 342 (59.8%) 162 (72.6%) 28 (68.3%) 78 (52.0%) 37 (52.1%) 37 (42.5%) <0.001 <75% 230 (40.2%) 61 (27.4%) 13 (31.7%) 72 (48.0%) 34 (47.9%) 50 (57.5%) Table 4: Postoperative ERAS adherence score in study cohort according to CCI. Postoperat. ERAS adh., postoperative ERAS adherence; CCI, Charlson comorbidity index; ERAS, enhanced recovery after surgery; * in %, median (range); ° number of patients. 4.4. Multivariate analysis of the postoperative ERAS protocol All patients were included in the multivariate analysis to identify predictive factors for achieving the required ERAS adherence score ≥ 75%. Based on the univariate analysis, patients were grouped according to their CCI score (CCI 0/1 vs. CCI ≥ 2). A CCI score ≥ 2, open surgical approach, and a higher index of complication were identified as negative predictors of achieving adequate postoperative ERAS adherence (Figure 3). 4.5 Proposed algorithm for preoperative risk stratification of adherence to postoperative ERAS Based on these findings, a two-step algorithm was developed for preoperative assessment of the risk of inadequate postoperative ERAS adherence (< 75%) (Figure 4). In the first step, risk assessment is based on the presence of malignancy; in the second step, patients are stratified according to their CCI score. This approach allows identification of a subgroup at elevated risk for low postoperative ERAS adherence. For internal consistency assessment, the study cohort was re-evaluated using this algorithm. A total of 106 patients (18.5%) were classified as being at elevated risk for a postoperative ERAS adherence < 75%. Their characteristics and surgical outcomes are summarized in Supplementary Tables 1 and 2. Significantly fewer patients in the elevated-risk group achieved ERAS adherence ≥ 75 % compared with the standard group (42.5% versus 63.9%; p < 0.001). In addition, the median postoperative ERAS adherence was significantly lower in the high-risk group, the hospital stay was longer, and the comprehensive complication index was higher (p < 0.001 each; Table 5). Patients with normal risk (n=466) Patients with elevated risk (n=106) p-value Postoperative ERAS adh.* 83.3 (15.4-1000) 69.2 (16.7-100) <0.001 Postoperative ERAS adh.° <0.001 ≥75% 298 (63.9%) 45 (42.5%) <75% 168 (36.1%) 61 (57.5%) LOS 7 (3-42) 9.5 (4-29) <0.001 Discharge <0.001 Home 395 (84.8%) 66 (62.3%) Other institutions 71 (15.2%) 40 (37.7%) Overall complication* <0.001 No 319 (68.5%) 51 (48.1%) Yes 147 (31.5%) 55 (51.9%) Severity of complication°° 0.3 1-3a 104 (70.7%) 35 (63.6%) 3b-4b 43 (29.3%) 20 (36.4%) Index of complications 9.1 (0-74.2) 16.9 (0-76.7) <0.001 Postoperative ileus <0.001 No 415 (89.1%) 80 (75.5%) Yes 51 (10.9%) 26 (24.5%) Anastomotic leakage 0.2 No 447 (97.0%) 97 (94.2%) Yes 14 (3.0%) 6 (5.8%) Table 5: Short-term outcome of the cohort adjusted to the proposed algorithm. Postoperat. ERAS adh., postoperative ERAS adherence; * in %, median (range); ° number of patients; LOS, length of hospitalization, median (in days); °° according to Clavien–Dindo classification; * within 30 days after operation. Discussion The present study revealed an association between higher CCI and lower postoperative adherence to the ERAS protocol. Furthermore, patients with a CCI ≥ 4 experienced significantly more postoperative complications and a longer LOS. Based on these findings, an algorithm using CCI to estimate the risk of low postoperative ERAS adherence is proposed, enabling preoperative identification of patients at risk and allowing adjustment of postoperative ERAS support. CCI is a widely accepted and well-validated comorbidity score ( 11 ). This morbidity score reflects a patient’s general medical condition and has been shown to possess superior predictive capacity compared with other preoperative risk assessment tools ( 16 ). Moreover, CCI is simple# to apply and is increasingly used as a surrogate marker of frailty—a condition of growing importance in light of demographic changes ( 17 ). In this study, the original CCI was used to assess patient comorbidities. According to the literature, several modified CCI versions exist that differ according to the diseases that are included. A crucial aspect is transparency regarding which CCI version is applied ( 18 ). The present results demonstrated that patients with a higher CCI were older. Although the CCI used in this study did not include age, age itself has previously been shown not to be an independent risk factor ( 9 ). To date, no minimum threshold value for ERAS adherence has been defined. Adherence scores above 70% -75% are generally considered sufficient to achieve the benefits of ERAS, without additional significant advantages at higher adherence levels ( 4 , 9 ). Accordingly, this study defined a postoperative ERAS adherence threshold of ≥ 75%. The focus of this study was on the postoperative ERAS phase, as adherence during this ERAS phase is typically the lowest due to less standardized protocols and therefore the greatest potential for improvement ( 8 ). During this phase, both patients and healthcare professionals play particularly active roles, which may contribute to deviations from the ERAS protocol. These findings are consistent with the ERAS elements showing the poorest adherence, namely early mobilization on postoperative days 1–3 and sufficient oral energy intake. Additionally, restrictive fluid management may still be insufficiently implemented in routine clinical practice. The reasons for these discrepancies can only be speculated upon. Even among patients with a CCI of 0, fewer than 75% met the oral energy intake criteria on the day of surgery, possibly due to the effects of anesthesia. Among patients with a CCI of ≥ 4, fewer than 75% adhered to the ERAS principles and there was generally poor adherence. In this group, two additional principles showed low adherence: timely removal of urinary drainage and weight changes on postoperative day 1. This phenomenon may reflect a reluctance to strictly adhere to ERAS recommendations in patients with a higher comorbidity burden, who may be perceived as more frail, despite current evidence indicating that age is not a risk factor for non-adherence to the ERAS program. The analysis demonstrates that patients more frequently underwent an open approach. In the multivariate analysis, the surgical approach was also identified as an independent factor, with any potential correlation statistically ruled out. Current evidence indicates that ERAS programs are effective in both minimally invasive and open surgical approaches ( 19 ). In the overall cohort, CCI ≥ 2 was identified as a risk factor for inadequate postoperative ERAS adherence (≤ 75%) in both univariate and multivariate analysis. As localized solid tumors contribute two points to the CCI, the clinically relevant cutoff for ERAS adherence is likely to depend on the underlying disease. The first step is to determine whether the disease is benign or malignant, as failing to do so would place all patients with malignant diseases at an increased risk of poor adherence to the ERAS protocol. Based on these findings identifying CCI as an independent risk factor in the overall cohort, an algorithm was proposed. As an internal consistency assessment, the algorithm was applied to the study cohort, revealing that fewer than 20% of patients were at elevated risk for postoperative ERAS adherence below 75%. This proportion represents a manageable group that could benefit from intensified perioperative care in routine clinical practice. Patients at an increased risk of non-adherence to the postoperative ERAS items should undergo intensified supervision, including more frequent involvement of specialized ERAS nursing services in collaboration with medical staff to ensure implementation of the required ERAS items. Although the algorithm requires an external cohort for robust validation, this internal consistency assessment demonstrated a significant improvement in short-term outcomes, supporting the proposed algorithm. Several limitations must be discussed in this study. The cohort includes various types of colorectal entities, which could be a potential bias, as the underlying disease may influence the general condition of the individual patients and, therefore, adherence to the ERAS program. A significant difference in the type of surgery is reflected in the study cohort and may indeed introduce a potential source of bias. Nutritional status, an important factor, is part of the preadmission ERAS items. In the study cohort, no difference could be observed in the other ERAS phase except in the postoperative ERAS period. Based on current evidence, adherence to the postoperative ERAS phase is therefore the primary determinant of achieving the benefits associated with ERAS. Furthermore, data on patients' personal medications, which may affect the postoperative course, were not available. Further, the cohort includes patients undergoing colorectal emergency surgery which can act as a potential confounder. However, current evidence supports the feasibility of the ERAS program in emergency patients ( 20 , 21 ). Nevertheless, the cohort reflects a typical colorectal patient population encountered in daily clinical practice. The proposed algorithm was developed to provide simple methods to stratify patients in a hectic daily clinical setting. Conclusions In conclusion, postoperative ERAS adherence was significantly lower in patients with higher CCI scores—associated with increased complication rates and prolonged hospital stays. The proposed algorithm enables identification of patients at risk for low postoperative ERAS adherence even before surgery. Based on this targeted risk stratification, intensified supervision of high-risk patients may improve short-term postoperative outcomes, which is particularly relevant in an ecologically sustainable healthcare system. Abbreviations The following abbreviations are used in this manuscript: ERAS Enhanced recovery after surgery CCI Charlson comorbidity index Declarations Ethics approval and consent to participate: This study was approved in November 2023 by the Ethics Committee of Northwestern and Central Switzerland (KEK-Nr. 2023-01684). All participants provided written informed consent prior to inclusion in the study. Availability of data and materials: The datasets analysed during the current study are available from the corresponding author on reasonable request. Consent for publication: Not applicable. Competing interests: None of the authors have a conflicts of interest. Funding: This research received no funding. Author Contributions: M.C., conceptualization, writing; A.T., review; O.K., review; N.K., data collection; A.H., review; R.R., conceptualization, review, and editing. Acknowledgements: Known . References Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg. 2002;183(6):630–41. Ljungqvist O, Scott M, Fearon KC. Enhanced Recovery After Surgery: A Review. JAMA Surg. 2017;152(3):292–8. Adamina M, Kehlet H, Tomlinson GA, Senagore AJ, Delaney CP. Enhanced recovery pathways optimize health outcomes and resource utilization: a meta-analysis of randomized controlled trials in colorectal surgery. Surgery. 2011;149(6):830–40. 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Krarup PM, Nordholm-Carstensen A, Jorgensen LN, Harling H. Association of Comorbidity with Anastomotic Leak, 30-day Mortality, and Length of Stay in Elective Surgery for Colonic Cancer: A Nationwide Cohort Study. Dis Colon Rectum. 2015;58(7):668–76. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373–83. Slankamenac K, Graf R, Barkun J, Puhan MA, Clavien PA. The comprehensive complication index: a novel continuous scale to measure surgical morbidity. Ann Surg. 2013;258(1):1–7. Clavien PA, Vetter D, Staiger RD, Slankamenac K, Mehra T, Graf R, Puhan MA. The Comprehensive Complication Index (CCI(R)): Added Value and Clinical Perspectives 3 Years "Down the Line". Ann Surg. 2017;265(6):1045–50. Lakomkin N, Zuckerman SL, Stannard B, Montejo J, Sussman ES, Virojanapa J, Kuzmik G, Goz V, Hadjipanayis CG, Cheng JS. Preoperative Risk Stratification in Spine Tumor Surgery: A Comparison of the Modified Charlson Index, Frailty Index, and ASA Score. Spine (Phila Pa 1976). 2019;44(13):E782–E7. Kim DH, Rockwood K. Frailty in Older Adults. N Engl J Med. 2024;391(6):538–48. Brusselaers N, Lagergren J. The Charlson Comorbidity Index in Registry-based Research. Methods Inf Med. 2017;56(5):401–6. Mohandes B, Abukar SH, Ponholzer F, Ofner D, Enodien B, Ortlieb N, Flaifel M, Frey DM, Vorburger S, Saad B, et al. The impact of ERAS protocols on postoperative outcomes in robotic, laparoscopic, and open colorectal surgery: A multicenter retrospective study. Am J Surg. 2026;251:116679. Hardcastle TC, Gaarder C, Balogh Z, D'Amours S, Davis KA, Gupta A, Mohseni S, Naess PA, Naidoo S, Razek T, et al. Guidelines for Enhanced Recovery After Trauma and Intensive Care (ERATIC): Enhanced Recovery After Surgery (ERAS) Society and International Association of Trauma Surgery and Intensive Care (IATSIC) Recommendations: Paper 1: Initial Care-Pre and Intraoperative Care Until ICU, Including Non-Operative Management. World J Surg. 2025;49(8):1997–2028. Wobith M, Strobel RM, Weimann A. Is enhanced recovery after surgery feasible, effective and well tolerated in emergency surgery and ICU? Curr Opin Clin Nutr Metab Care. 2026;29(2):177–83. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9149720","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":633672134,"identity":"890005b0-b6ad-4c66-83ac-5b43c34e548a","order_by":0,"name":"Marionna Cathomas","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0ElEQVRIiWNgGAWjYJCCAxCK+QDJWtgSoDTxOnkMiNOi23724YGPO+7IM7Cf+fzqZhtDHr98A34tZmfSDQ7OPPPMsIEnd5t1zhmGYsk2AraYHUhjOMzbdpixQYJ3m3FOBUPihmOEtJx/BtZi3yDB88w4x4AhcT9BLTcgtiQCtTA/BttCyPtmN54xHJzZdji5gSfNjDnnjETijGMJhByWxvzhY9th2wb2w48/57bZJPY3HyBgDQzYH2Bgk2BgkCBSORQwfyBN/SgYBaNgFIwUAABeXkW0qyiFTQAAAABJRU5ErkJggg==","orcid":"","institution":"Kantonsspital Baselland","correspondingAuthor":true,"prefix":"","firstName":"Marionna","middleName":"","lastName":"Cathomas","suffix":""},{"id":633672135,"identity":"ff07a187-a0d8-4ae5-8bc9-baec03346c08","order_by":1,"name":"Anas Taha","email":"","orcid":"","institution":"Kantonsspital Baselland","correspondingAuthor":false,"prefix":"","firstName":"Anas","middleName":"","lastName":"Taha","suffix":""},{"id":633672136,"identity":"ac663e34-6260-46d9-99d7-3f22ca4eae23","order_by":2,"name":"Otto Kollmar","email":"","orcid":"","institution":"Kantonsspital Baselland","correspondingAuthor":false,"prefix":"","firstName":"Otto","middleName":"","lastName":"Kollmar","suffix":""},{"id":633672137,"identity":"e6aef0e1-de28-4dd6-9409-1e08241d6811","order_by":3,"name":"Nicole Kunst","email":"","orcid":"","institution":"Kantonsspital Baselland","correspondingAuthor":false,"prefix":"","firstName":"Nicole","middleName":"","lastName":"Kunst","suffix":""},{"id":633672138,"identity":"2991a649-a708-450d-be6c-ef7035efb8b4","order_by":4,"name":"Andres Heigl","email":"","orcid":"","institution":"Kantonsspital Baselland","correspondingAuthor":false,"prefix":"","firstName":"Andres","middleName":"","lastName":"Heigl","suffix":""},{"id":633672139,"identity":"11bdf5b0-e899-4ef2-a40a-331ab7346a6c","order_by":5,"name":"Robert Rosenberg","email":"","orcid":"","institution":"Kantonsspital Baselland","correspondingAuthor":false,"prefix":"","firstName":"Robert","middleName":"","lastName":"Rosenberg","suffix":""}],"badges":[],"createdAt":"2026-03-17 13:56:37","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9149720/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9149720/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108819670,"identity":"9dd29499-a1a3-44a9-9d1a-7f14b76dfd7e","added_by":"auto","created_at":"2026-05-08 16:38:20","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":118061,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart of the study cohort.\u003c/p\u003e\n\u003cp\u003eCCI, Charlson comorbidity index; ERAS, enhanced recovery after surgery.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9149720/v1/54ab7819600ef8ad6e65acc4.png"},{"id":108820129,"identity":"23a3ceff-e2a0-4d90-b75e-6af9c60a8d80","added_by":"auto","created_at":"2026-05-08 16:40:10","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":92458,"visible":true,"origin":"","legend":"\u003cp\u003eUnivariate analysis of the postoperative ERAS adherence (in %) according to the Charlson comorbidity index. In the boxplot, the line represents the median.\u003c/p\u003e\n\u003cp\u003eERAS, enhanced recovery after surgery.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9149720/v1/72908baf92ce6eba47b4161d.png"},{"id":108819671,"identity":"7088e065-ff49-4653-b0bb-3e525a539792","added_by":"auto","created_at":"2026-05-08 16:38:20","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":159419,"visible":true,"origin":"","legend":"\u003cp\u003eMultivariate analysis to investigate independent factors for adherence to the ERAS protocol of\u003c/p\u003e\n\u003cp\u003e\u0026lt; 75%. Predictive factors were CCI ≥ 2, index of complications, and open surgical approach.\u003c/p\u003e\n\u003cp\u003eBMI, body mass index (kg/m2); \u0026nbsp;IC, index of complications; CCI, Charlson comorbidity index; \u0026nbsp;CI, confidence interval; ERAS, enhanced recovery after surgery.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-9149720/v1/a6d49b7251f735b6979df77e.png"},{"id":108819969,"identity":"a845ed1c-e6ee-4fa1-ac97-46b9a6362a10","added_by":"auto","created_at":"2026-05-08 16:39:34","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":62369,"visible":true,"origin":"","legend":"\u003cp\u003eProposal for a two-step algorithm to preoperatively stratify the risk of postoperative ERAS adherence below 75%.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-9149720/v1/feab80542aa634608b38bab0.png"},{"id":108822500,"identity":"1473b1d3-8084-40ee-ad57-a9dbcaa1a568","added_by":"auto","created_at":"2026-05-08 16:49:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":836443,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9149720/v1/e75701bd-24c7-42ad-96d9-cc730ca66ea8.pdf"},{"id":108819668,"identity":"cc2e9f3a-dde1-46f2-9665-0110e6f3f23e","added_by":"auto","created_at":"2026-05-08 16:38:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":26848,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTablesCathomasetal..pdf","url":"https://assets-eu.researchsquare.com/files/rs-9149720/v1/b0fdb4b9c36c1070d1e0dfa5.pdf"},{"id":108819669,"identity":"b9d38be8-fb6b-4db4-adba-496b2e0aef09","added_by":"auto","created_at":"2026-05-08 16:38:19","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":276011,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFiguresCathomasetal..pdf","url":"https://assets-eu.researchsquare.com/files/rs-9149720/v1/d42c2a7a0de0d19fb2be189a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Impact of Charlson Comorbidity Index (CCI) on Enhanced Recovery after Surgery (ERAS) in colorectal surgery Proposal of an algorithm to predict patients at risk for an inadequate ERAS score","fulltext":[{"header":"Introduction","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe enhanced recovery after surgery (ERAS) program was developed to reduce patients\u0026rsquo; recovery time after surgery by minimizing the perioperative stress response (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Nowadays, ERAS is a widely accepted concept in the perioperative management of patients across various surgical fields and has been shown to improve short-term outcomes (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Implementation of ERAS is associated with lower rates of postoperative complications and a shorter length of hospital stay (LOS) (\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe ERAS program divides the perioperative period into four phases, with specific principles recommended for each phase (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Adherence to these principles is measured using a point-based system, with a maximum adherence score of 100% per phase. To achieve the full clinical benefit of ERAS, an adherence score of at least 75% is required (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Previous studies have demonstrated that adherence to ERAS principles is lowest during the postoperative ERAS phase, mainly due to the high activity level required from both patients and healthcare professionals (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). However, the factors influencing adherence during the postoperative ERAS phase remain insufficiently understood, potentially leading to a suboptimal postoperative phase. In a previous study, we investigated the impact of patients\u0026acute; age on the postoperative ERAS phase. Although older age was associated with a lower postoperative ERAS adherence, age was not identified as an independent predictor (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). This highlights the need to consider additional factors, such as comorbidities, which are well known to influence the postoperative clinical course (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe aim of this study was to evaluate the predictive value of CCI with respect to postoperative ERAS adherence and its subsequent impact on the short-term clinical outcome (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Based on the results presented, an algorithm is proposed to identify patients at increased risk of inadequate postoperative ERAS adherence.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Study design\u003c/h2\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThis study is a retrospective analysis of prospectively collected ERAS data of patients undergoing colorectal resections in the Department of Surgery at Cantonal Hospital Baselland, Switzerland. Since the implementation of the ERAS program in 2016, the Department of Surgery at Cantonal Hospital Baselland has been a certified ERAS center and, since 2017, a certified colorectal cancer center. In accordance with the recommendations of the ERAS\u0026reg; Society, all ERAS-related data were prospectively recorded in an interactive ERAS audit system by a specially trained ERAS nurse. Demographic and clinical data were retrieved from the ERAS system and the patients\u0026rsquo; medical records.\u003c/p\u003e\u003cp\u003e All included patients provided written general consent. The study was approved by the Ethics Committee of Northwestern and Central Switzerland (KEK-Nr. 2023\u0026thinsp;\u0026minus;\u0026thinsp;01684).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Study population\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eAll adult patients (\u0026gt;\u0026thinsp;18 years old) undergoing colorectal resection between May 1, 2016 and October 31, 2022 at the Department of Surgery of the Cantonal Hospital Baselland, Switzerland, were eligible for inclusion. Colorectal resections were performed with primary anastomosis and/or definitive or temporary stoma. Inclusion required a postoperative ERAS dataset with less than 5% missing data. Further, no patients with chronic inflammatory bowel disease were included in the cohort.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e3.3. ERAS program and perioperative management\u003c/h2\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eAll patients were managed perioperatively according to an ERAS protocol adapted from the ERAS\u0026reg; Society guidelines (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). In this study, the postoperative ERAS phase comprised a total of 13 recommended principles (Supplementary Data Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Full adherence to all recommended principles corresponded to an adherence score of 100%. An adherence score of \u0026ge;\u0026thinsp;75%, which is recommended to achieve the full clinical benefit of ERAS, was therefore defined as sufficient adherence.\u003c/p\u003e\u003cp\u003eDuring hospitalization, all patients received low-molecular-weight heparin in a prophylactic dose and those who required full anticoagulation were fully heparinized based on the indication for anticoagulation and the bleeding risk. To enhance intestinal motility, all patients initially received magnesium orally. Subsequently, medical therapy was extended to metoclopramide, gastrographin, or neostigmine if needed. All medications were prescribed following a thorough assessment of any contraindications. The standard basic analgetic regimen was acetaminophen combined with metamizole sodium monohydrate. Additionally, patients received either patient-controlled analgesia (PCA) pumps or epidural anesthesia (PDA). When pain control after the removal of PCA and PDA was inadequate, patients were administered oxycodone in combination with naloxone during hospitalization. Upon discharge, patients were typically prescribed basic analgesic therapy. No non-steroidal anti-inflammatory drugs (NSAIDs) were administered.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e3.4. Charlson comorbidity index (CCI)\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe original CCI as described by Charlson et al., excluding age, was used in this study (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). This version includes 16 chronic diseases coded according to the International Classification of Diseases, 10th Revision (ICD-10) (Supplementary Data Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCCI was assessed retrospectively for all included patients. Patients with a CCI score of \u0026ge;\u0026thinsp;4 were grouped together for analysis.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e3.5. Outcomes and variables\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe primary endpoint was the predictive value of CCI for adherence to the postoperative ERAS phase. Secondary endpoints included the association of CCI with postoperative complications and LOS.\u003c/p\u003e \u003cp\u003eLOS was defined as the number of nights spent in hospital after surgery. Patients undergoing elective surgery were admitted one day before surgery, whereas emergency patients were admitted following presentation to the emergency department. Emergency surgery was defined according to ERAS\u0026reg; Society recommendations as surgery performed within 2 hours, within 2 to 48 hours, or more than 48 hours after emergency department assessment. These categories were summarized as emergency surgery. Emergency patients provided informed consent on postoperative day 1, while all other patients provided consent during the preoperative consultation.\u003c/p\u003e \u003cp\u003eConversions from minimally invasive to open procedures were classified as open surgery. Postoperative complications, defined as any medical or surgical deviation from the normal postoperative course, were classified according to the Clavien\u0026ndash;Dindo classification and summarized as the complication index (IC) (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Postoperative ileus was defined as impaired gastrointestinal motility requiring a nasogastric tube placement. Anastomotic leakage was either confirmed using reoperation or endoscopic intervention or diagnosed based on documented extraluminal air or contrast leakage adjacent to the anastomosis. All complications occurring within 30 days after operation were included. The American Society of Anesthesiologists (ASA) scores were grouped as I/II and III/IV.\u003c/p\u003e \u003cp\u003eFurthermore, the predictive value of postoperative ERAS adherence was evaluated in a multivariate analysis including all patients. An ERAS adherence score of \u0026ge;\u0026thinsp;75% was defined as sufficient.\u003c/p\u003e \u003cp\u003eIn addition, adherence to the individual postoperative ERAS items was analyzed. Poor adherence was defined as fulfillment of a given item in fewer than 75% of patients.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3.6. Statistical analysis\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eStatistical analyses were performed using the statistical program R (version 4.1.2). Descriptive and univariate analyses were conducted using Student\u0026rsquo;s t test and the Mann\u0026ndash;Whitney U test for normally and non-normally distributed continuous variables, respectively, and the results are presented as medians. Categorical variables were analyzed using the chi-square test, multivariable analysis was performed using binary regression, and the results are reported as odds ratios (ORs), with OR\u0026thinsp;\u0026lt;\u0026thinsp;1 considered as an independent factor. Parameters identified as independent factors were additionally assessed for multicollinearity to statistically evaluate and exclude any potential correlations. Statistical significance was defined as p\u0026thinsp;\u0026le;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003e4.1. Patient characteristics\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003eDuring the 6-year study period, a total of 608 patients underwent colorectal surgery with perioperative care according to the ERAS protocol. During the exclusion process, 36 (5.9%) patients were excluded based on the predefined criteria (Figure 1). The remaining 572 (94.1%) were included in the final analysis and stratified into five groups according to their CCI score (CCI 0 n=223 [39.0%], CCI 1: n=41 [7.2%], CCI 2: n=150 [26.2%], CCI 3: n=71 [12.4%], CCI \u0026ge; 4: n=87 [15.2%]; Figure 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePatient characteristics are summarized in Table 1. The median age in the CCI \u0026ge; 4 patient group was significantly higher than in the CCI 0 group (CCI 0: 61 [range 18-89] years vs. CCI \u0026ge; 4: 74 [range 49-88] years). There were more male patients in the CCI \u0026ge; 4 group with significantly higher ASA scores III/IV (CCI 0: 49 [22.0%] patients vs. CCI \u0026ge; 4: 80 [92.0%] patients; p\u0026lt;0.001). Regarding the CCI score, patients received two points for localized solid tumors. Therefore, the patients in CCI groups 0 and 1 had only non-malignant underlying diseases. Consequently, the presence of malignancies differed significantly among the CCI groups (p\u0026lt;0.001).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e4.2. Surgical data and clinical outcome\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn the CCI 0 patient group, significantly more patients underwent emergency intervention (p=0.04) and received minimally invasive treatments (p\u0026lt;0.001). Among patients with a CCI of 0, sigmoid resections were most commonly performed (n=192 [86.1%]), whereas anterior resections were the most frequent surgical procedures in patients with a CCI \u0026ge; 4 (n=33 [37.9%]) (Table 2). The median blood loss and duration of surgery differed significantly among the groups (both p\u0026lt;0.001). The median LOS increased with higher CCI scores (6 days [range 3-21] in the CCI 0 group vs. 11 days [range 5-29] in the CCI \u0026ge; 4 group; p \u0026lt; 0.001; Table 2). Significantly more patients with a CCI \u0026ge; 4 were discharged to other healthcare facilities (p \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003eThe overall complication rates increased with higher CCI scores (p \u0026lt; 0.001). Furthermore, patients with a CCI \u0026ge; 4 experienced significantly more \u0026gt;3a complications according to the Clavien\u0026ndash;Dindo classification and, consequently, had a higher index of complication (p \u0026lt; 0.001 each, Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e4.3. Adherence of the postoperative ERAS protocol\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn the univariate analysis of the study cohort, significantly fewer patients with a CCI \u0026ge; 4 achieved the required postoperative ERAS adherence score of \u0026ge; 75% necessary to obtain a clinical benefit (CCI 0: 162 patients [72.6%] vs. 37 patients [42.5%]; p\u0026lt;0.001; Table 4). The median postoperative ERAS adherence score, expressed as a percentage, decreased significantly with increasing CCI scores (84.6 % [range 23.1-100] in patients with CCI 0 vs. 69.2 % [range 16.7-100] in patients with CCI \u0026ge; 4; p\u0026lt;0.001; Table 3). When comparing group medians, a marked decrease in adherence was observed between patients with CCI scores of 1 and 2, respectively (Figure 2). A detailed analysis identified seven items with particularly low adherence: mobilization on postoperative days 1 \u0026ndash; 3, oral energy intake on day of surgery and postoperative day 1, duration of intravenous fluid infusion, and balanced fluid on the day of surgery (Supplementary Data Figure 3).\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"671\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAll\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=572)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCCI 0\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=223)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCCI 1\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=41)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCCI 2\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=150)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCCI 3\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=71)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCCI \u0026ge; 4\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=87)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e66.2 (18-93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e61 (18-89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e71 (37-87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e68 (24-92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e74 (46-93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e74 (49-88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e26.1 (12.1-45.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e26.4 (16.6-45.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e26.7 (18.6-40.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e25.8 (17.8-39.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e26.7 (12.1-38.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e25 (17.3-40.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender (male)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e289 (52.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e99 (44.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e16 (39.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e77 (51.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e50 (70.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e56 (64.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eASA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e1+2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e227 (39.37%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e174 (78.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e20 (48.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e21 (14.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e5 (7.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e7 (8.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e3+4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e345 (60.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e49 (22.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e21 (51.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e129 (86.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e66 (93.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e80 (92.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTumor type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eBenign\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e283 (49.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e223 (78.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e41 (14.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e11 (3.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e8 (2.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eMalignant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e289 (50.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e139 (48.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e63 (21.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e87 (30.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 1: Patient characteristics of the study cohort in accordance with the CCI.\u003c/p\u003e\n\u003cp\u003eAge, median; BMI, body mass index (kg/m2), median; ASA, American Society of Anesthesiologists score.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"723\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 203px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAll\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=572)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCCI 0\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=223)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCCI 1\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=41)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCCI 2\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=150)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCCI 3\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=71)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCCI \u0026ge; 4\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=87)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 203px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 203px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgery scheduling type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 203px;\"\u003e\n \u003cp\u003eElective\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e509 (89.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e187 (83.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e37 (90.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e140 (93.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e65 (91.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e80 (92.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 203px;\"\u003e\n \u003cp\u003eEmergency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e63 (11.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e36 (16.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e4 (9.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e10 (6.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e6 (8.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e7 (8.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 203px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 203px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgical approach\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 203px;\"\u003e\n \u003cp\u003eOpen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e131 (22.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e23 (10.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e4 (9.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e40 (26.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e27 (38.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e37 (42.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 203px;\"\u003e\n \u003cp\u003eLaparoscopic/robotic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e441 (77.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e200 (89.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e37 (90.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e110 (73.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e44 (62.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e50 (57.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 203px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 203px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgical procedure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 203px;\"\u003e\n \u003cp\u003eRight hemicolectomy/ileocecal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e132 (23.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e16 (7.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e5 (12.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e54 (36.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e29 (40.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e28 (32.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 203px;\"\u003e\n \u003cp\u003eLeft hemicolectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e35 (6.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e6 (2.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e1 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e9 (6.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e8 (11.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e11 (12.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 203px;\"\u003e\n \u003cp\u003eSigmoid resection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e289 (50.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e192 (86.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e34 (82.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e36 (24.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e15 (21.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e12 (13.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 203px;\"\u003e\n \u003cp\u003eAnterior resection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e101 (17.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e5 (2.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e1 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e44 (29.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e18 (25.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e33 (37.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 203px;\"\u003e\n \u003cp\u003eAbdominoperineal resection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e5 (0.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e1 (0.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e3 (2.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e1 (1.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 203px;\"\u003e\n \u003cp\u003eTotal/subtotal colectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e10 (1.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e3 (1.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e4 (2.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e1 (1.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e2 (2.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 203px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 203px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBlood loss (ml, median)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e50 (0-3000)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e20 (0-700)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e50 (5-250)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e37.5 (0-1800)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e50 (0-800)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e50 (0-3000)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 203px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 203px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration of the surgical procedure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e200 (80-500)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e180 (80-470)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e185 (90-360)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e211 (100-480)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e225 (100-486)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e240 (90-500)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 2:\u0026nbsp;Surgical outcome in study cohort according to CCI.\u003c/p\u003e\n\u003cp\u003eOpen surgical approach including conversion from minimally invasive to open; CCI, Charlson comorbidity index.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"704\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAll\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=572)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCCI 0 (n=223)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCCI 1\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=41)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCCI 2 (n=150)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCCI 3\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=71)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCCI \u0026ge; 4 (n=87)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLOS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e8.7 (3-42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e6 (3-21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e7 (5-28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e7.5 (3-27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e7 (5-42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e11 (5-29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDischarge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eHome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e461 (80.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e207 (92.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e40 (97.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e116 (77.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e46 (64.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e52 (59.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eOther institutions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e111 (19.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e16 (7.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e34 (22.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e25 (35.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e35 (40.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall complications*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e370 (64.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e165 (74.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e27 (65.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e97 (64.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e41 (57.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e40 (46.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e202 (35.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e58 (26.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e14 (34.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e53 (35.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e30 (42.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e47 (54.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeverity of complications\u0026deg;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e1-3a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e140 (24.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e39 (17.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e6 (14.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e44 (29.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e23 (32.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e28 (32.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e3b-4b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e64 (11.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e19 (8.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e8 (19.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e9 (6.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e7 (9.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e19 (21.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIndex of complications\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e10.6 (0-76.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e7.2 (0-58.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e11.2 (0-59.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e10.3 (0-74.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e11.8 (0-68.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e18.4 (0-76.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative ileus\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e495 (86.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e210 (94.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e37 (90.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e126 (84.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e59 (83.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e63 (73.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e77 (13.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e13 (5.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4 (9.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e24 (16.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e12 (16.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e24 (27.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnastomotic leakage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e544 (96.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e219 (89.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e40 (97.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e142 (96.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e65 (92.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e78 (92.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e20 (3.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e3 (1.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e5 (3.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e5 (7.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e6 (7.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 3: Clinical outcome in study cohort according to CCI.\u003c/p\u003e\n\u003cp\u003eLOS, length of hospitalization, median (in days); CCI, Charlson comorbidity index;\u003c/p\u003e\n\u003cp\u003e\u0026deg; according to Clavien\u0026ndash;Dindo classification; * within 30 days after operation.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"718\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAll\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=572)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCCI 0\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;(n=223)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCCI 1\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;(n=41)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCCI 2\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=150)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCCI 3\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=71)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCCI \u0026ge; 4\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=87)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostop. ERAS adh.*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e76.9 (15.4-100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e84.6 (23.1-100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e84.6 (25.0-100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e75.0 (15.4-100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e75.0 (23.1-100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e69.2 (16.7-100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostop. ERAS adh.\u0026deg;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e\u0026ge;75%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e342 (59.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e162 (72.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e28 (68.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e78 (52.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e37 (52.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e37 (42.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e\u0026lt;75%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e230 (40.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e61 (27.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e13 (31.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e72 (48.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e34 (47.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e50 (57.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 4: Postoperative ERAS adherence score in study cohort according to CCI.\u003c/p\u003e\n\u003cp\u003ePostoperat. ERAS adh., postoperative ERAS adherence; CCI, Charlson comorbidity index; ERAS, enhanced recovery after surgery; * in %, median (range); \u0026deg; number of patients.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e4.4. Multivariate analysis of the postoperative ERAS protocol\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll patients were included in the multivariate analysis to identify predictive factors for achieving the required ERAS adherence score \u0026ge; 75%. Based on the univariate analysis, patients were grouped according to their CCI score (CCI 0/1 vs. CCI \u0026ge; 2). A CCI score \u0026ge; 2, open surgical approach, and a higher index of complication were identified as negative predictors of achieving adequate postoperative ERAS adherence (Figure 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e4.5 Proposed algorithm for preoperative risk stratification of adherence to postoperative ERAS\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBased on these findings, a two-step algorithm was developed for preoperative assessment of the risk of inadequate postoperative ERAS adherence (\u0026lt; 75%) (Figure 4). In the first step, risk assessment is based on the presence of malignancy; in the second step, patients are stratified according to their CCI score. This approach allows identification of a subgroup at elevated risk for low postoperative ERAS adherence.\u003c/p\u003e\n\u003cp\u003eFor internal consistency assessment, the study cohort was re-evaluated using this algorithm. A total of 106 patients (18.5%) were classified as being at elevated risk for a postoperative ERAS adherence \u0026lt; 75%. Their characteristics and surgical outcomes are summarized in Supplementary Tables 1 and 2. Significantly fewer patients in the elevated-risk group achieved ERAS adherence \u0026ge; 75 % compared with the standard group (42.5% versus 63.9%; p \u0026lt; 0.001). In addition, the median postoperative ERAS adherence was significantly lower in the high-risk group, the hospital stay was longer, and the comprehensive complication index was higher (p \u0026lt; 0.001 each; Table 5).\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"719\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 30.4954%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.1146%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatients with normal risk\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=466)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.1022%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatients with elevated risk\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=106)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2879%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 30.4954%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative ERAS adh.*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.1146%;\"\u003e\n \u003cp\u003e83.3 (15.4-1000)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.1022%;\"\u003e\n \u003cp\u003e69.2 (16.7-100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2879%;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 30.4954%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.1146%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.1022%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2879%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 30.4954%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative ERAS adh.\u0026deg;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.1146%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.1022%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2879%;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 30.4954%;\"\u003e\n \u003cp\u003e\u0026ge;75%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.1146%;\"\u003e\n \u003cp\u003e298 (63.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.1022%;\"\u003e\n \u003cp\u003e45 (42.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2879%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 30.4954%;\"\u003e\n \u003cp\u003e\u0026lt;75%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.1146%;\"\u003e\n \u003cp\u003e168 (36.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.1022%;\"\u003e\n \u003cp\u003e61 (57.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2879%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 30.4954%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.1146%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.1022%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2879%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 30.4954%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLOS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.1146%;\"\u003e\n \u003cp\u003e7 (3-42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.1022%;\"\u003e\n \u003cp\u003e9.5 (4-29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2879%;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 30.4954%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.1146%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.1022%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2879%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 30.4954%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDischarge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.1146%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.1022%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2879%;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 30.4954%;\"\u003e\n \u003cp\u003eHome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.1146%;\"\u003e\n \u003cp\u003e395 (84.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.1022%;\"\u003e\n \u003cp\u003e66 (62.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2879%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 30.4954%;\"\u003e\n \u003cp\u003eOther institutions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.1146%;\"\u003e\n \u003cp\u003e71 (15.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.1022%;\"\u003e\n \u003cp\u003e40 (37.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2879%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 30.4954%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.1146%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.1022%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2879%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 30.4954%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall complication*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.1146%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.1022%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2879%;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 30.4954%;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.1146%;\"\u003e\n \u003cp\u003e319 (68.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.1022%;\"\u003e\n \u003cp\u003e51 (48.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2879%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 30.4954%;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.1146%;\"\u003e\n \u003cp\u003e147 (31.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.1022%;\"\u003e\n \u003cp\u003e55 (51.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2879%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 30.4954%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.1146%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.1022%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2879%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 30.4954%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeverity of complication\u0026deg;\u0026deg;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.1146%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.1022%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2879%;\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 30.4954%;\"\u003e\n \u003cp\u003e1-3a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.1146%;\"\u003e\n \u003cp\u003e104 (70.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.1022%;\"\u003e\n \u003cp\u003e35 (63.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2879%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 30.4954%;\"\u003e\n \u003cp\u003e3b-4b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.1146%;\"\u003e\n \u003cp\u003e43 (29.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.1022%;\"\u003e\n \u003cp\u003e20 (36.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2879%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 30.4954%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.1146%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.1022%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2879%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 30.4954%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIndex of complications\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.1146%;\"\u003e\n \u003cp\u003e9.1 (0-74.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.1022%;\"\u003e\n \u003cp\u003e16.9 (0-76.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2879%;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 30.4954%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.1146%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.1022%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2879%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 30.4954%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative ileus\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.1146%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.1022%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2879%;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 30.4954%;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.1146%;\"\u003e\n \u003cp\u003e415 (89.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.1022%;\"\u003e\n \u003cp\u003e80 (75.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2879%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 30.4954%;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.1146%;\"\u003e\n \u003cp\u003e51 (10.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.1022%;\"\u003e\n \u003cp\u003e26 (24.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2879%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 30.4954%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.1146%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.1022%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2879%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 30.4954%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnastomotic leakage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.1146%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.1022%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2879%;\"\u003e\n \u003cp\u003e0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 30.4954%;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.1146%;\"\u003e\n \u003cp\u003e447 (97.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.1022%;\"\u003e\n \u003cp\u003e97 (94.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2879%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 30.4954%;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.1146%;\"\u003e\n \u003cp\u003e14 (3.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.1022%;\"\u003e\n \u003cp\u003e6 (5.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2879%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 5:\u0026nbsp;Short-term outcome of the cohort adjusted to the proposed algorithm.\u003c/p\u003e\n\u003cp\u003ePostoperat. ERAS adh., postoperative ERAS adherence; * in %, median (range); \u0026deg; number of patients; LOS, length of hospitalization, median (in days); \u0026deg;\u0026deg; according to Clavien\u0026ndash;Dindo classification; * within 30 days after operation.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe present study revealed an association between higher CCI and lower postoperative adherence to the ERAS protocol. Furthermore, patients with a CCI\u0026thinsp;\u0026ge;\u0026thinsp;4 experienced significantly more postoperative complications and a longer LOS. Based on these findings, an algorithm using CCI to estimate the risk of low postoperative ERAS adherence is proposed, enabling preoperative identification of patients at risk and allowing adjustment of postoperative ERAS support.\u003c/p\u003e \u003cp\u003eCCI is a widely accepted and well-validated comorbidity score (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). This morbidity score reflects a patient\u0026rsquo;s general medical condition and has been shown to possess superior predictive capacity compared with other preoperative risk assessment tools (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Moreover, CCI is simple# to apply and is increasingly used as a surrogate marker of frailty\u0026mdash;a condition of growing importance in light of demographic changes (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn this study, the original CCI was used to assess patient comorbidities. According to the literature, several modified CCI versions exist that differ according to the diseases that are included. A crucial aspect is transparency regarding which CCI version is applied (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). The present results demonstrated that patients with a higher CCI were older. Although the CCI used in this study did not include age, age itself has previously been shown not to be an independent risk factor (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo date, no minimum threshold value for ERAS adherence has been defined. Adherence scores above 70% -75% are generally considered sufficient to achieve the benefits of ERAS, without additional significant advantages at higher adherence levels (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Accordingly, this study defined a postoperative ERAS adherence threshold of \u0026ge;\u0026thinsp;75%.\u003c/p\u003e \u003cp\u003eThe focus of this study was on the postoperative ERAS phase, as adherence during this ERAS phase is typically the lowest due to less standardized protocols and therefore the greatest potential for improvement (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). During this phase, both patients and healthcare professionals play particularly active roles, which may contribute to deviations from the ERAS protocol. These findings are consistent with the ERAS elements showing the poorest adherence, namely early mobilization on postoperative days 1\u0026ndash;3 and sufficient oral energy intake. Additionally, restrictive fluid management may still be insufficiently implemented in routine clinical practice. The reasons for these discrepancies can only be speculated upon. Even among patients with a CCI of 0, fewer than 75% met the oral energy intake criteria on the day of surgery, possibly due to the effects of anesthesia. Among patients with a CCI of \u0026ge;\u0026thinsp;4, fewer than 75% adhered to the ERAS principles and there was generally poor adherence. In this group, two additional principles showed low adherence: timely removal of urinary drainage and weight changes on postoperative day 1. This phenomenon may reflect a reluctance to strictly adhere to ERAS recommendations in patients with a higher comorbidity burden, who may be perceived as more frail, despite current evidence indicating that age is not a risk factor for non-adherence to the ERAS program.\u003c/p\u003e \u003cp\u003eThe analysis demonstrates that patients more frequently underwent an open approach. In the multivariate analysis, the surgical approach was also identified as an independent factor, with any potential correlation statistically ruled out. Current evidence indicates that ERAS programs are effective in both minimally invasive and open surgical approaches (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the overall cohort, CCI\u0026thinsp;\u0026ge;\u0026thinsp;2 was identified as a risk factor for inadequate postoperative ERAS adherence (\u0026le;\u0026thinsp;75%) in both univariate and multivariate analysis. As localized solid tumors contribute two points to the CCI, the clinically relevant cutoff for ERAS adherence is likely to depend on the underlying disease. The first step is to determine whether the disease is benign or malignant, as failing to do so would place all patients with malignant diseases at an increased risk of poor adherence to the ERAS protocol. Based on these findings identifying CCI as an independent risk factor in the overall cohort, an algorithm was proposed. As an internal consistency assessment, the algorithm was applied to the study cohort, revealing that fewer than 20% of patients were at elevated risk for postoperative ERAS adherence below 75%. This proportion represents a manageable group that could benefit from intensified perioperative care in routine clinical practice. Patients at an increased risk of non-adherence to the postoperative ERAS items should undergo intensified supervision, including more frequent involvement of specialized ERAS nursing services in collaboration with medical staff to ensure implementation of the required ERAS items. Although the algorithm requires an external cohort for robust validation, this internal consistency assessment demonstrated a significant improvement in short-term outcomes, supporting the proposed algorithm.\u003c/p\u003e \u003cp\u003eSeveral limitations must be discussed in this study. The cohort includes various types of colorectal entities, which could be a potential bias, as the underlying disease may influence the general condition of the individual patients and, therefore, adherence to the ERAS program. A significant difference in the type of surgery is reflected in the study cohort and may indeed introduce a potential source of bias. Nutritional status, an important factor, is part of the preadmission ERAS items. In the study cohort, no difference could be observed in the other ERAS phase except in the postoperative ERAS period. Based on current evidence, adherence to the postoperative ERAS phase is therefore the primary determinant of achieving the benefits associated with ERAS. Furthermore, data on patients' personal medications, which may affect the postoperative course, were not available. Further, the cohort includes patients undergoing colorectal emergency surgery which can act as a potential confounder. However, current evidence supports the feasibility of the ERAS program in emergency patients (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Nevertheless, the cohort reflects a typical colorectal patient population encountered in daily clinical practice. The proposed algorithm was developed to provide simple methods to stratify patients in a hectic daily clinical setting.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eIn conclusion, postoperative ERAS adherence was significantly lower in patients with higher CCI scores\u0026mdash;associated with increased complication rates and prolonged hospital stays. The proposed algorithm enables identification of patients at risk for low postoperative ERAS adherence even before surgery. Based on this targeted risk stratification, intensified supervision of high-risk patients may improve short-term postoperative outcomes, which is particularly relevant in an ecologically sustainable healthcare system.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eThe following abbreviations are used in this manuscript:\u003c/p\u003e\n\u003cp\u003eERAS \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Enhanced recovery after surgery\u003c/p\u003e\n\u003cp\u003eCCI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Charlson comorbidity index\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eThis study was approved in November 2023 by the Ethics Committee of Northwestern and Central Switzerland (KEK-Nr. 2023-01684). All participants provided written informed consent prior to inclusion in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe datasets analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eNone of the authors have a conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This research received no funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u0026nbsp;\u003c/strong\u003eM.C., conceptualization, writing; A.T., review; O.K., review; N.K., data collection; A.H., review; R.R., conceptualization, review, and editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eKnown\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eKehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg. 2002;183(6):630\u0026ndash;41.\u003c/li\u003e\n \u003cli\u003eLjungqvist O, Scott M, Fearon KC. Enhanced Recovery After Surgery: A Review. JAMA Surg. 2017;152(3):292\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003eAdamina M, Kehlet H, Tomlinson GA, Senagore AJ, Delaney CP. Enhanced recovery pathways optimize health outcomes and resource utilization: a meta-analysis of randomized controlled trials in colorectal surgery. Surgery. 2011;149(6):830\u0026ndash;40.\u003c/li\u003e\n \u003cli\u003eGillissen F, Hoff C, Maessen JM, Winkens B, Teeuwen JH, von Meyenfeldt MF, Dejong CH. Structured synchronous implementation of an enhanced recovery program in elective colonic surgery in 33 hospitals in The Netherlands. World J Surg. 2013;37(5):1082\u0026ndash;93.\u003c/li\u003e\n \u003cli\u003eGustafsson UO, Rockall TA, Wexner S, How KY, Emile S, Marchuk A, Fawcett WJ, Sioson M, Riedel B, Chahal R, et al. Guidelines for perioperative care in elective colorectal surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations 2025. Surgery. 2025;184:109397.\u003c/li\u003e\n \u003cli\u003eMilone M, Elmore U, Manigrasso M, Ortenzi M, Botteri E, Arezzo A, Silecchia G, Guerrieri M, De Palma GD, Agresta F, et al. ERas and COLorectal endoscopic surgery: an Italian society for endoscopic surgery and new technologies (SICE) national report. Surg Endosc. 2022;36(10):7619\u0026ndash;27.\u003c/li\u003e\n \u003cli\u003eRoulin D, Muradbegovic M, Addor V, Blanc C, Demartines N, Hubner M. Enhanced Recovery after Elective Colorectal Surgery - Reasons for Non-Compliance with the Protocol. Dig Surg. 2017;34(3):220\u0026ndash;6.\u003c/li\u003e\n \u003cli\u003eAyinde BO, Chokshi P, Adhikari S, Jaimalani A, Yeritsyan A, Surve AV, Khan S. Challenges and Elements Hindering the Adoption of Enhanced Recovery After Surgery (ERAS) Protocols in Colorectal Surgery and Their Resolutions: A Systematic Review. Cureus. 2024;16(6):e63222.\u003c/li\u003e\n \u003cli\u003eCathomas M, Taha A, Kunst N, Burri E, Vetter M, Galli R, Rosenberg R, Heigl A. Adherence to enhanced recovery after surgery (ERAS) in older adults following colorectal resection. J Geriatr Oncol. 2024;15(8):102062.\u003c/li\u003e\n \u003cli\u003eSchlager L, Monschein M, Schuller J, Bergmann M, Krall C, Razek P, Stift A, Unger LW. The predictive value of comorbidities on postoperative complication rates and overall survival in left-sided oncological colorectal resections: a multicentre cohort study. Int J Surg. 2023;109(12):4113\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003eCharlson ME, Carrozzino D, Guidi J, Patierno C. Charlson Comorbidity Index: A Critical Review of Clinimetric Properties. Psychother Psychosom. 2022;91(1):8\u0026ndash;35.\u003c/li\u003e\n \u003cli\u003eKrarup PM, Nordholm-Carstensen A, Jorgensen LN, Harling H. Association of Comorbidity with Anastomotic Leak, 30-day Mortality, and Length of Stay in Elective Surgery for Colonic Cancer: A Nationwide Cohort Study. Dis Colon Rectum. 2015;58(7):668\u0026ndash;76.\u003c/li\u003e\n \u003cli\u003eCharlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373\u0026ndash;83.\u003c/li\u003e\n \u003cli\u003eSlankamenac K, Graf R, Barkun J, Puhan MA, Clavien PA. The comprehensive complication index: a novel continuous scale to measure surgical morbidity. Ann Surg. 2013;258(1):1\u0026ndash;7.\u003c/li\u003e\n \u003cli\u003eClavien PA, Vetter D, Staiger RD, Slankamenac K, Mehra T, Graf R, Puhan MA. The Comprehensive Complication Index (CCI(R)): Added Value and Clinical Perspectives 3 Years \u0026quot;Down the Line\u0026quot;. Ann Surg. 2017;265(6):1045\u0026ndash;50.\u003c/li\u003e\n \u003cli\u003eLakomkin N, Zuckerman SL, Stannard B, Montejo J, Sussman ES, Virojanapa J, Kuzmik G, Goz V, Hadjipanayis CG, Cheng JS. Preoperative Risk Stratification in Spine Tumor Surgery: A Comparison of the Modified Charlson Index, Frailty Index, and ASA Score. Spine (Phila Pa 1976). 2019;44(13):E782\u0026ndash;E7.\u003c/li\u003e\n \u003cli\u003eKim DH, Rockwood K. Frailty in Older Adults. N Engl J Med. 2024;391(6):538\u0026ndash;48.\u003c/li\u003e\n \u003cli\u003eBrusselaers N, Lagergren J. The Charlson Comorbidity Index in Registry-based Research. Methods Inf Med. 2017;56(5):401\u0026ndash;6.\u003c/li\u003e\n \u003cli\u003eMohandes B, Abukar SH, Ponholzer F, Ofner D, Enodien B, Ortlieb N, Flaifel M, Frey DM, Vorburger S, Saad B, et al. The impact of ERAS protocols on postoperative outcomes in robotic, laparoscopic, and open colorectal surgery: A multicenter retrospective study. Am J Surg. 2026;251:116679.\u003c/li\u003e\n \u003cli\u003eHardcastle TC, Gaarder C, Balogh Z, D\u0026apos;Amours S, Davis KA, Gupta A, Mohseni S, Naess PA, Naidoo S, Razek T, et al. Guidelines for Enhanced Recovery After Trauma and Intensive Care (ERATIC): Enhanced Recovery After Surgery (ERAS) Society and International Association of Trauma Surgery and Intensive Care (IATSIC) Recommendations: Paper 1: Initial Care-Pre and Intraoperative Care Until ICU, Including Non-Operative Management. World J Surg. 2025;49(8):1997\u0026ndash;2028.\u003c/li\u003e\n \u003cli\u003eWobith M, Strobel RM, Weimann A. Is enhanced recovery after surgery feasible, effective and well tolerated in emergency surgery and ICU? Curr Opin Clin Nutr Metab Care. 2026;29(2):177\u0026ndash;83.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Enhanced recovery after surgery (ERAS), colorectal surgery, Charlson Comorbidity Index","lastPublishedDoi":"10.21203/rs.3.rs-9149720/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9149720/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction: \u003c/strong\u003eEnhanced recovery after surgery (ERAS) is a widely accepted program aimed at improving short-term outcomes in patients undergoing colorectal surgery. To achieve good postoperative outcomes, adherence of at least 75% to ERAS principles is required, which is particularly challenging during the postoperative period.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e Patients undergoing colorectal resection between May 2016 and October 2022 were prospectively enrolled in the ERAS protocol and stratified according to the retrospectively assessed CCI. Patients with ≥ 5% missing data were excluded. The primary outcome of this study was to evaluate the predictive value of patients’ comorbidities, summarized using the Charlson comorbidity index (CCI), with regard to postoperative ERAS adherence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eA total of 572 patients were included (CCI 0: 223 [39.0%], CCI 1: 41 [7.2%], CCI 2: 150 [26.2%], CCI 3: 71 [12.4%], CCI ≥ 4: 87 [15.2%]). Patients with a CCI score of 0 had a median postoperative ERAS adherence of 84.6% (range: 15.4-100) compared with 69.2% (range: 16.7-100) in patients with a CCI score of ≥ 4 (p\u0026lt;0.001). Increasing CCI was significantly associated with a higher complication index (p\u0026lt;0.001) and a longer length of hospitalization stay (p\u0026lt;0.001). In the multivariate analysis, CCI ≥2 was an independent predictor of low adherence to the ERAS protocol.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eIn line with these findings, adaptation of ERAS protocols according to the preoperatively assessed CCI may improve short-term postoperative outcomes. Therefore, a CCI-based algorithm is proposed.\u003c/p\u003e","manuscriptTitle":"Impact of Charlson Comorbidity Index (CCI) on Enhanced Recovery after Surgery (ERAS) in colorectal surgery Proposal of an algorithm to predict patients at risk for an inadequate ERAS score","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-08 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