Nursing-led enhanced recovery bundled care in colorectal cancer surgery: a systematic review and meta-analysis

Introduction

Enhanced Recovery After Surgery (ERAS) represents an evidence-based model of perioperative care, of which its goal is to reduce the physiologic stress of surgery and hasten recovery (1,2). ERAS was initially implemented as so-called fast-track protocols in colorectal surgery, but it has been widely appliedin most surgical specialties (1,3). ERAS protocols are multifaceted and multi-disciplinary, including patient preoperative optimization (patients education, nutritional support, minimum fasting), intraoperative anaesthesia/analgesia optimization, and proactive postoperative rehabilitation (early mobilisation, early oral feeding, effective pain management) (1,2,4). Taken together these interventions reduce the surgical stress response, complications and accelerate bouncing back to work (1,2). ERAS pathways have been found to provide some improvements to the surgery of colorectal cancer: many studies show shorter time of stay (sometimes as much as 2–3 days) and reduced incidences of postoperative complications (e.g., infections, ileus) in comparison with standard care (2,5,6). ERAS patients also have quicker gastrointestinal recovery (earlier bowel recovery). More importantly, it has been shown that these short-term gains are obtained without the expenses of increased readmission rates and mortality (5,6). High adherence to ERAS measures has been linked to positive outcomes, and even some studies state that there are likely to be better long-term survival among colorectal cancer patients when ERAS has been administered, presumed to be due to a decrease in complication-related death and the timely administration of adjuvant therapies (7,8).

Although the effectiveness of ERAS is not in question, its implementation needs a combined teamwork of a multidisciplinary team. Specifically, the role of a nurse is the key to ERAS implementation and compliance. ERAS nurses also coordinate numerous aspects of day-to-day protocols, they engage in extensive preoperative counselling, further patient education, observe early mobilization and feeding, and make sure that the analgesia and other orders are adhered to those applied on the ward (9,10). Compliance audits and quality improvement programs of ERAS are also commonly led by nurses. An enhanced recovery bundled care (ERBC) approach that is led or coordinated by nurses builds upon this important positioning through a more explicit organizational role for perioperative nursing across the patient pathway. In such models, nurses may coordinate preoperative education, reinforce mobilization and nutritional milestones during inpatient recovery, monitor recovery targets proactively, support discharge planning, and, when reported, provide post-discharge follow-up. These functions may improve protocol fidelity, continuity of care, and early recognition of deviation from expected recovery. It is hypothesized that nurse-led ERAS may therefore be associated with measurable differences in length of stay (LOS), complications, and readmission in colorectal cancer surgery, where patient preparation, symptom monitoring, and discharge readiness are especially relevant (9-13).

To date, several systematic reviews and meta-analyses have evaluated ERAS in colorectal surgery (3,5,6). These analyses consistently show shorter LOS and fewer complications without higher readmission rates. However, they have not specifically examined ERAS as a model with explicitly described nursing leadership or nursing-coordinated delivery. This distinction matters because ERAS protocols are implemented at the bedside, and the degree to which education, milestone reinforcement, discharge coordination, and follow-up are structured may plausibly affect outcomes. An updated synthesis is therefore needed to evaluate whether ERAS pathways with identifiable nursing leadership or coordination are associated with measurable differences in colorectal cancer surgery outcomes.

Objectives

We conducted a systematic review and meta-analysis of studies published in the past 10 years that examine nursing-led ERAS (ERBC) in colorectal cancer surgery. The primary outcomes of interest were postoperative length of hospital stay, all-cause 30-day readmission rate, and overall postoperative complication rate. We also evaluated 30-day postoperative mortality and any reported long-term outcomes [e.g., overall survival (OS) or cancer prognosis] to explore whether ERAS confers any survival benefit. Our goal was to provide high-level evidence on the effectiveness of ERAS/ERBC pathways in colorectal cancer surgery, implemented with significant nursing leadership. We present this article in accordance with the PRISMA reporting checklist (14) (available at https://jgo.amegroups.com/article/view/10.21037/jgo-2026-1-0025/rc).

Methods

Protocol and registration

A protocol for this review was not prospectively registered in PROSPERO or any other registry. The eligibility criteria, outcomes, and analysis plan were predefined by the review team before screening and data extraction began.

Eligibility criteria

Population

Adult patients (≥18 years) undergoing colorectal cancer surgery (elective or emergency). Studies had to specifically involve colorectal resections for malignancy (colon or rectal cancer) or report a subset analysis for colorectal cancer patients if a mixed population was included.

Intervention

Nursing-led ERAS or enhanced recovery bundled care protocols. For this review, “nurse-led” was operationalized as an ERAS-consistent multimodal perioperative pathway in which the source report explicitly described at least one nursing leadership or nursing-coordinated responsibility within the perioperative continuum. These responsibilities included one or more of the following: preoperative education or counselling, inpatient facilitation of ERAS milestones such as early mobilization, early feeding, multimodal analgesia support, drain or tube management, protocol adherence monitoring, discharge planning, or post-discharge follow-up. We recorded whether a dedicated ERAS nurse or nurse coordinator was explicitly named. Studies that mentioned ERAS without any identifiable nursing-led or nursing-coordinated component were not considered eligible.

Comparators

Conventional perioperative care or standard practice without ERAS (historical or concurrent control groups). We included both comparative studies (ERAS vs. non-ERAS) and single-arm ERAS studies if they reported outcomes against historical benchmarks.

Outcomes

We included studies reporting at least one of the specified outcomes, length of hospital stay (primary recovery metric), postoperative complication rates (overall and/or major complications within 30 days), hospital readmission rates (within 30 days of surgery), or survival/prognostic outcomes (such as 30-day mortality or longer-term OS). Studies not reporting these outcomes were excluded.

Study designs

We considered randomized controlled trials (RCTs), non-randomized controlled studies, prospective or retrospective cohort studies, and case-control studies. We excluded case series without a comparator and narrative reviews, editorials, or expert opinion pieces. No minimum sample size threshold was applied, although extremely small studies (n<10 per group) were considered prone to bias.

Time frame and language

We limited the search to studies published from January 2015 through October 2025 to capture the last 10 years of evidence. Studies in any other language other than English were excluded (translations made on any non-English articles found, but all the included studies reported are in English).

Information sources and search strategy

A search of the literature was conducted in five databases, including PubMed (MEDLINE), Embase, Cochrane Library (CENTRAL), Web of Science, and Scopus. The search strategy involved a combination of keywords and controlled vocabulary in three concepts namely (I) colorectal cancer surgery; (II) enhanced recovery or ERAS protocols; and (III) nursing or nurse-led care. We used a broad set of terms for ERAS (e.g., “enhanced recovery”, “fast track surgery”, “ERAS protocol”) and for nursing leadership (e.g., “nurse-led”, “nursing care”, “nurse coordinator”), ensuring sensitivity. The search was initially conducted in August 2025 and updated in October 2025 to capture any newly published studies. No filters for study design were applied. Reference lists of relevant reviews and included articles were hand-searched for additional citations. The full database-specific search strategies for each database are provided in Table S1.

Study selection

Search results from all databases were imported into a reference manager, and duplicates were removed. Title and abstract screening were then performed independently by two reviewers to exclude clearly irrelevant reports. Studies remaining after initial screening underwent full-text review for eligibility. At least two reviewers evaluated each full text against the inclusion criteria. Discrepancies were resolved through discussion or by consulting a third reviewer. We recorded reasons for exclusion at the full-text stage (e.g., wrong patient population, no relevant outcomes, etc.). The study selection process is illustrated in the PRISMA flow diagram (Figure 1). PRISMA flow chart depicting the number of records identified, screened, excluded, and included at each phase. We identified 2,586 records through database and citation searchings. After removing 343 duplicates, 2,243 unique records were screened by title/abstract, of which 1,985 were excluded as irrelevant. We sought 258 full-text reports for eligibility; 245 were excluded (reasons included ineligible population or intervention, lack of English full text, or no extractable outcomes). A total of 13 studies met all criteria and were included in the qualitative and quantitative synthesis.

Figure 1 PRISMA 2020 flow diagram of study identification and selection.

Data extraction and outcomes

From each included study, two reviewers independently extracted relevant data using a standardized form. Extracted data included study design, country or setting, sample size, patient demographics, details of the surgical procedure, and ERAS pathway characteristics. For the nursing-led component, we extracted whether a dedicated ERAS nurse or nurse coordinator was explicitly reported and which perioperative phase or phases involved nursing leadership or coordination, namely preoperative education or counselling, inpatient protocol facilitation and milestone monitoring, discharge planning, and post-discharge follow-up. For outcomes, we recorded definitions and values for: postoperative LOS (in days, often reported as median or mean), postoperative complications (incidence of any complications and/or major complications within 30 days, following each study’s definitions or common classifications such as Clavien-Dindo grade ≥ II), 30-day readmission rate, reoperation rate, 30-day mortality, and any longer-term outcomes (e.g., disease-free or OS if reported). Where outcomes were reported at multiple time points, we extracted the 30-day or in-hospital outcome for consistency. When studies reported median LOS with interquartile range, we approximated mean [standard deviation (SD)] using established methods for meta-analysis (6). In case of any conflict in data extraction, it was sorted out by revisiting the source publication.

Risk of bias assessment

According to study design, we assessed the risk of bias of each study through the application of various tools. In the case of randomized trials, we relied on the Cochrane Risk of Bias 2 (RoB2) tool that evaluates bias in the following domains randomization process, not adhering to planned interventions, missing outcomes, measurement of outcomes, and choice of reported outcomes. Each domain and overall trial bias was rated as “low”, “some concerns”, or “high” risk of bias. For non-randomized (observational) studies, we used the Newcastle-Ottawa Scale (NOS), judging each study on selection of cohorts, comparability, and outcome ascertainment (scores range 0–9, with ≥7 indicating high quality). Two independent reviewers performed bias assessments, with discrepancies resolved by consensus. We present a summary of the risk-of-bias results in the Results section. In brief, most RCTs showed low risk of bias in randomization and data completeness, but had some risk in blinding domains (due to unblinded personnel/outcome assessment), yielding an overall moderate risk of bias. The cohort studies were generally high quality (NOS scores 7–9), with some limitations in controlling confounders, but largely reliable.

Data synthesis and statistical analysis

We conducted meta-analyses for the main outcomes (LOS, complications, readmission, mortality) using Review Manager 5.4 and Stata 17 software. For each outcome, we pooled results comparing ERAS/ERBC vs. conventional care. Continuous outcomes (LOS) were analyzed using the inverse-variance method with mean difference (MD) as the effect measure (ERAS minus control). Dichotomous outcomes (complications, readmission, mortality) were analyzed using the Mantel-Haenszel method with risk ratio (RR) as the effect measure. All meta-analyses were performed with a random-effects model (DerSimonian-Laird), anticipating clinical and methodological heterogeneity across studies (6). The magnitude of between-study heterogeneity was quantified by the I² statistic (with I²>50% indicating substantial heterogeneity) and tested with Cochran’s Q (χ²) P value. In cases of negligible heterogeneity (I²≈0%), we also examined fixed-effect model results for comparison, although primary inferences were drawn from random-effects to be conservative. Pooled effect estimates are presented with 95% confidence intervals (CIs). Statistical significance was set at a two-tailed α of 0.05.

We assessed publication bias for the primary outcomes by inspecting funnel plots for asymmetry and applying Egger’s regression test for small-study effects. Where ≥10 studies were available (e.g., for complications and LOS), these methods were used (fewer studies limit the power of these tests). We conducted a sensitivity analysis for LOS, excluding each study one at a time, to evaluate the stability of the pooled estimate. We also planned subgroup analyses to explore heterogeneity by factors such as study design (RCT vs. observational), ERAS protocol compliance, and patient subgroup (e.g., elderly vs. non-elderly) if sufficient data were available. However, due to limited reporting on compliance and overlap of subgroups, formal subgroup meta-analysis was not feasible; we instead performed qualitative comparisons (see “Discussion” section). All analyses adhered to intention-to-treat principles for RCTs (using group outcomes as reported).

The overall certainty of evidence for each outcome was not formally graded in this report, but results are interpreted in context of study limitations and consistency. The meta-analysis results are summarized in forest plots (Figures 2-4) and a summary outcomes table.

Figure 2 Forest plot comparing 30-day postoperative readmission rates between ERAS pathways and conventional care following colorectal cancer surgery. ERAS, Enhanced Recovery After Surgery.

Figure 3 Forest plot comparing postoperative length of hospital stay between ERAS pathways and conventional perioperative care in colorectal cancer surgery. ERAS, Enhanced Recovery After Surgery.

Figure 4 Forest plot comparing overall postoperative complication rates between ERAS pathways and conventional perioperative management in colorectal cancer surgery. ERAS, Enhanced Recovery After Surgery.

Results

Study selection

Our searches across five databases yielded a total of 2,586 records. After removal of duplicates, 2,243 unique titles/abstracts were screened. We excluded 1,985 records based on irrelevance or failing to meet inclusion criteria. We retrieved 258 articles for full-text review. Of these, 245 were excluded for reasons such as: not focusing on colorectal surgery or ERAS (n=135), lacking a control or comparison (n=48), not reporting our outcomes of interest (n=34), or being non-English or conference abstracts without full text (n=28). Ultimately, 13 studies met all criteria and were included in the review (Figure 1). The included studies comprised five RCTs and eight observational cohort studies, published between 2015 and 2025.

Study characteristics

Table 1 summarizes the 13 included studies, with a complete list provided in Table S2. Overall, approximately 5,603 patients were enrolled (about 2,750 ERAS and 2,850 controls), with individual study sizes ranging from 82 to 1,001 patients. Most studies examined elective colorectal cancer resections, although a small number included advanced or emergency cases or broader gastrointestinal surgery populations. Mean patient age ranged from the mid-50s to early 70s, with some studies focusing on older adults. Studies were largely single-center and conducted across multiple countries (4). ERAS protocols comprised multimodal, nursing-supported perioperative bundles, while control groups received conventional care. Across eligible studies, the reported nursing responsibilities most commonly included preoperative counselling or education, reinforcement of early feeding and mobilization milestones, analgesia support, discharge planning, and pathway adherence monitoring; only a subset explicitly identified a dedicated ERAS nurse or nurse coordinator.

Outcomes measured

Length of hospital stay was reported in all included studies and defined as days from surgery to discharge. Overall postoperative complications were reported in all studies, although definitions varied, with some using Clavien-Dindo thresholds and others reporting any complication. Several studies also described specific events such as anastomotic leak, surgical site infection, ileus, or cardiopulmonary complications. Thirty-day readmission was reported in seven studies, while reoperation rates and 30-day mortality were each reported in three. Long-term oncologic outcomes were rarely assessed; only two cohort studies extended follow-up beyond 30 days, with no adverse survival impact attributed to ERAS.

Risk of bias within studies

Overall, the RCTs were judged to have moderate risk of bias. Random sequence generation and allocation concealment were adequately reported in most trials. However, none of the trials could blind participants or clinicians to ERAS vs. usual care (inherent due to the nature of the intervention), leading to potential performance bias. Outcome assessment blinding was unclear in several trials, especially for subjective outcomes like “complication” (which might be influenced by assessor knowledge of group). Encouragingly, outcome data were near-complete in all trials, and no selective reporting was evident (all prespecified outcomes were reported). For the cohort studies, quality was generally high. On the NOS, six cohorts scored 7–9 (high quality) and two scored 6 (medium). Most had clear definitions of exposed (ERAS) vs. control cohorts and adequate follow-up duration. A few lacked adjustment for confounders in analysis, which could bias results (e.g., if ERAS patients were younger or had fewer comorbidities in some studies). We note that in the largest cohorts, patient groups were fairly similar at baseline or were consecutive patients before vs. after ERAS implementation, partially mitigating selection bias. No major concerns about reporting bias were detected; many studies had published protocols or referenced adherence to standard ERAS protocols. Risk-of-bias visualizations were generated using the robvis web application (28). The risk-of-bias assessments for RCTs are summarized in Figure 5, while the corresponding assessment for non-randomized studies is presented in Figure 6.

Figure 5 Risk of bias assessment for randomized controlled trials (RoB 2). Traffic light plot showing domain-level judgments for included randomized trials using the Cochrane RoB 2 tool. RoB 2, Risk of Bias 2.

Figure 6 Risk of bias assessment for non-randomized studies (ROBINS-I). Traffic light plot summarizing domain-level judgments for included cohort studies. ROBINS-I, Risk Of Bias In Non-randomized Studies of Interventions.

Synthesis of results: meta-analysis outcomes

We quantitatively synthesized the outcomes of ERAS/ERBC vs. conventional care across the included studies. Table 2 summarizes the pooled results. Forest plots for each outcome are shown in Figures 2-4. We report the findings for each primary endpoint below.

Length of hospital stay

Eleven studies contributed data on postoperative LOS (two studies did not report LOS or provided insufficient data for pooling). ERAS significantly shortened hospital stay compared to usual care in colorectal surgery. The pooled MD was −3.16 days (95% CI: −4.10 to −2.21, P<0.001) favouring ERAS. In practical terms, patients managed with ERAS were discharged approximately 3 days earlier on average than those with standard recovery. Figure 3 displays the forest plot; all individual studies demonstrated a reduction in mean LOS with ERAS (ranging from ~1–5 days shorter across studies). While the magnitude of the LOS benefit varied, likely reflecting differences in hospital discharge policies and protocols, the direction was consistently toward shorter stays under ERAS. Heterogeneity was substantial (I²=82%), indicating inter-study variability. We explored potential causes: variation in types of surgery (major rectal resection vs. minor colonic resection), healthcare system differences, and partial compliance in some studies could all contribute. Sensitivity analysis in which a study was omitted in turn revealed that the pooled LOS reduction was 2.9–3.4 days and statistically significant in all instances indicating strong results. We also observe that one of the studies dealing with geriatric patients experienced a marginally lower LOS decrease (approximately 2 days) yet significant (4), which shows that ERAS benefits are applicable to elderly patients. Notably, there was no study that found an elevated LOS in case of ERAS. Rather, the rate of reduction was the primary difference, which emphasized that even under the conditions of a small ERAS effect, it did not lead to the increase of the hospital stay. Random-effects was used to estimate the LOS because it is heterogeneous; the same MD (~−2.8 days) was obtained using a fixed-effect model, which supports the findings that ERAS reduces hospital stay.

Postoperative complications

The rate of patients who experienced one or more postoperative complication in 30 days was reported in all 13 studies. ERAS significantly decreased the total complications. It had a 0.70 pooled RR (95% CI: 0.59–0.84, P<0.001) in favour of ERAS. This is equivalent to 30 percent of relative reduction in risks. In the absolute terms, assuming that the complication rate in the standard care is, e.g., 30% then it would be approximately 21% in the ERAS. The forest plot (Figure 4) shows the study-specific RRs and the pooled RR for overall postoperative complications across studies. Several cohort studies demonstrated significant reductions (e.g., one large series saw complications drop from 46.9% to 38.3% with ERAS). Common complications reduced under ERAS included surgical site infections, anastomotic leak rates, postoperative ileus, and pulmonary infections, as reported by the individual trials. Notably, the benefit spanned both minor and major complications: a few studies found ERAS specifically lowered severe complications (Clavien grade ≥ III) as well. Heterogeneity for complications was moderate (I²=64%, P<0.01). Variation may stem from differences in baseline risk (some studies included higher-risk emergency cases, others only elective), and how comprehensively complications were tracked. Nonetheless, the effect favoring ERAS was consistent, no study showed a statistically higher complication rate with ERAS. We used a random-effects model for this outcome. A subgroup analysis by study design (not formally shown) indicated both RCTs and observational studies aligned in showing complication reduction, though the effect size from RCT-only was around RR 0.75 in one prior meta-analysis, slightly less pronounced than our overall estimate, possibly because well-implemented cohort ERAS programs can achieve larger improvements with system-wide changes. Overall, these results affirm that ERAS protocols, coordinated by nursing and multidisciplinary teams, significantly improve surgical safety by preventing complications (4).

Readmission rates

Seven studies of RCT and large cohort studies reported unplanned readmission to the hospital within 30 days of surgery. Meta-analysis concluded that ERAS led to significant reduction of readmission rates as compared to traditional care. The relative RR was 0.75 (95% CI: 0.58–0.96; P=0.02), which reveals a 25% relative decrease in the risk of readmission. As an illustration, in one multicentre cohort the rate of readmissions decreased by nearly half, i.e., 15 to 10 percent following the implementation of ERAS (4). A different RCT having intensive ERAS measures did in fact numerically fewer readmissions in ERAS (yet not statistically significant on an individual basis), adding to the cumulative advantage. Notably, readmissions had an insignificant heterogeneity (I²=0). This homogeneity suggests a consistent effect across diverse settings: ERAS does not increase early postoperative readmissions and in fact tends to reduce them. This finding allays a common concern that sending patients home earlier (shorter LOS) might lead to more bounce-backs. In our data, earlier discharge under ERAS was achieved safely, likely because complications and issues were genuinely fewer (not just delayed to outpatient). The enhanced patient education and post-discharge support by ERAS programs might also contribute to fewer readmissions (patients recognize warning signs and intervene early via outpatient channels). We note that a large recent meta-analysis of RCTs across surgeries found no significant difference in readmissions, which might differ from our result partly due to inclusion of non-colorectal cases or the more stringent selection of RCTs. In colorectal cancer populations, our findings support that ERAS can reduce readmissions, possibly by preventing complication-related returns (e.g., fewer infections and ileus requiring readmission). We applied a fixed-effect model given I²=0%, which yielded the same RR 0.75. Thus, we have high confidence that readmission risk is at least not increased by ERAS and is likely improved.

30-day mortality and long-term survival

Only three studies reported any deaths within 30 days; when pooled, no significant difference in 30-day mortality was observed between ERAS and standard care (RR ≈0.58; 95% CI: 0.01–24.16; P=0.59). Essentially, short-term mortality was very low in both groups across studies (each study had zero or 1–2 events per group). ERAS pathways are not expected to directly impact immediate postoperative mortality in elective surgery, and our data reflect that: there was no harm from ERAS in terms of perioperative survival, consistent with previous findings. Heterogeneity was minimal (I²=0%) and the CI was wide due to few events.

Regarding longer-term OS or cancer-specific outcomes, none of the trials had long enough follow-up to directly measure these within the scope of ERAS vs. standard care. However, one included cohort was noted to follow stage III patients and mentioned that ERAS adoption did not negatively affect 3-year survival (25). More broadly, some external studies have hinted at improved long-term prognosis with ERAS: for example, a narrative review noted that colorectal cancer patients on ERAS may have better OS rates, hypothesizing that reductions in complications could translate to better cancer outcomes. This is plausible since postoperative complications (like infection or anastomotic leak) are known to adversely impact cancer recurrence and survival. That said, definitive evidence on ERAS improving oncologic outcomes is still lacking. Our review’s scope was short-term outcomes; we did not find any significant survival difference in the short term, and data were insufficient to assess long-term survival. An interesting observation is that in an emergency colorectal surgery context (often obstructing cancers), an ERAS protocol applied in a Thai study was associated with a mortality reduction compared to historical care (25). Those results suggest that in high-risk urgent cases, the bundle of optimized care can be lifesaving. In our primarily elective surgery-focused analysis, mortality is too rare to show differences, but clearly ERAS does not increase early mortality and may confer survival benefits in selected contexts.

Additional analyses: implementation and subgroup insights

Though not predefined outcomes, several secondary observations emerged:

• Compliance with ERAS: many studies did not quantify protocol compliance, but the success of ERAS in reducing complications and LOS likely correlates with adherence level. Only a partial ERAS (which excluded certain components) was used in one trial, and it had smaller benefits, which points to the possibility that increased compliance can be more effective. Other studies have associated higher ERAS compliance (usually born of nursing vigilance) with better outcomes.
• The intervention led by nurses: despite the fact that any ERAS use presupposes the participation of nurses, several studies have attributed the role of nursing interventions directly (e.g., an ERAS nurse educator teaching stoma care made patients more confident). The qualitative reports repeatedly emphasised the importance of effective communication, patient education, and regular monitoring, many activities that nurses perform, as the keys to the success of ERAS. This highlights the fact that the nursing-led model was an effective motor of the outcome changes that we were able to measure.

Subgroup differences: qualitatively, elderly patients (70 years and above) as compared to young patients advantages of ERAS, and one of the studies in the elderly colorectal patients demonstrated a reduction in LOS by about 2 days and less complications. Minimally invasive surgeries (laparoscopic/robotic) combined with ERAS might further enhance recovery [as seen in (21,29)]. Conversely, emergency surgeries or those with advanced disease can still benefit, though baseline complication risks are higher; ERAS in an emergency setting was feasible and possibly improved survival, but more data are needed.

Hospital resource use: several studies commented that ERAS patients required less intensive care unit (ICU) utilization and had lower overall costs. A formal cost-effectiveness analysis was beyond our scope, but shorter LOS and fewer complications intuitively translate to cost savings and more efficient care, an important consideration for healthcare systems.

Publication bias

For the primary outcomes (LOS and complications), we assessed publication bias. The funnel plot for LOS (studies’ effect sizes vs. standard error) appeared symmetric, and Egger’s test was not significant (P=0.66), suggesting a low likelihood of small negative studies being missing. Similarly, for complications, visual inspection did not reveal marked asymmetry. The number of studies for readmission was small (7), limiting formal bias testing, but given many were multi-center cohorts or trials published in diverse journals, we suspect the risk of publication bias is low. We cannot rule out that very small studies with null results exist unpublished, but the robustness of findings across large samples mitigates this concern.

Discussion

This systematic review and meta-analysis suggests that ERAS pathways with identifiable nursing leadership or coordination are associated with better short-term postoperative outcomes in colorectal cancer surgery. Compared with conventional perioperative care, these pathways were associated with shorter hospital stay, lower overall complication rates, and lower readmission rates, without evidence of increased short-term mortality. The consistency of effect direction across randomized and observational studies supports clinical relevance, but heterogeneity in intervention reporting and study design limits causal interpretation.

Comparison with the existing literature

Our results are consistent with the existing literature on ERAS in colorectal surgery, as well as in other aspects. Indicatively, in a meta-analysis of 74 RCTs published in 2024 by Sauro et al. the ERAS guidelines reduced LOS by approximately 1.9 days and complications by approximately 29 days, without influencing readmissions or mortality (6). The review that involved both RCTs and observational studies of patients with colorectal cancer showed that the LOS reduction (approximately, 3 days) was slightly greater and also found that there was a significant reduction in readmissions (25 percent). The high LOS effect in our analysis is probably since large cohort studies were included in which the implementation of ERAS in the system can have efficiencies of a dramatic nature (e.g., some hospitals avoided the implementation of ERAS in their system and cut average LOS by more than three days). The small difference in readmissions (Sauro et al. did not find a significant difference, but we did) may be attributed to the fact that we incorporated high-quality observational data and possibly a more specific focus on the cases of colorectal surgery in the ERAS protocols, that is, stoma care education, early follow-up, etc. may specifically prevent readmissions due to dehydration or stoma problems (6). In fact, our studies which consisted of a full-follow up by nurses revealed extremely low readmission rates.

Our reduction (RR =−0.70) of complications is reflective of many other studies. This covers evidence of different contexts: Arrick et al. (30) and Ripollés-Melchor et al. (31) in colorectal surgery both reported the reduction in complications with ERAS of an order of magnitude of 30−40 percent, in line with our estimate. We also support the results of specialized studies, such as a meta-analysis conducted by Slim et al. (32), comparing ERAS in low- vs. high-income countries, as ERAS demonstrated better results in both of them. We also find agreement with the audits of the ERAS Society itself, which have reported the reduction of LOS, as well as complications, in high-compliance ERAS centres.

It is important to note that there was no statistically significant difference in 30-day mortality; that is to be expected as mortality in elective colorectal surgery is low. A fascinating difference can be noted to one by Lohsiriwat et al. (25) in Updates in Surgery that concentrated on emergency colorectal cancer operations and that found that perioperative mortality decreased with the use of ERAS. This implies that, in high-risk populations (e.g. obstructing cancers requiring urgent surgery), ERAS can be lifesaving, presumably through careful perioperative care that avoids the occurrence of fatal complications such as sepsis. The main elective cases were included in our analysis, and this could be why we did not observe the mortality impact. In elective cases, death is too rare to believe that a significant difference is achievable unless tens of thousands of patients are followed. It is however encouraging that in the >5,000 patients in this case, ERAS never had a risk of mortality which underscores its safety.

Nursing-led ERAS and implementation

One reason for undertaking this review was to examine whether ERAS pathways with identifiable nursing leadership or coordination differ meaningfully from ERAS described only at the protocol level. Across the included studies, the nursing contribution most commonly involved preoperative counselling, reinforcement of early mobilization and feeding milestones, pain and symptom monitoring, discharge readiness assessment, and, in some reports, pathway coordination or follow-up. These responsibilities are clinically relevant because they may improve protocol fidelity, strengthen patient understanding, support earlier recognition of deviation from recovery milestones, and facilitate continuity from ward care to discharge. However, the extent of nursing accountability was variably reported, and direct comparisons between nurse-led and non-nurse-led implementation were not available. Therefore, our findings should be interpreted as supporting an association between ERAS pathways with identifiable nursing coordination and improved short-term recovery outcomes, rather than proving an independent causal effect of nursing leadership itself.

Clinical implications

The observed effect sizes are clinically relevant. A reduction of 2–3 days in hospital stay may decrease bed utilization and patient exposure to hospital-acquired complications, and lower complication rates may facilitate smoother postoperative recovery. However, because nursing leadership and ERAS adherence were not uniformly defined or measured, these findings should not be interpreted as proof that nursing leadership alone caused the observed differences. Rather, they support further development of structured ERAS nursing roles and prospective evaluation of how specific nursing components influence protocol fidelity and outcomes.

Heterogeneity, context

We observed moderate to high heterogeneity in the outcomes of LOS, and complication. This highlights the fact that outcomes may be relative. As an example, LOS gains may be less in healthcare systems with a low baseline LOS (e.g., some centres in Europe even have less than 5-day LOS in traditional care) or greater in areas with traditionally high hospital lengths of stay. Through this, it can also be true that reductions in complications may be greater in those environments where the baseline complication is high (e.g., older or weaker populations) compared to those settings where the baseline complication is low and surgical practices are highly optimized. In our subgroup observation, there was a suggestion that in even colorectal surgery, there can be some subtleties: gastric surgery patients on ERAS may experience various nutritional issues compared to colorectal, emergency vs. elective cases, etc. Our summary effect is, however, an average, given that we put all in a single meta-analysis. Notably, there was no sub-population that seemed to be unaffected; apparently it is a question of quantity. It implies that ERAS can be widely used, but one only has to modify the protocol to fit the individual group of patients. Indicatively, the introduction of prehabilitation and geriatric co-management of the elderly patient, or more aggressive use of post-discharge follow-ups in patients with stomas, would be additional improvements in the two subgroups.

Limitations

This review has several limitations. Observational studies were included to improve generalizability, but they remain vulnerable to selection bias and residual confounding. ERAS protocols were heterogeneous, and some studies reported only partial bundles or incompletely described adherence. Importantly, the definition and reporting of the nursing component were inconsistent across reports. Dedicated ERAS nurse roles, discharge coordination, and post-discharge follow-up were not uniformly specified, which limits the ability to isolate the independent effect of nursing leadership from the broader ERAS pathway. Long-term oncologic outcomes were sparsely reported, precluding firm conclusions regarding survival or recurrence.

Future directions

Future research should prospectively operationalize nursing leadership within ERAS pathways and measure protocol fidelity using reproducible definitions. Multicenter studies should specify whether a dedicated ERAS nurse or nurse coordinator is present, which perioperative phases are nurse-led, and how adherence to individual ERAS elements is monitored. Such work would help determine whether specific nursing-led components add value beyond ERAS implementation itself. Longer follow-up and health-economic evaluation are also needed.

Conclusions

Nursing-led or nursing-coordinated ERAS pathways in colorectal cancer surgery were associated with favorable short-term postoperative outcomes, including shorter hospital stay and lower complication and readmission rates, without evidence of increased short-term mortality. These findings support the clinical relevance of structured nursing involvement within multidisciplinary ERAS care. However, the available literature does not yet permit definitive causal attribution to nursing leadership alone because the nursing components and adherence measures were variably reported. Future prospective studies should standardize the definition and measurement of nurse-led ERAS components and evaluate long-term oncologic and implementation outcomes.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://jgo.amegroups.com/article/view/10.21037/jgo-2026-1-0025/rc

Peer Review File: Available at https://jgo.amegroups.com/article/view/10.21037/jgo-2026-1-0025/prf

Funding: None.

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