Surgical heuristics with ‘opting out’ from an enhanced recovery pathway in octogenarian colorectal cancer patients: a retrospective cohort study

The benefits of enhanced recovery after surgery (ERAS) in the octogenarian colorectal cancer population are not well established. Many colorectal centres use an ‘opt out’ policy for those patients who have a high risk of ‘failing’ an ERAS pathway. This paper explores the heuristics involving key baseline, functional and operative factors that affect a surgeon’s decision-making when ‘opting out’ of an ERAS pathway. This is a single-centre retrospective cohort study using prospectively collected data. Octogenarian patients, with colorectal resections from 2013 to 2020 were included. An ERAS pathway was the standard of care. The surgeon decided to ‘opt out’ patients unlikely to recover by an ERAS pathway at the time of the operation. An exploratory analysis was performed using multivariable logistic regression to identify factors associated with the surgical decision to ‘opt out’ of an ERAS pathway. Two hundred fourteen patients were included in total. One hundred fifty-four and sixty were in the ERAS and non-ERAS pathways respectively. After multivariate analysis, admission acuity (OR 8.56 [95% CI 2.27–32.2], p < 0.001), frailty (OR 2.84 [95% CI 1.11–7.25], p = 0.029), significant adhesions (OR 6.35 [95% CI 2.74–14.7], p < 0.001), an open procedure (OR 5.77 [95% CI 2.44–13.6], p < 0.001, and bleeding requiring haemostatic agents (OR 7.40 [95% CI 1.50–36.5], p = 0.014) were found to be significantly associated with the decision-making process in opting out of an ERAS pathway. The presence of an emergency resection, a frail patient, significant adhesiolysis, open operations and intraoperative bleeding are factors that may influence the surgeon’s decision to not place their octogenarian patients on an ERAS pathway.