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Introduction Postoperative ileus(POI) and anastomotic leakage(AL) are highly associated but the direction of this link is unknown. Indeed, it has traditionally been stated that AL leads to POI(secondary POI). The objective was to statistically determine the best model of link between POI and AL by comparing different Structural Equation Models(SEM). Methods This is a retrospective analysis of a prospective multicentric database from the Francophone Group for Enhanced Recovery after surgery(GRACE) including patients undergoing colorectal resection or Hartmann reversal between 2014 and 2017. The main outcome measure was the occurrence of postoperative ileus defined by the absence of Gastrointestinal (GI)-3 recovery in or after postoperative day 4 and the occurrence of AL. Results Among the 2227 patients included, 223 patients experienced POI (10 %) and 72 patients experienced anastomotic leakage (3.2 %). In all the models, POI was significantly increased in case of male gender, older age, opioids consumption, right colectomy, chronic obstructive bronchopneumopathy disease and performance of a stoma, and reduced by Enhanced Recovery Programs (ERP) compliance ≥ 70 % and intake of Non-Steroidal Anti-Inflammatory Drugs. Open surgery was not significantly associated with POI in all the models. In contrast, the male gender was the only factor increasing AL in the model drawn with ERP risk factors for AL. In all the models, POI was highly associated with AL and statistical analyses advocate for POI leading to AL. Conclusion The findings of the present large study suggest that the more statistically probable model is the one in which POI come first before AL.

Enhanced recovery programs (ERP) improve post-operative outcomes in proportion to how fully they are implemented. Maintaining an optimal level of application of all the ER components is thus essential. Our aim was to assess the sustainability of ER surgical components 2 years after their first implementation.Patients undergoing elective colorectal resections were included in a prospective database. To retrospectively analyze compliance with ERP over a period of 24 months, the following components were considered: colonic preparation, surgical approach, nasogastric tube omission and absence of abdominal drainage.2565 patients with a mean age of 63.6 ± 14.4 years from 63 colorectal centers were included. There were 1853 (72.2%) colectomies and 558 (21.7%) rectal resections. The median duration of hospital stay was 5 days [Interquartiles 4-8]. Overall morbidity was 21.9%, surgical morbidity was 8.1%, including 2.8% anastomotic fistulae. Overall, the ERP component most often applied with was postoperative nasogastric tube omission (93.6%), followed by laparoscopic approach (81.7%), absence of drainage (74.9%), and colonic preparation omission (67.3%). Implementation of surgical components significantly decreased over time: less laparoscopy (from 86.8% to 76.6%, p 0.001), less drain omission (from 88.7% to 72%, p 0.001), less nasogastric tube omission (from 100% to 93.4%, p = 0.002) and less colonic preparation omission (from 73.6% to 65.6%, p = 0.01).This large-scale study found that implementation of surgical components in ERP decreased over time. Further efforts are needed to sustain compliance with ERP and surgical teams should focus on repeated audits.