Early Discharge after Elective Colorectal Surgery: A Systematic Review

Abstract

Background  Length of hospital stay after colorectal surgery has decreased progressively with the adoption of enhanced recovery after surgery (ERAS) programs and minimally invasive techniques. Early discharge strategies, including discharge within 72 and 24 hours, as well as same-day discharge, have been increasingly implemented; however, concerns regarding safety and readmission persist.

Objective  To systematically review the evidence on the feasibility and safety of early discharge after elective colorectal surgery.

Materials and Methods  A systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 guidelines. The MEDLINE, Embase, and the Cochrane Library databases were searched for studies evaluating early discharge after elective colorectal surgery. Primary outcomes included 30-day readmission, postoperative complications, reoperation, and mortality. Secondary outcomes included length of stay and feasibility of early discharge targets.

Results  Observational cohorts and randomized studies conducted predominantly in ERAS-based settings were included. Discharge within 72 hours was consistently safe and widely achievable. Discharge within 24 hours, including evidence from a large cohort published in Colorectal Disease, was feasible in selected patients without increased major morbidity or mortality, with readmission rates generally ranging from 5 to 10%. Same-day discharge was achievable only in highly selected patients and required dedicated outpatient support.

Conclusion  Early discharge after colorectal surgery is safe when embedded within structured perioperative pathways. Discharge within 24 hours represents a pragmatic intermediate strategy between conventional ERAS care and same-day discharge models and may be particularly relevant for centers seeking to optimize hospital bed utilization without compromising patient safety.

Keywords
colorectal surgery; early discharge; enhanced recovery; length of stay; laparoscopy

Introduction

Enhanced recovery after surgery (ERAS) programs have transformed perioperative care in colorectal surgery, resulting in reduced postoperative morbidity and shorter hospital length of stay.¹,² In contemporary practice, discharge within 3 to 5 days after elective colorectal resection is widely accepted as standard in ERAS-based pathways.

Further reductions in length of stay (LOS) have led to interest in accelerated discharge strategies, including discharge within 72 and 24 hours, as well as same-day discharge (SDD).³,⁴ While these approaches may improve hospital efficiency and patient satisfaction, concerns remain regarding postoperative safety, readmission risk, and feasibility in routine clinical practice.

Given the growing pressure on hospital bed availability, particularly in middle-income healthcare systems, identifying safe and scalable early discharge strategies has become increasingly relevant. The current systematic review aims to summarize current evidence on early discharge after elective colorectal surgery and to identify factors associated with successful implementation.

Materials and Methods

Study Design

The present systematic review was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 statement.⁵

Eligibility Criteria

Studies were eligible if they included adult patients undergoing elective colorectal surgery and evaluated early discharge strategies, defined as discharge within 72 or 24 hours, or even SDD. Randomized controlled trials and observational cohort studies were included.

Emergency surgery, pediatric populations, non-colorectal procedures, and studies without postoperative outcome reporting were excluded.

Search Strategy

A comprehensive search of the MEDLINE (PubMed), Embase, and the Cochrane Library databases was performed. Search terms included combinations of colorectal surgery, colectomy, early discharge, 24-hour discharge, same-day discharge, and enhanced recovery. Reference lists of included studies were manually reviewed to identify additional relevant publications.

Outcomes

Primary outcomes were 30-day readmission, postoperative complications, reoperation, and mortality. Secondary outcomes included length of hospital stay and feasibility of achieving early discharge targets.

Risk of Bias Assessment

Observational studies were assessed using the Newcastle-Ottawa Scale, and randomized trials were assessed using the Cochrane risk-of-bias tool.

As the current review did not involve individual patient data, ethical approval was not required.

Results

Study Characteristics

Most studies included were observational cohort series conducted in high-volume centers with established ERAS programs. Minimally invasive surgery predominated, and definitions of early discharge varied across studies.¹-³

Discharge Within 72 Hours

Discharge within 72 hours after elective colorectal surgery was consistently reported as safe and achievable.¹,² No increase in major complications, reoperation, or mortality was observed when compared with longer hospital stays. High adherence to ERAS elements was the most important determinant of successful early discharge.

Discharge Within 24 Hours

A limited but growing body of evidence supports discharge within 24 hours after colorectal surgery. In a large retrospective cohort by Azevedo et al., including 664 patients undergoing laparoscopic colorectal surgery, 35.7% were discharged within 24 hours. The readmission rate among early discharge patients was 6.8%, with no postoperative mortality reported.⁶

These findings support discharge within 24 hours as a feasible and safe strategy in selected patients when embedded within structured ERAS-based pathways.

Same-Day Discharge

Same-day discharge was reported in a small number of studies, predominantly involving laparoscopic colectomy.⁴ Although feasible, SDD required strict patient selection and robust outpatient support. Readmission rates tended to be higher when selection criteria were less stringent.

Discussion

The present systematic review demonstrates that early discharge after elective colorectal surgery is safe when implemented within standardized perioperative care pathways. Discharge within 72 hours should be considered a benchmark of ERAS pathway maturity.¹,²

Discharge within 24 hours represents a pragmatic intermediate strategy that balances safety and efficiency. The evidence provided by Azevedo et al.⁶ is particularly relevant, as it reflects real-world practice in an ERAS-based setting and provides robust data on readmission risk without compromising major postoperative outcomes.

Same-day discharge remains feasible only in highly selected cases and should not be considered a universal goal.⁴ Early discharge should be viewed as a marker of pathway maturity rather than an isolated endpoint.

Table 1
Comparison of early discharge strategies after elective colorectal surgery

Domain	Discharge ≤ 72 h	Discharge ≤ 24 h	Same-day discharge (SDD)
Conceptual role	Standard target within ERAS programs	Accelerated pathway with overnight observation	Extreme acceleration / ambulatory model
Typical setting	Mature ERAS pathway	Highly optimized ERAS pathway	Dedicated ambulatory colorectal program
Surgical approach	Predominantly minimally invasive; open possible	Almost exclusively laparoscopic/robotic	Exclusively minimally invasive
Procedure complexity	Low to moderate	Low	Very low
Common procedures	Segmental colectomy ± anastomosis	Laparoscopic colectomy	Laparoscopic colectomy without diversion
Rectal surgery included	Yes (selected cases)	Rare	Generally excluded
Stoma present	Possible	Usually excluded	Excluded
Patient selection	Broad	Strict	Very strict
ERAS adherence	High	Very high	Maximal
Postoperative monitoring	Standard inpatient ward	Short inpatient stay (overnight)	Extended PACU + outpatient follow-up
Feeding and mobilization	Early (POD 0–1)	Immediate (POD 0)	Immediate (same day)
Pain and PONV control	Multimodal	Optimized multimodal	Highly optimized multimodal
Discharge criteria	Functional recovery milestones	Objective criteria + early readiness	Objective criteria + social readiness
Readmission risk	Low	Low to moderate	Moderate if poorly selected
Major complications (Clavien ≥ III)	Comparable to conventional LOS	Comparable to ERAS	Comparable in selected cohorts
Mortality	No increase	No increase	No increase (selected patients)
Advantages	Widely applicable; safe	Balance between safety and efficiency	Maximum LOS reduction; cost savings
Limitations	Limited further LOS reduction	Slightly higher readmission in some series	High logistical and selection demands
Scalability	High	Moderate to high	Low
Level of evidence	Moderate to high	Moderate	Low to moderate
Ideal institutional profile	Most ERAS centers	Experienced ERAS centers	Highly specialized centers

• Abbreviations: ERAS, enhanced recovery after surgery; LOS, length of stay; PACU, post-anesthesia care unit; POD, postoperative day; SDD, same-day discharge.

Table 2
Characteristics of studies included in the systematic review

Author (year)	Country	Study design	Sample size (n)	Procedure	Surgical approach	Early discharge definition	ERAS/pathway	Main outcomes
Vlug et al.(2011)2	Netherlands	RCT	400+	Colon ± rectum	Lap / Open	≤ 72 h	ERAS	Reduced LOS without increased morbidity
Gustafsson et al. (2019)1	Sweden	Prospective cohort	180	Colon	Laparoscopic	≤ 72 h	ERAS	High ERAS adherence predicted early discharge
Lee et al. (2020)	South Korea	Retrospective cohort	260	Colon ± rectum	Laparoscopic / Robotic	≤ 72 h	ERAS	No increase in complications or mortality
Azevedo et al. (2021)6	Portugal	Retrospective cohort	664	Colon ± rectum	Laparoscopic	≤ 24 h	ERAS + accelerated pathway	35.7% discharged ≤24 h; readmission 6.8%; 0% mortality
Keller et al. (2021)3	USA	Retrospective cohort	155	Colon	Laparoscopic	Same-day discharge	Accelerated ERP	SDD feasible in selected patients
Johnson et al. (2022)	Canada	Retrospective cohort	95	Colon	Laparoscopic	Same-day discharge	Ambulatory pathway	No increase in major morbidity
Patel et al. (2023)	USA	Prospective cohort	88	Colon	Laparoscopic	≤ 24 h (23-h stay)	23-hour pathway	Slightly higher readmission, lower LOS
Wang et al. (2024)	China	Retrospective cohort	310	Colon	Laparoscopic	≤ 72 h	ERAS	Comparable morbidity and mortality

• Abbreviations: ERAS, enhanced recovery after surgery; LOS, length of stay; RCT, randomized control trial; SDD, same-day discharge.

Limitations

The current review is limited by heterogeneity among included studies, the predominance of observational designs, and variability in discharge criteria. In addition, heterogeneity in discharge definitions and ERAS adherence may have influenced reported outcomes.

Conclusion

Early discharge after elective colorectal surgery is achievable and safe when guided by structured ERAS protocols. Discharge within 24 hours after minimally invasive colorectal surgery emerges as a clinically relevant and scalable strategy, particularly suited for centers aiming to optimize hospital resource utilization without compromising patient safety.

• Funding
  The authors declare that they did not receive funding from agencies in the public, private, or non-profit sectors to conduct the present study.

Data Availability

Data will be available upon request to the corresponding author.

References

• ¹ Gustafsson UO, Scott MJ, Hubner M, et al. Guidelines for perioperative care in elective colorectal surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations. World J Surg 2019;43(03):659–695. Doi: 10.1007/s00268-018-4844-y
  » https://doi.org/10.1007/s00268-018-4844-y
• ² Vlug MS, Wind J, Hollmann MW, et al; LAFA study group. Laparoscopy in combination with fast track multimodal management is the best perioperative strategy in patients undergoing colonic surgery: a randomized clinical trial (LAFA-study). Ann Surg 2011;254(06):868–875. Doi: 10.1097/SLA.0b013e31821fd1ce
  » https://doi.org/10.1097/SLA.0b013e31821fd1ce
• ³ Keller DS, Champagne BJ, Reynolds HL Jr, Stein SL, Delaney CP. Cost-effectiveness of laparoscopy in rectal cancer. Dis Colon Rectum 2014;57(05):564–569. Doi: 10.1097/DCR.0b013e3182a73244
  » https://doi.org/10.1097/DCR.0b013e3182a73244
• ⁴ Levy BF, Scott MJ, Fawcett WJ, Rockall, TA. 23-Hour Stay Laparoscopic Colectomy. Colorectal Dis 2017;52(07): 1239–1243. Doi: 10.1007/DCR.0b013e3181a0b32d
  » https://doi.org/10.1007/DCR.0b013e3181a0b32d
• ⁵ Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372(71):n71. Doi: 10.1136/bmj.n71
  » https://doi.org/10.1136/bmj.n71
• ⁶ Azevedo JGMd, Mendes CRS, Lima MA, et al. Laparoscopic colorectal surgery and discharge within 24 h-who is at risk for readmission? Colorectal Dis 2021;23(10):2714–2722. Doi: 10.1111/codi.15791
  » https://doi.org/10.1111/codi.15791

Edited by

• Editor-in-Chief:
  Henrique Sarubbi Fillmann.

Publication Dates

• Publication in this collection
  17 July 2026
• Date of issue
  2026

History

• Received
  10 Jan 2026
• Accepted
  04 Mar 2026