# Right vs. Left Colon Surgery: Understanding Differences in Recovery After Enhanced Recovery Surgery (ERAS)

This study compared how patients recover after right-sided versus left-sided colon surgery (colectomy) when both groups follow the same Enhanced Recovery After Surgery (ERAS) protocol. Researchers followed 223 patients and found that while patients adhered equally well to the recovery program regardless of which side of the colon was operated on, right colectomy patients experienced slower return of bowel function, a significantly higher need for nasogastric tube placement (24% vs. 8%), and a longer hospital stay (6 vs. 5 days). These findings suggest that the standard recovery pathway may need to be adjusted — particularly regarding early feeding — specifically for patients undergoing right-sided colon resections.

# Right vs. Left Colon Surgery: Understanding Differences in Recovery After Enhanced Recovery Surgery (ERAS)

## Table of Contents

- Key Points
- Background: Why This Research Matters
- Study Methods: How the Research Was Conducted
- Key Findings: Detailed Results With All Numbers
- Clinical Implications: What This Means for Patients
- Limitations: What the Study Couldn't Prove
- Recommendations: Actionable Advice for Patients
- Frequently Asked Questions
- Source Information

## Key Points

- In a study of 223 patients, those having right colectomy more often required a nasogastric tube (24% vs. 8%) than left colectomy patients.
- Right colectomy patients had a median hospital stay of 6 days versus 5 days for left colectomy patients, a statistically significant difference.
- First stool occurred on day 3 after right colectomy and day 2 after left colectomy, suggesting slower bowel recovery after right-sided surgery.
- Overall complication rates were 49% for right and 37% for left colectomy, but this difference was not statistically significant.
- Patients complied with the ERAS protocol equally well regardless of surgery side, but the authors recommend more cautious early feeding after right colectomy.

## Background: Why This Research Matters

Colon surgery — medically called a **colectomy** — involves removing a portion of the large intestine (colon). Depending on which part of the colon is diseased, surgeons perform either a **right colectomy** (removing the right side of the colon, also called the ascending colon) or a **left colectomy** (removing the left side, including the descending and sigmoid colon). These are two of the most common operations performed for colon cancer, diverticulitis, and other colorectal conditions.

Over the past decade, a care approach called **Enhanced Recovery After Surgery (ERAS)** has transformed how patients recover from colon surgery. Instead of traditional practices that involved long fasting periods, heavy pain medication, and days of bed rest, ERAS uses a bundle of evidence-based measures designed to help patients recover faster. These measures include minimizing fasting before surgery, using nerve-block pain relief instead of opioids, encouraging patients to eat and move early after surgery, and avoiding routine use of nasogastric tubes (tubes inserted through the nose into the stomach).

Research has consistently shown the benefits of ERAS programs. A meta-analysis of randomized controlled trials published by Greco and colleagues in *World Journal of Surgery* (2014) found that ERAS significantly improved outcomes after colorectal surgery. Other studies, including those by Rawlinson et al. (2011) and Wind et al. (2006), reached similar conclusions. A landmark study by Gustafsson and colleagues (2011) demonstrated that higher adherence to the ERAS protocol leads to better patient outcomes, and an international registry study published by the ERAS Compliance Group in *Annals of Surgery* (2015) confirmed this relationship across multiple centers. Cost-effectiveness has also been established — Roulin and colleagues (2013) showed that implementing ERAS for colorectal surgery reduces hospital costs without compromising quality of care.

Despite the widespread success of ERAS, one important question remained unanswered: **Do right and left colectomies result in different recovery experiences, even under the same ERAS protocol?** While the official ERAS guidelines published by Gustafsson et al. in *World Journal of Surgery* (2013) do not differentiate between right- and left-sided resections, several earlier studies suggested that recovery might differ between the two procedure types.

Previous research on surgical outcomes has hinted at such differences. For example, Veyrie and colleagues (2007) reported that the rate of anastomotic leakage (leaking at the surgical connection site) differs between right and left colectomies performed for cancer. Kwaan and colleagues (2013), using data from the large ACS NSQIP database, found that right-sided colectomy outcomes differ from left-sided outcomes. A large German study by Benedix and colleagues (2010) compared 17,641 patients with right- and left-sided colon cancer and found significant differences in epidemiology, perioperative course, histology, and survival. Similarly, Masoomi et al. (2011) and Rana et al. (2007) both reported outcome differences between right- and left-sided colectomies.

The researchers behind this study — Anne Kummer, Juliette Slieker, Fabian Grass, Dieter Hahnloser, Nicolas Demartines, and Martin Hübner from Switzerland — set out to specifically compare how well the ERAS recovery pathway works for right versus left colectomy patients.

## Study Methods: How the Research Was Conducted

This study was conducted at a single surgical center in Switzerland. The research team used a prospective database (a database created in advance to track outcomes over time) that included all patients who underwent elective (planned, non-emergency) colon surgery at their institution.

The study period spanned from **June 2011 through September 2014**. During this time, every patient undergoing elective colonic (colon) resection was treated according to a standardized ERAS protocol and entered into the prospective database. The study was registered in the Research Registry under identification number **UIN 372**.

This was a **retrospective analysis** — meaning the researchers looked back at data that had already been collected — comparing patients who had right colectomy versus those who had left colectomy. The comparison focused on four key areas:

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**Application of the ERAS pathway** — how well each group followed the protocol
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**Bowel recovery** — measured by time to first flatus (passing gas) and first stool (bowel movement)
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**Complications** — any medical issues that arose after surgery
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**Hospital stay** — how many days patients remained in the hospital after their operation

To ensure a fair comparison, the researchers examined baseline demographics (patient characteristics like age, sex, and health status) for both groups. The study also tracked how many patients required a **nasogastric tube** (a tube passed through the nose and down into the stomach to drain digestive fluids) after surgery — an important indicator of **postoperative ileus**, a condition in which the bowel temporarily stops functioning properly after surgery.

Complications were graded using a widely accepted classification system developed by Dindo, Demartines, and Clavien (published in *Annals of Surgery*, 2004), which was validated in a cohort of 6,336 patients. This system assigns severity grades to surgical complications, allowing researchers to distinguish between minor and major issues.

## Key Findings: Detailed Results With All Numbers

### Patient Population

The study included a total of **223 patients**: **85 patients who underwent right colectomy** and **138 patients who underwent left colectomy**. The two groups were well matched for baseline demographics, meaning that patient characteristics such as age, sex, and overall health were similar between the groups at the start — a critical factor for making valid comparisons.

### ERAS Protocol Compliance

Overall compliance with the ERAS protocol was nearly identical between the two groups:

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**Right colectomy patients:** 76% compliance
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**Left colectomy patients:** 77% compliance
- Statistical comparison: p = 0.492 (not statistically significant)

This finding is important because it demonstrates that the ERAS protocol was **equally applicable and feasible** for both types of surgery. Differences in outcomes between the groups therefore could not be explained by one group simply receiving a different standard of care. This matters in light of earlier research by Cakir et al. (2013) and Gustafsson et al. (2011) showing that adherence to ERAS protocols directly affects length of stay and postoperative outcomes.

### Bowel Recovery

Bowel function recovery was measured through two milestones:

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**First flatus (passing gas):** Both right and left colectomy patients had their first flatus on **postoperative day 2** (p = 0.057). While this difference was not statistically significant, it was very close to the threshold, suggesting a possible trend toward later recovery in the right colectomy group.
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**First stool (bowel movement):** Right colectomy patients passed their first stool after a median of **3 days**, compared to **2 days** for left colectomy patients (p = 0.189). Although not statistically significant, this represents a one-day delay in the right colectomy group.

### Nasogastric Tube Requirement (Postoperative Ileus Indicator)

The most striking difference between the groups involved the need for a nasogastric tube after surgery, which indicates that the bowel was not recovering normally (postoperative ileus):

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**Right colectomy:** **20 patients (24%)** required a nasogastric tube
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**Left colectomy:** **11 patients (8%)** required a nasogastric tube
- This difference was **highly statistically significant (p = 0.002)**, meaning that right colectomy patients were approximately **three times more likely** to need nasogastric tube decompression.

**Postoperative ileus** is a temporary impairment of bowel function that occurs after abdominal surgery. It is a common and frustrating complication, causing abdominal bloating, nausea, vomiting, and delayed ability to eat and drink. Risk factors for prolonged ileus have been extensively studied. Chapuis and colleagues (2013) analyzed 2,400 consecutive colorectal cancer patients and identified several independent risk factors. Moghadamyeghaneh et al. (2015), Vather and Bissett (2013), and Millan et al. (2012) similarly examined risk factors for prolonged ileus, while Wolthuis and colleagues (2016) conducted a systematic review and meta-analysis establishing the incidence of prolonged postoperative ileus after colorectal surgery. Other research by Svatek and colleagues (2010) found that age and body mass index (BMI) are independent risk factors for postoperative paralytic ileus after major abdominal surgery, and Pikarsky et al. (2002) and Ay et al. (2011) examined obesity as a risk factor.

### Overall Complication Rates

The researchers tracked all complications occurring within the postoperative period:

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**Right colectomy:** **49% complication rate**

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**Left colectomy:** **37% complication rate**

- Statistical comparison: p = 0.071 (did not reach statistical significance, but suggests a potential trend toward more complications after right colectomy)

While this difference did not meet the conventional threshold for statistical significance (usually p < 0.05), the 12-percentage-point gap is clinically meaningful and deserves attention.

### Length of Hospital Stay

Hospital stay was significantly different between the two groups:

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**Right colectomy:** **Median 6 days** (interquartile range [IQR] 4–9)
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**Left colectomy:** **Median 5 days** (interquartile range [IQR] 4–7.5)
- Statistical comparison: **p = 0.020 (statistically significant)**

The **interquartile range** describes how spread out the data are. For right colectomy patients, the middle 50% of patients stayed between 4 and 9 days; for left colectomy patients, the middle 50% stayed between 4 and 7.5 days. This one-day median difference in hospital stay is clinically relevant both for patient experience and for healthcare costs.

## Clinical Implications: What This Means for Patients

This study provides valuable information for patients facing colon surgery and for the surgical teams caring for them.

**First, the good news:** The ERAS pathway worked equally well for both types of colon surgery in terms of how consistently patients followed the protocol. With compliance rates of 76% and 77%, this study demonstrates that the same standardized recovery pathway can be successfully applied regardless of which side of the colon is being operated on. This is reassuring for patients who want the benefits of accelerated recovery no matter what type of colectomy they need.

**However, the study also reveals an important pattern:** Patients undergoing right colectomy appear to have a slower functional recovery compared to left colectomy patients. The one-day delay in first stool (3 days vs. 2 days), the nearly significant delay in first flatus, the significantly higher rate of nasogastric tube placement (24% vs. 8%), and the longer hospital stay (6 vs. 5 days) all point in the same direction.

These findings are particularly relevant in light of research on interventions that may help prevent or treat postoperative ileus. For example:

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**Alvimopan** (a medication that blocks opioid effects on the bowel): Simorov et al. (2014) showed that alvimopan reduces length of stay and costs in patients undergoing segmental colonic resections. Abodeely et al. (2011) specifically examined its use in laparoscopic right colectomy, and Kelley et al. (2013) evaluated its cost-effectiveness in fast-track pathways. A meta-analysis by Tan et al. (2007) confirmed alvimopan's superiority over placebo for treating postoperative ileus.
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**Chewing gum:** Short and colleagues (2015) published a Cochrane systematic review finding that chewing gum can improve postoperative recovery of gastrointestinal function.
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**Coffee:** Müller and colleagues (2012) conducted a randomized clinical trial demonstrating that coffee consumption significantly affects postoperative ileus following elective colectomy.
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**Laxatives:** Zingg and colleagues (2008) showed in a prospective randomized trial that bisacodyl improves postoperative bowel motility in elective colorectal surgery.
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**Systemic lidocaine:** Sun and colleagues (2012) performed a meta-analysis of randomized controlled trials showing that perioperative systemic lidocaine improves postoperative analgesia and recovery after abdominal surgery.

Based on their findings, the study authors suggest that **more cautious early feeding after right colectomy should be considered**. This means the current one-size-fits-all approach to postoperative feeding may need to be tailored specifically for right colectomy patients.

The authors' conclusion is clear: "Overall compliance with the protocol was equally high in both groups showing that ERAS protocol was applicable for right and left colectomy. Functional recovery however, tended to be slower after right colectomy, and postoperative ileus rate was significantly higher. More cautious early feeding after right colectomy should be considered."

Why might right-sided surgery be associated with slower recovery? The authors point to several possible explanations. Right-sided resections may involve different anatomical considerations, including a different type of anastomosis (the surgical reconnection of the bowel). Hübner and colleagues (2012) published a technical description of radical right colectomy with a specific side-to-side stapled ileo-colonic anastomosis technique. The ileum (the last part of the small intestine) is involved in right colectomy, and the connection between the small intestine and the colon may have different functional characteristics than a connection between two parts of the large intestine in left colectomy. Additionally, the surgical approach and the type of anastomosis (stapled versus handsewn) have been studied by Neutzling et al. (2012) in a Cochrane review, though that analysis focused on different comparisons.

## Limitations: What the Study Couldn't Prove

As with any medical study, this research has important limitations that patients and clinicians should understand when interpreting the findings.

**Retrospective design:** The study analyzed data that were collected prospectively but were reviewed retrospectively. This means the researchers were working with existing data rather than randomly assigning patients to treatment groups. While baseline characteristics were well matched between the two groups, a retrospective design cannot eliminate all potential confounding factors (variables that might influence outcomes independently of the surgery type).

**Potential for selection bias:** Surgeons decided which patients received right versus left colectomy based on clinical need (the location of disease), not by randomization. While the groups were well matched for demographics, other unmeasured factors could have influenced outcomes.

**Single-center study:** All patients were treated at one Swiss surgical center. While this ensures consistency in surgical technique and ERAS protocol application, it also means the results may not be fully generalizable to other hospitals with different patient populations, surgical approaches, or ERAS protocols. The findings should ideally be replicated in multicenter studies to confirm their applicability. The ERAS Compliance Group's international registry study (2015) showed that compliance varies substantially across institutions, which could affect outcomes.

**Moderate sample size:** With 85 right colectomy patients, the study had limited statistical power to detect small differences between groups. Some differences that appeared clinically meaningful (such as the 49% vs. 37% complication rates, p = 0.071) did not reach statistical significance, potentially because the sample size was too small to detect these differences reliably. Similarly, the difference in first flatus timing (both on day 2, p = 0.057) approached but did not cross the significance threshold.

**Statistical significance vs. clinical significance:** It is also worth noting that statistical significance does not always equal clinical importance, and conversely, the lack of statistical significance does not always mean a finding is clinically irrelevant. The higher complication rate and delayed bowel recovery in the right colectomy group, while only borderline or non-significant in some measures, may still be important for individual patients.

**Operating surgeon variability:** The study did not report on how many different surgeons performed the operations, and individual surgical technique can influence outcomes. Anastomotic leakage rates, which have been shown to differ between right and left colectomies by Veyrie et al. (2007), can also be surgeon-dependent.

## Recommendations: Actionable Advice for Patients

Based on this study and the broader body of ERAS research, here is what patients facing colon surgery should keep in mind:

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**Ask about the ERAS protocol:** Before your surgery, ask whether your surgical team uses an Enhanced Recovery After Surgery pathway. The evidence strongly supports ERAS for improving recovery and shortening hospital stays. Multiple studies — including meta-analyses by Greco et al. (2014) and systematic reviews by Rawlinson et al. (2011) and Wind et al. (2006) — confirm its benefits.
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**Understand that recovery differs by surgery type:** If you are having a right colectomy, be prepared for the possibility of a slightly slower return of bowel function. If you are having a left colectomy, recovery of bowel function may be somewhat quicker. While the ERAS protocol works well for both, right colectomy patients in this study had a significantly higher need for nasogastric tube placement (24% vs. 8%) and a longer average hospital stay (6 vs. 5 days).
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**Discuss feeding plans after right colectomy:** Given that this study found a significantly higher rate of postoperative ileus after right colectomy, the authors recommend considering a more cautious approach to early feeding after this procedure. Ask your surgeon about the specific feeding plan they recommend for your type of surgery.
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**Know the signs of postoperative ileus:** Postoperative ileus can cause abdominal swelling, nausea, vomiting, and the inability to pass gas or have a bowel movement. If you experience these symptoms after surgery, tell your healthcare team immediately. Prompt recognition is key — research by Vather and colleagues (2013, 2015) has helped develop definitions and risk stratification tools for this condition.
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**Advocate for multimodal pain management:** ERAS protocols typically use **epidural analgesia** (pain relief delivered through a small tube near the spinal cord) or other non-opioid approaches to minimize the constipating effects of narcotic pain medications. The Postoperative Pain Forum Group's meta-analysis (2007) confirmed the benefits of epidural analgesia over parenteral opioids after colorectal surgery, and Levy et al. (2011) and Hübner et al. (2014) performed randomized trials on epidural versus patient-controlled analgesia in laparoscopic colorectal surgery.
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**Ask about other ileus-prevention strategies:** Several evidence-based approaches have been shown to help bowel function recover after colon surgery. These include chewing gum (Cochrane review by Short et al., 2015), drinking coffee (Müller et al., 2012), and possibly the medication alvimopan, which has been shown to reduce length of stay and costs (Simorov et al., 2014). Ask your surgeon whether any of these interventions could be appropriate for you.
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**Discuss your specific risk factors:** Research has identified several risk factors for prolonged postoperative ileus, including age, body mass index (Svatek et al., 2010), and other patient characteristics (Vather and Bissett, 2013; Millan et al., 2012; Moghadamyeghaneh et al., 2015; Xu and Chi, 2014). Have an honest conversation with your surgical team about your individual risk profile.
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**Be an active participant in your recovery:** ERAS protocols rely heavily on patient engagement — getting out of bed early, walking soon after surgery, eating as soon as you're able, and actively participating in your recovery plan. Ask the nursing staff to help you stay on track with these goals.

It is important to remember that this study looked at patients at a single center and that individual results always vary. Your specific surgeon, the surgical technique used (including the type of anastomosis created — techniques such as those described by Senagore et al., 2003, and Hübner et al., 2012), your overall health, and your condition's severity all influence your personal recovery timeline.

This study adds to the accumulating evidence that enhanced recovery programs can and should be tailored to individual patient needs and procedure types. While the same general ERAS principles apply to both right and left colectomies, this research suggests that right colectomy patients may require extra attention to bowel recovery — and perhaps a somewhat more gradual reintroduction of oral nutrition — during the crucial early days after surgery.

## Frequently Asked Questions

### What is the Enhanced Recovery After Surgery (ERAS) protocol?

ERAS is a set of evidence-based measures used before, during, and after colon surgery to speed up recovery. It includes shorter fasting times, non-opioid pain relief such as nerve blocks, early eating and movement after surgery, and avoiding routine nasogastric tubes. Research shows ERAS improves outcomes and shortens hospital stays after colorectal operations.

### What is the difference between right-sided and left-sided colon surgery?

Right colectomy removes the ascending colon on the right side. Left colectomy removes the descending and sigmoid colon on the left side. These operations treat conditions like colon cancer and diverticulitis. This study compared recovery after each when both patient groups followed the same ERAS recovery protocol.

### Which patients had a higher need for a nasogastric tube after surgery?

In a study of 223 patients, those who had right colectomy required a nasogastric tube more often than those who had left colectomy. Specifically, 24% of right colectomy patients needed the tube, compared to 8% of left colectomy patients. This difference was statistically significant and suggests slower bowel recovery after right-sided surgery.

### Did right or left colectomy patients have a longer hospital stay?

Right colectomy patients stayed in the hospital longer. The median stay was 6 days for right colectomy, compared to 5 days for left colectomy. This was a statistically significant difference. The longer recovery likely relates to slower return of bowel function and a higher rate of postoperative ileus after right-sided colon surgery.

### How did bowel function recovery compare between the two surgery types?

Recovery of bowel function tended to be slower after right colectomy. The first stool occurred after a median of 3 days in right colectomy patients versus 2 days in left colectomy patients. First gas passage was on day 2 for both groups, but the difference almost reached statistical significance.

### Should patients expect different recovery based on which side of the colon is operated on?

Yes, based on this study, right-sided colon surgery may be followed by slower return of bowel function and a higher chance of needing a nasogastric tube. The study authors suggest that right colectomy patients might need a more cautious early feeding plan. However, the ERAS protocol was equally applicable and effective for both surgery types.

### What does compliance with the ERAS protocol mean for patient outcomes?

This study found that patients complied with the ERAS protocol equally well after right or left colectomy, with 76% and 77% adherence, respectively. Good compliance matters because earlier research shows that higher adherence to ERAS protocols is associated with better outcomes, such as a shorter hospital stay and fewer complications after colorectal surgery.

### Should patients scheduled for a right-sided colon resection seek a second opinion about their recovery plan, since recovery seems different from left-sided colon surgery?

Patients facing a right colectomy may benefit from a second opinion to discuss how their recovery can differ from a left colectomy. In a large cohort following the same ERAS recovery pathway, right colectomy patients needed a nasogastric tube more often (24% vs. 8%) and had a longer hospital stay (median 6 vs. 5 days). The authors suggest considering more cautious early feeding after right colectomy. A second opinion can help clarify these specific risks and allow you to develop an individualized postoperative feeding and recovery plan with your surgical team. Diagnostic Detectives Network provides independent expert second opinions.

## Source Information

**Original Article Title:** Enhanced Recovery Pathway for Right and Left Colectomy Comparison of Functional Recovery - Kummer - 2016 - World Journal of Surgery - Wiley Online Library

**DOI:** [10.1007/s00268-016-3563-5](https://doi.org/10.1007/s00268-016-3563-5)

**Authors:** Anne Kummer, Juliette Slieker, Fabian Grass, Dieter Hahnloser, Nicolas Demartines, and Martin Hübner

**Journal:** World Journal of Surgery, Volume 40, Issue 10, pages 2519–2527

**Publication Details:** First published online on May 18, 2016. DOI: 10.1007/s00268-016-3563-5

**Trial Registration:** Research Registry UIN 372

**Meeting Presentation:** Congrès Suisse, Société Suisse de Chirurgie, Berne, Switzerland, May 20–22, 2015

**Funding/Access:** This article has been cited 32 times in the scientific literature.

*Note: This patient-friendly article is based on peer-reviewed research. The original study is available through the World Journal of Surgery and Wiley Online Library. This translation is intended for educational purposes and does not constitute medical advice. Patients should always discuss their individual surgical and recovery plans with their healthcare provider.*


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