The impact of compliance with an enhanced recovery after surgery protocol on short-term outcomes in patients undergoing hepatectomy.

Background: Enhanced recovery after surgery (ERAS) protocols are multimodal, evidence-based pathways designed to attenuate the surgical stress response and accelerate recovery. While ERAS principles have been successfully applied in various surgeries, the impact of overall protocol compliance on outcomes after liver resection, a procedure with unique physiological demands, requires further elucidation. This study aimed to assess the effect of adherence to an ERAS protocol on short-term postoperative outcomes in patients undergoing hepatectomy. Materials and methods: This retrospective analysis included 156 patients who underwent elective hepatectomy at a single center from 2020 to 2024. All patients were managed according to a standardized 20-item ERAS protocol. Overall compliance was calculated as the percentage of protocol elements delivered per patient. Patients were stratified into high-compliance, defined as 70% or greater, with 98 patients, and low-compliance, defined as less than 70%, with 58 patients, based on the median compliance rate. Primary outcomes were postoperative complications within 30 days, graded by the Clavien-Dindo classification, and length of postoperative hospital stay. Secondary outcomes included time to first flatus, postoperative ileus, readmission rate, and Comprehensive Complication Index. Results: The high-compliance group demonstrated significantly fewer overall complications, 24.5% versus 50.0%, and major complications, 6.1% versus 19.0%. The median length of stay was substantially shorter in the high-compliance group, 6 days compared to 9 days. Multivariate analysis identified high ERAS compliance as an independent protective factor against major complications, with an odds ratio of 0.32, and prolonged length of stay, with an odds ratio of 0.24. Time to gastrointestinal recovery was also faster in the high-compliance group. The overall readmission rate was similar between groups. Conclusions: High overall compliance with a multimodal ERAS protocol is independently associated with reduced postoperative morbidity and shorter hospital stay following hepatectomy. These findings underscore the importance of strict adherence to ERAS elements throughout the perioperative journey. Efforts should be directed towards optimizing compliance through multidisciplinary teamwork and patient engagement to maximize the benefits of ERAS pathways in liver surgery.