ERAS pathway adherence and its association with return to intended oncological therapy after gastrectomy.

BACKGROUND

Enhanced Recovery After Surgery (ERAS) pathways improve short-term outcomes in abdominal surgery, but their impact on timely initiation of adjuvant chemotherapy (Return to Intended Oncologic Therapy, RIOT) in gastric cancer remains uncertain.

METHODS

This multicenter, prospective cohort study (POWER4, NCT03865810) analysed 742 patients undergoing gastrectomy across 72 Spanish hospitals (2019-2020). ERAS adherence was assessed by quartiles.

PRIMARY OUTCOME: timely RIOT (chemotherapy initiation ≤56 days post-surgery).

SECONDARY OUTCOME: time to RIOT (days). Multivariable logistic and Cox regression models adjusted for clinical/tumour factors.

RESULTS

Of 742 patients, 65 % achieved timely RIOT. Quartile-based univariable analysis revealed shorter time to RIOT with higher adherence (Q4 vs. Q1: HR 0.64, 95 % CI 0.42-0.97, *p* = 0.034), but this association disappeared in multivariable models. Advanced TNM stage (e.g.

, IIIC: HR 18.6, *p* < 0.001) and ASA class were stronger predictors of delayed RIOT.

CONCLUSIONS

While ERAS pathways may aid recovery, their impact on RIOT depends on high adherence and is overshadowed by tumour-related factors. Future efforts should integrate ERAS with prehabilitation for high-risk patients and target adherence thresholds ≥70 %.