Enhanced recovery after surgery compliance and postoperative outcomes after liver resection: retrospective cohort study.

BACKGROUND

Enhanced recovery after surgery (ERAS) pathways improve postoperative outcomes across surgical specialties, but the impact of ERAS compliance on outcomes after liver resection remains unclear. A retrospective cohort study of consecutive patients undergoing liver resection in an ERAS-certified centre was conducted to examine the association between overall and item-specific ERAS compliance and postoperative morbidity and length of hospital stay (LOS).

METHODS

This retrospective cohort included elective liver resections performed between 2020 and 2024 at an ERAS-certified centre of excellence. ERAS compliance was prospectively recorded and categorized as high (≥ 70%) versus low/moderate (< 70%). Primary outcomes were any postoperative complication, major morbidity (Clavien-Dindo grade ≥ IIIa), and LOS; these were assessed by univariable and multivariable analyses, including a sensitivity analysis using an early compliance score excluding postoperative items.

RESULTS

Data from 637 consecutive liver resections were analysed. Mean (standard deviation) overall ERAS compliance was 64.0 (10.2%) and remained stable over time. High compliance was associated with fewer complications (51% (104) versus 69.8% (303); odds ratio (OR) 0.45; 95% confidence interval (c.i.) 0.30 to 0.67; P < 0.001), lower major morbidity (7.25% (15) versus 12.8% (55); OR 0.25, 95% c.i. 0.10 to 0.64; P = 0.001), and shorter LOS (7.42 versus 10.62 days; mean difference -3.21 days; P < 0.001). In multivariable analyses, high overall compliance was associated with major morbidity (OR 0.16; 95% c.i. 0.04 to 0.56; P = 0.005). Minimally invasive surgery independently decreased overall complications (OR 0.41; 95% c.i. 0.21 to 0.75; P = 0.005), major morbidity (OR 0.13; 95% c.i. 0.01 to 0.66; P = 0.050), and LOS (β = -2.31 days; P = 0.020). In sensitivity analyses, high compliance remained associated with fewer complications (OR 0.62; 95% c.i. 0.40 to 0.96; P = 0.035). Higher intraoperative intravenous fluid volume independently predicted morbidity and prolonged LOS (P < 0.001).

CONCLUSION

Higher ERAS compliance after liver resection is associated with lower severe morbidity and shorter LOS. Prioritizing potentially high-impact items may maximize recovery benefits.