Determinants of Compliance to Enhanced Recovery Protocol After Emergency Laparotomy

Background: Enhanced recovery protocols (ERP) are comprehensive, evidence-based approaches aimed at accelerating patient recovery and improving surgical results; increasing evidence exists about their adoption in emergency laparotomy. The study aimed to evaluate the compliance to the proposed postoperative pathway and the determinants of late recovery. Methods: This is a multicenter observational prospective study involving 13 Italian centers. Inclusion criteria targeted adults undergoing emergency surgery for intestinal occlusion or perforation. The primary end point was the early recovery rate (discontinuation of intravenous fluids and the initiation of oral intake on postoperative day three) and its determinants. The secondary end point were reasons for uncompliance to postoperative ERP items. Results: Between March 2023 and March 2024, 760 patients were recruited and analyzed, 60.2 with intestinal obstruction and 39.8 with intra-abdominal infections. Recovery was achieved by 53.7% of patients on postoperative Day 3. Among determinants, clinical frailty and ASA status negatively correlated with recovery whereas the absence of surgical drains, anesthetic depth monitoring and intraoperative goal-directed fluid therapy positively correlated with recovery. An analysis of the reasons for noncompliance with postoperative items revealed that aside from postoperative complications, the most frequently cited reason was protocol deviation for clinical decision, accounting for approximately 10%–15% of noncompliance for each item. Conclusions: This study showed that half of the patients reached the recovery goal on postoperative Day 3 and that early recovery after surgery is influenced both by intrinsic patient factors and by adherence to ERP strategies. Future research should prioritize strategies to improve ERP adherence and postoperative compliance.