Adherence to enhanced recovery protocol in emergency general surgery: a prospective observational study

Enhanced recovery pathways (ERPs) are evidence-based, multimodal strategies designed to promote early recovery and to optimize surgical outcomes. While extensively implemented in elective surgery, their adaptation to emergency general surgery (EGS) raises challenges due to patient instability and limited preoperative time. The study aimed to evaluate the adherence to each ERPs item and the impact on short-term outcomes in patients undergoing emergency general surgery. This is a multicenter observational prospective study carried out in 13 Italian centers. Inclusion criteria targeted adults undergoing surgery for intestinal occlusion or perforation. Patients re-operated after elective surgery were excluded. The primary endpoints were the adherence to intraoperative ERP items and the compliance to the postoperative recovery pathway. Secondary endpoints were postoperative mortality, morbidity, and length of hospital stay. Between March 2023 and March 2024, 760 patients were analyzed. The highest adherence was observed for active warming (97%), PONV prevention (92%), and long-acting opioid avoidance (87%). The lowest adherence was found for invasive arterial pressure monitoring (35%), depth of anesthesia monitoring (34%), locoregional analgesia (31%), and minimally invasive surgery (26%). By postoperative day 3, 66% of patients tolerated solid diets and 58% had discontinued intravenous fluids. Postoperative mortality, morbidity, and major complications occurred in 3%, 33%, and 9% of patients, respectively. Median hospital stay was 7 days. This study underscores the adherence to ERP in EGS, highlighting the potential of ERP to improve perioperative outcomes in a high-risk population. Future research should prioritize strategies to enhance adherence, particularly to underutilized components as goal-directed fluid therapy and minimally invasive surgery and further optimize ERP protocols for emergency settings.