Implementation Rates and Predictors of Compliance with Enhanced Recovery After Surgery Protocols in Gynecologic Oncology: A Prospective Multi-Institutional Cohort Study

Background: The importance of integrating enhanced recovery after surgery (ERAS) protocols in gynecologic oncology has been proven in numerous studies. However, the actual adherence to protocol among institutions remains inconsistent in clinical practice, particularly among those without prior structured implementation. This pragmatic multicenter study provides a preliminary report from the ongoing ERGO (Enhanced Recovery in Gynecologic Oncology) cohort study (ClinicalTrials.gov: NCT06655506) and aims to evaluate adherence to ERAS protocols during the early phases of its adoption as well as to determine factors determining low uptake. Methods: Overall, 300 consecutive patients undergoing gynecologic oncology surgery across five institutions were included in the present study. Adherence to preoperative, intraoperative, and postoperative ERAS elements was documented using standardized forms. Optimal adherence was predetermined as fulfillment of more than 70% of the ERAS components included in the pathway. Multinomial analysis was used to identify predictors of adherence. Results: Overall, 70.3% of patients achieved optimal adherence; however, rates varied across centers (26.9%–84.4%), reflecting the limited institutional familiarity with ERAS pathways in most participating centers. The actual volume of cases handled was as an important determinant of adherence, with high-volume units consistently demonstrating substantially higher compliance compared with lower-volume hospitals. Routine preoperative items demonstrated high uptake, whereas several intraoperative and early postoperative components showed low and heterogeneous implementation, that might be the result of anesthesiology-driven practices. Higher surgical complexity and poorer ECOG performance status independently predicted reduced adherence. Visual mapping confirmed that complex procedures resulted in lower adherence. Conclusion: The significant variability in ERAS adherence that was observed in our study indicates the need to institute structured workflows that help increase team familiarization, particularly in high-complexity cases and centers new to ERAS.