Identification of core items and impact of adherence to an ERAS protocol in open aortic surgery

Introduction Enhanced Recovery After Surgery (ERAS) protocols represent a multidisciplinary strategy designed to optimize perioperative management and accelerate postoperative recovery. However, their adoption in vascular surgery—particularly in open aortic procedures—remains limited due to procedural complexity and the large number of elements required for implementation. In other surgical specialties, specific perioperative components have been identified as key determinants of outcome improvement, with adherence rates exceeding 70% considered essential to achieve significant clinical benefits. The aim of this study was to identify the core elements within an ERAS protocol for open aortic surgery that most significantly influence outcomes, and to evaluate the impact of overall protocol adherence on postoperative results. Methods A prospective study was conducted including 206 patients managed under an ERAS protocol (ERAVS group) between January 2019 and December 2025. Early outcomes assessed included time to discharge (TTD), 30-day mortality, postoperative complications, and readmissions. Late outcomes comprised overall survival, freedom from reintervention, and freedom from complications. The relationship between protocol adherence and clinical outcomes was analyzed, as well as the effect of individual protocol components. Based on the proportion of perioperative items applied, six adherence groups were defined (29%, 43%, 57%, 71%, 86%, and 100%), and mean hospital stay and complication rates were compared among them. Results A protocol adherence above 70% was achieved in 112 patients (54.5%). No statistically significant differences in baseline characteristics or comorbidities were observed between patients with adherence below or above 70%. The mean TTD across the six groups was 9.4, 7.8, 8.8, 6.0, 5.1, and 4.0 days, respectively (p < 0.001). Thirty-day postoperative complications occurred in 18 patients (19.1%) with adherence below 70%, compared with only 2 patients (1.8%) with adherence above 70% (p < 0.001). No 30-day mortality or readmissions were reported in any group. Follow-up was available for 99.5% of patients, with a mean duration of 44.4 months (SD 21.4; range 3–86). Four-year overall survival was 89% in patients with adherence below 70% and 95% in those with adherence ≥70% (p = 0.029). Linear regression analysis identified preoperative fasting/bowel preparation (B = 2.78; p=0.003), delayed removal of the central venous catheter (B = 0.15; p=0.054), nasogastric tube (B = 0.23; p=0.019), and urinary catheter (B = 0.90; p < 0.001) as independent predictors of prolonged hospital stay. Conclusions Adherence to more than 70% of the ERAS protocol components was associated with a significant improvement in postoperative outcomes and long-term survival, although this adherence level was achieved in just over half of the cohort. Multivariate analysis confirmed the influence of specific perioperative elements on length of stay. Further multicenter studies are warranted to validate these findings and to assess the reproducibility and generalizability of ERAS pathways in open aortic surgery.