Compliance with early postoperative ambulation and Its associated barriers in hepatobiliary surgery patients within an enhanced recovery after surgery framework

Background Early postoperative ambulation is a core element of the Enhanced Recovery After Surgery (ERAS) pathway for hepatobiliary surgery, yet real-world compliance has been reported to be variable and the patient-level barriers in this surgical population remain incompletely characterised. We therefore retrospectively reviewed the routinely collected ERAS quality-control archive of our hepatobiliary surgical unit to describe the actual compliance status and to identify factors associated with non-compliance. Methods We retrospectively extracted the records of 320 consecutive adult patients who had undergone elective hepatobiliary surgery between January 2022 and December 2024 and whose perioperative care had followed the institutional ERAS clinical pathway as standard practice. The institutional pathway comprised eight standardised components organised across the preoperative, intraoperative and postoperative phases, including structured patient education, carbohydrate loading, goal-directed fluid therapy, multimodal opioid-sparing analgesia, restrictive abdominal drainage, omission of routine nasogastric tubes, early oral feeding, and the early-ambulation prescription. Compliance with the early ambulation protocol [out-of-bed activity by postoperative day (POD) 1 and ambulation distance ≥30 m by POD 2] and patient-reported barriers documented in the routine nursing-assessment questionnaire were retrieved from the electronic medical record. The primary outcome was compliance status, while postoperative length of stay, time to first flatus, pulmonary complications, surgical site infection, symptomatic venous thromboembolism, major postoperative haemorrhage, in-hospital all-cause mortality and 30-day readmission were pre-specified secondary outcomes. Group allocation (compliant vs. non-compliant) reflected real-world clinical and patient/family decisions, not investigator-led randomisation. Univariable comparisons (chi-square, Fisher exact for low-frequency events, or Welch t-test as appropriate) and multivariable logistic regression adjusted for age, sex, BMI and the pre-specified clinical predictors were used to identify factors associated with non-compliance. Results Two hundred and three of 320 patients (63.4%) were classified as compliant with the early ambulation protocol. Compliance varied markedly by procedure, ranging from 80.0% after laparoscopic hepatectomy to 33.3% after biliary reconstruction. The most frequently documented patient-reported barriers were postoperative pain (46.3%), fatigue/weakness (37.0%), knowledge deficit (35.6%), and the presence of multiple drainage tubes (35.0%). In multivariable analysis, open or major hepatobiliary surgery [adjusted odds ratio (aOR) 3.53, 95% CI 1.92–6.48], having ≥3 drainage tubes (aOR 2.52, 1.43–4.42), Clinical Frailty Scale score ≥4 (aOR 2.51, 1.45–4.34), age ≥65 years (aOR 2.30, 1.26–4.18), and absence of a documented family companion (aOR 1.80, 1.03–3.13) were all independently associated with non-compliance. The model demonstrated acceptable discrimination (Hosmer–Lemeshow χ 2 = 6.41, P = 0.602; area under the ROC curve 0.812, 95% CI 0.765–0.859) without evidence of problematic multicollinearity (all variance inflation factors <1.8). Non-compliance was associated with longer hospital stay (11.9 ± 3.2 vs. 7.5 ± 2.3 days, P < 0.001) and higher rates of pulmonary complications (23.9% vs. 7.4%, P < 0.001) and 30-day readmission (14.5% vs. 3.4%, P = 0.001). Conclusions In this retrospective single-centre cohort, just under two-thirds of hepatobiliary surgery patients were compliant with the early ambulation component of the ERAS pathway. Compliance was associated with surgical magnitude, drainage burden, frailty, age, and family companionship, and may be related to the higher rate of postoperative complications observed in non-compliant patients. These findings suggest that targeted, multifactorial barrier-mitigation strategies could improve early-ambulation adherence in hepatobiliary surgery, although the observational design does not permit causal inference.