Practical Application of ERAS Protocols in Older Adults with Hepatocellular Carcinoma Undergoing Hepatectomy: A Propensity Score Matching Study

Introduction: This retrospective observational study aimed to evaluate the safety and efficacy of Enhanced Recovery After Surgery (ERAS) protocols in older adult patients (≥ 65 years) with hepatocellular carcinoma (HCC) undergoing radical hepatectomy. Methods: In this retrospective observational study, 498 patients who underwent radical resection for HCC between January 2018 and December 2023 were included and divided into four groups: Older adult ERAS (OE Group, n=60), Younger adult ERAS (YE Group, n=148), Older adult non-ERAS (ONE Group, n=88), and Younger adult non-ERAS (YNE Group, n=202). Propensity score matching (PSM) was performed to balance baseline covariates, generating three pairwise matched cohorts: PSM-OE Group 1 vs PSM-YE Group (both n=37), PSM-OE Group 2 vs PSM-ONE Group (both n=53), and PSM-OE Group 3 vs PSM-YNE Group (both n=35). Short-term postoperative outcomes were compared across groups. Results: Results showed that postoperative pain control was significantly superior in PSM-OE Group 1 compared to PSM-YE Group (91.9% vs 70.3% pain-free, p=0.018) and in PSM-OE Group 2 compared to PSM-ONE Group (90.6% vs 69.8% pain-free, 7.328, p=0.013), with no significant difference between PSM-OE Group 3 and PSM-YNE Group (85.7% vs 74.3%, p=0.319). PSM-OE Group 2 had significantly shorter length of hospital stays (LOS: 13.17± 4.71 vs 16.68± 6.42 days, p=0.002) and length of postoperative stays (LPS: 6.94± 3.26 vs 9.64± 5.02 days, p=0.001) than PSM-ONE Group, while PSM-OE Group 3 also showed shorter LOS (13.31± 4.74 vs 17.34± 9.75 days, p=0.031) and LPS (7.26± 3.53 vs 10.49± 6.58 days, p=0.013) compared to PSM-YNE Group. The complication rate was notably lower in PSM-OE Group 2 than PSM-ONE Group (χ 2 =13.747, p=0.001), with no significant differences in complication rates between other matched pairs. Blood transfusion rates, average hospitalization costs, liver reserve function (assessed by PALBI score), and 30-day readmission rates (p=0.700) showed no significant differences across all matched cohorts. Multivariate regression analysis confirmed ERAS as an independent factor associated with reduced LOS (OR=1.733, p=0.038), LPS (OR=1.901, p=0.015), postoperative pain (OR=5.014, p=0.035), and complications (OR=5.235, p=0.021). Conclusion: ERAS protocols are safe and effective in enhancing postoperative recovery for older adult patients with HCC undergoing hepatectomy, supporting their adoption as standard perioperative care for this population.