Risk factors for failure of enhanced recovery after surgery protocols following laparoscopic radical gastrectomy in older patients

Enhanced Recovery After Surgery (ERAS) protocols have demonstrated significant benefits in gastric cancer surgery. However, data regarding risk factors for ERAS failure specifically in older patients remain limited. This study aimed to identify risk factors associated with ERAS failure in older patients undergoing laparoscopic radical gastrectomy (LRG). A consecutive cohort of 307 older patients who underwent elective LRG with an ERAS protocol between January 2021 and December 2025 was retrospectively analyzed. ERAS failure was defined as a composite endpoint comprising: (1) prolonged postoperative hospital stay exceeding the 75th percentile (> 9 days) attributable to postoperative complications; (2) unplanned readmission within 30 days after discharge; or (3) 30-day mortality. Univariate and multivariate logistic regression analyses were performed to identify independent risk factors for ERAS failure. Among the 307 enrolled patients, 76 (24.76%) encountered ERAS failure, and there were no fatalities. Pneumonia ( n = 13) is the most significant postoperative complication leading to an extended postoperative hospital stay. Univariable and multivariable analysis showed that ASA grade III (OR 1.969, 95% CI 1.109–3.495, P = 0.021) and total gastrectomy (OR 2.567, 95% CI 1.472–4.476, P = 0.001) were independent risk factors for ERAS failure. ASA grade III and total gastrectomy were identified as independent risk factors for ERAS failure after LRG in older patients with gastric cancer. Preoperative risk stratification and optimization are crucial for enhancing ERAS outcomes in this vulnerable population. Sensitivity analyses confirmed the robustness of these findings.