Objectives This study evaluates compliance with Enhanced Recovery After Surgery (ERAS) protocol for open gynecologic oncologic surgery at a tertiary center and relationship between levels of compliance and perioperative outcomes.

Methods Our retrospective cohort study included 1879 patients between November 2014 and December 2020. Two groups were identified based on compliance level (<80% versus ≥80%). Our primary outcomes were 30-day readmission, reoperation, length of stay, and postoperative complications. We also assessed compliance with each ERAS item over time (P1: 2014–2016, P2: 2017–2018, P3: 2019–2020) categorizing patients according to date of surgery. Values were compared between P3 and P1. Multivariable logistic regression analyses were performed to evaluate associations between high compliance and perioperative outcomes.

Results Overall compliance was 74% (95%, CI 71.9–78.2). Compliance with ERAS >80% was associated with lower Clavien-Dindo grades II (OR 0.74, 95%CI 0.59–0.93), III (OR 0.55, 95%CI 0.33–0.93), and V (OR 0.08, 95%CI 0.01–0.60) complication rates, readmission rates (OR 0.61; 95%CI 0.43–0.88) and shorter length of stay (OR 0.59; 95%CI 0.47–0.75). Preoperatively, there was increased adherence to counseling (50%, p=0.01), optimization (21%, p=0.02), and carbohydrate-loading (74%, p=0.02). Intraoperatively, use of short-acting anesthetics and adherence to avoiding abdominal drainage (7%, p=0.04) increased. Compliance with goal directed fluid therapy (16%, p=0.04) and normothermia (8%, p=0.03) decreased. Postoperatively, there was increased compliance with avoiding saltwater overload (8%, p=0.02) and multimodal analgesia (5%, p=0.02).

Conclusions Compliance (>80%) with ERAS is associated with lower complication rates, 30-day readmissions, and shorter length of stay without impacting reoperation rates and postoperative opioid use.