Impact of enhanced recovery after surgery protocol on elderly patients undergoing laparoscopic hepatectomy for hepatocellular carcinoma: a retrospective propensity score matched analysis

BACKGROUND: Elderly patients with hepatocellular carcinoma (HCC) are particularly vulnerable to postoperative complications after liver resection. Evidence on enhanced recovery after surgery (ERAS) specifically in elderly individuals undergoing laparoscopic hepatectomy for HCC remains limited. METHODS: We retrospectively analyzed elderly patients (70-85 years) with pathologically confirmed HCC who underwent elective laparoscopic hepatectomy at a single tertiary center between June 2018 and June 2024. Patients managed with a standardized ERAS pathway were compared with those receiving conventional perioperative care. Propensity score matching (1:1) was performed based on demographic characteristics, comorbidities, liver function, and surgical factors. The primary endpoint was postoperative length of stay (LOS). Secondary endpoints included time to gastrointestinal recovery, postoperative pain scores, complications (Clavien-Dindo classification), rates of pleural effusion, 30-day readmission, and total hospitalization costs. RESULTS: After matching, baseline characteristics were well balanced between the ERAS and conventional care groups. Compared with conventional care, the ERAS group achieved earlier gastrointestinal recovery (shorter time to first flatus and liquid diet) and shorter urinary catheterization. Median postoperative LOS was significantly reduced, and total hospitalization costs were lower in the ERAS group. ERAS patients reported lower pain scores on postoperative days 1 and 3 and experienced fewer overall and pulmonary complications, particularly pleural effusion, without an increase in life-threatening (Clavien-Dindo grade IV-V) complications or 30-day readmissions. CONCLUSIONS: In carefully selected elderly patients undergoing laparoscopic hepatectomy for HCC, implementation of an ERAS protocol appears safe and feasible, and is associated with accelerated recovery, fewer complications, and reduced healthcare costs compared with conventional perioperative care. Prospective multicenter studies are warranted to confirm these findings and to further define the role of ERAS in more vulnerable elderly subgroups.