Implementation of Enhanced Recovery After Surgery in CRS plus HIPEC in a high-volume tertiary center in a lowe-middle income country

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is associated with significant morbidity. Enhanced Recovery After Surgery (ERAS) protocols may improve perioperative outcomes, but data from low- and middle income countries (LMICs) are limited. An ambispective study at the AIIMS center in Delhi (India) compared patients undergoing CRS-HIPEC before (January 2015-June 2022; n=294) and after (July 2022 –June 2024; n=70) ERAS implementation. Overall, ERAS compliance was 77.1%. Compliance was highest for preoperative and intraoperative components, while postoperative elements showed lower adherence. Median postoperative length of stay decreased significantly for 8 to 5 days (p=0.02). Major morbidity declined from 20.1% to 12.9% (not statistically significant). Ninety-day mortality (4.6% versus 4.3%), readmission (15% versus 12.9%), and reoperation rates (13% versus 10%) were comparable between groups. The authors conclude that implementation of an ERAS pathway for CRS-HIPEC in a high-volume LMIC center is feasible and safe, resulting in shorter hospital stay without increasing morbidity or mortality.