Enhanced Recovery Protocols in Gastrectomy for Gastric Cancer: Evaluating the Impact of Frailty

Introduction: Frailty is a known risk factor for adverse postoperative outcomes after gastrectomy for gastric cancer. However, its impact within standardized enhanced recovery protocols (ERPs) has not been fully elucidated. This study aimed to evaluate the association of frailty with postoperative outcomes and protocol adherence in patients undergoing gastrectomy managed under ERP across six Italian centers. Methods: This retrospective multicenter study included 957 patients undergoing gastrectomy within an ERP between 2018 and 2024. Frailty was assessed using the 5-item modified frailty index (5MFI), classifying patients as frail (5MFI ≥ 2) or nonfrail (5MFI < 2). Postoperative outcomes and compliance with individual ERP components were compared between frail and nonfrail patients. Entropy balancing was applied to adjust for confounders including surgical approach, procedure type, lymphadenectomy, and neoadjuvant therapy. Results: Among ERP patients, 291 (30.4%) were frail. Frail patients were older (median 75 vs. 67 years; p < 0.001) and had higher comorbidity scores. Compliance to ERP items was significantly lower in the frail group for urinary catheter removal within 48 h (64.3% vs. 73.1%, p = 0.024) and avoidance of central venous catheters (36.7% vs. 45.0%, p = 0.043). Overall complication rates (36.8% vs. 32.0%, p = 0.212) and 90-day mortality (2.7% vs. 1.0%, p = 0.146) did not differ significantly between groups. However, frail patients experienced higher rates of pulmonary complications (13.0% vs. 6.2%, p = 0.008) and ICU admissions (15.8% vs. 9.3%, p = 0.029). Length of hospital stay and readmission rates were similar between groups. Conclusions: Frailty remains a significant factor associated with specific postoperative complications and ICU admissions despite standardized ERP management. Although overall adherence to ERP items was largely comparable, frail patients showed lower compliance with selected preoperative components, suggesting the need for targeted strategies to support full protocol implementation in this vulnerable population.