Real-World Implementation of Neurosurgical Enhanced Recovery After Surgery Protocol for Gliomas in Patients Undergoing Elective Craniotomy

Abstract

ObjectiveTo design a multidisciplinary enhanced recovery after surgery (ERAS) protocol for glioma patients undergoing elective craniotomy and evaluate its clinical efficacy and safety after implementation in a tertiary neurosurgical center in China.MethodsERAS protocol for glioma patients was developed and modified based on the best available evidence. Patients undergoing elective craniotomy for treatment of glioma between September 2019 to May 2021 were enrolled in a randomized clinical trial comparing a conventional neurosurgical perioperative care (control group) to an ERAS protocol (ERAS group). The primary outcome was postoperative hospital length of stay (LOS). Secondary outcomes were 30-day readmission rate, postoperative complications, duration of the drainage tube, time to first oral fluid intake, time to ambulation and functional recovery status.ResultsA total of 151 patients were enrolled (ERAS group: n = 80; control group: n = 71). Compared with the control group, postoperative LOS was significantly shorter in the ERAS group (median: 5 days vs. 7 days, p<0.0001). No 30-day readmission or reoperation occurred in either group. The time of first oral intake, urinary catheter removal within 24 h and early ambulation on postoperative day (POD) 1 were earlier and shorter in the ERAS group compared with the control group (p<0.001). No statistical difference was observed between the two groups in terms of surgical- and nonsurgical-related complications. Functional recovery in terms of Karnofsky Performance Status (KPS) scores both at discharge and 30-day follow-up was similar in the two groups. Moreover, no significant difference was found between the two groups in the Hospital Anxiety and Depression Scale (HADS) scores.ConclusionThe implementation of the ERAS protocol for glioma patients offers significant benefits over conventional neurosurgical perioperative management, as it is associated with enhancing postoperative recovery, without additional perioperative complications and risks.Clinical Trial RegistrationChinese Clinical Trial Registry (http://www.chictr.org.cn/showproj.aspx?proj=42016), identifier ChiCTR1900025108

Designing Enhanced Recovery After Surgery Protocols in Neurosurgery: A Contemporary Narrative Review

“…These elements include preoperative patient education, nutritional optimization, minimally invasive surgical techniques, standardized anesthetic management, multimodal analgesia, and standardized postoperative care protocols including early mobilization. 8,[21][22][23] Studies have shown that patients under these protocols experience no increase in postoperative complications, benefit from shorter hospital stays, and report enhanced satisfaction. 5,6,8,11 Spine Surgery ERAS protocols in spine surgery, especially procedures involving lumbar and cervical regions, have been reported to reduce postoperative pain, result in fewer complications, and reduce hospital lengths of stay.…”

“…8,[21][22][23] Studies have shown that patients under these protocols experience no increase in postoperative complications, benefit from shorter hospital stays, and report enhanced satisfaction. 5,6,8,11 Spine Surgery ERAS protocols in spine surgery, especially procedures involving lumbar and cervical regions, have been reported to reduce postoperative pain, result in fewer complications, and reduce hospital lengths of stay. 7,24 Furthermore, the Society for Neuroscience in Anesthesiology and Critical Care (SNACC) produced guidelines for complex spine surgery 25 that align with current ERAS recommendations.…”

“…Supporting studies Benefits of ERAS Craniotomy Qu et al (2020), 5 Wang et al (2022) 8 Reduced length of hospital stays Liu et al (2020), 9 Wang et al (2022) 8 Decreased time to functional recovery Liu et al (2020), 9 Wang et al (2022), 8 Wang et al (2022) 10 Reduced postoperative nausea and vomiting Wang et al (2018), 6 Qu et al (2020), 5 Wang et al (2022) 10 Reduced postoperative pain and its duration Wang et al (2022), 8 Wang et al (2022) 10 Potential cost savings Liu et al (2019) 11 Enhanced patient satisfaction Spine surgery Soffin et al (2019), 12 Staartjes et al (2019), 13 Debono et al (2019) 14 Shorter length of hospital stays Staartjes et al (2019) 13 Reduction in operative time Mathiesen et al (2013), 15 Grasu et al (2018), 16 Ali et al (2018) 17 Reduced postoperative opioid use Mathiesen et al (2013) 15 Reduced postoperative nausea and vomiting Chakravarthy et al (2019) 18 Decrease in surgical site infections Chakravarthy et al (2019) 18 Reduction in perioperative transfusion requirements Mathiesen et al (2013), 15 Debono et al (2017), 19 Ali et al (2018) 17 Quicker return to mobilization and ambulation Debono et al (2017), 19 Feng et al (2019) 20 Reduction in health care costs Debono et al (2019) 14 Improved patient satisfaction…”

“…In ERAS protocols designed for craniotomy, certain elements are directly correlated with favorable outcomes. These elements include preoperative patient education, nutritional optimization, minimally invasive surgical techniques, standardized anesthetic management, multimodal analgesia, and standardized postoperative care protocols including early mobilization 8,21–23 . Studies have shown that patients under these protocols experience no increase in postoperative complications, benefit from shorter hospital stays, and report enhanced satisfaction 5,6,8,11 …”

“…To overcome this resistance, continuous education, training, and support from institutional and professional leaders are imperative 50 . A multidisciplinary approach, with close collaboration among neurosurgeons, neuroanesthesiologists, intensivists, nursing staff, and other health care professionals, is essential for the development and adoption of procedure-specific ERAS protocols, with ongoing quality improvement initiatives required for the full potential of ERAS to be realized 4,8,51 . However, establishing and sustaining such collaboration can pose challenges, especially within large or fragmented health care systems.…”