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Early versus delayed mobilization after aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis of efficacy and safety

*Alberto Morello, Antonio Spinello, Victor E. Staartjes, Enrico Lo Bue, Diego Garbossa, Menno R. Germans, Luca Regli, and Carlo Serra

OBJECTIVE

A central tenet of Enhanced Recovery After Surgery (ERAS) is evidence-based medicine. Survivors of aneurysmal subarachnoid hemorrhage (aSAH) constitute a fragile patient population prone to prolonged hospitalization within neurointensive care units (NICUs), prolonged immobilization, and a range of nosocomial adverse events. Potentially, well-monitored early mobilization (EM) could constitute a beneficial element of ERAS protocols in this population. Therefore, the objective was to summarize the available evidence on EM strategies in patients with aSAH.

METHODS

The authors retrieved prospective and retrospective studies that reported efficacy or safety data on EM (defined as EM in the NICU starting ≤ 7 days after ictus) versus delayed mobilization (DM) (any strategy that comparatively delayed mobilization) after aSAH and were published after January 1, 2000, in PubMed/MEDLINE, Embase, and the Cochrane Library. Random-effects meta-analysis was performed.

RESULTS

Ten studies analyzing 1292 patients were included for quantitative synthesis, including 1 randomized, 1 prospective nonrandomized, and 8 retrospective studies. Modified Rankin Scale scores at discharge were not different between the EM and DM groups (mean difference [MD] [95% CI] −0.86 [−2.93 to 1.20] points, p = 0.41). Hospital length of stay in days was markedly reduced in the EM group (MD [95% CI] −6.56 [−10.64 to −2.47] days, p = 0.002). Although there was a statistically significant reduction in radiological vasospasms (OR [95% CI] 0.65 [0.44–0.97], p = 0.03), the reduction in clinically relevant vasospasms was nonsignificant (OR [95% CI] 0.63 [0.31–1.26], p = 0.19). The odds of shunting were significantly lower in the EM group (OR [95% CI] 0.61 [0.39–0.95], p = 0.03). The rates of mortality, pneumonia, and thrombosis were similar among groups (p > 0.05).

CONCLUSIONS

Due to a lack of high-quality studies, vastly varying protocols, and resulting statistical clinical and statistical heterogeneity, the level of evidence for recommendations regarding EM in patients with aSAH remains low. The currently available data indicated that mobilization within the first 5 days after aneurysm repair was feasible and safe without significant excessive adverse events, that neurological outcome with EM was almost certainly not worse than with prolonged immobilization, and that there was likely at least some reduction in length of hospital stay. Radiological and clinical vasospasms were not more frequent—with signals even trending toward a decrease—in patients who mobilized early. Higher-quality studies and implementation of full ERAS protocols are necessary to evaluate efficacy and safety with a higher level of evidence and to guide practical implementation through increased standardization.

Clinical trial registration no.: CRD42023432828 (www.crd.york.ac.uk/prospero)

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Editorial. Overcoming implementation barriers in enhanced recovery using theory-based approaches

Walavan Sivakumar

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Effect of the enhanced recovery protocol in patients with brain tumors undergoing elective craniotomies: a systematic review and meta-analysis

Suchada Supbumrung, Anukoon Kaewborisutsakul, Chanatthee Kitsiripant, Wilairat Kankuan Kaewborisutsakul, and Chaitong Churuangsuk

OBJECTIVE

Enhanced recovery after surgery, or the enhanced recovery protocol (ERP), introduces a contemporary concept for perioperative care within neurosurgery. In recent years, mounting evidence has highlighted the significant impact of this approach on brain tumor surgery. The authors conducted a systematic review and meta-analysis of current publications, with a primary focus on assessing the efficiency and safety of implementing ERP in the management of patients undergoing elective craniotomies for brain tumor resection.

METHODS

This study followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and was registered in the PROSPERO database. A comprehensive search of the MEDLINE, Cochrane, Scopus, and Embase databases was performed, and two independent reviewers extracted the data, assessed bias, and resolved disagreements through discussion. Primary outcomes included hospital length of stay (LOS) and hospitalization cost. The secondary outcomes were complications, including death, reoperation, readmission, intracerebral hemorrhage, CNS infection, and deep vein thrombosis. A random-effects model was used to evaluate the effects of implementing the ERP using the mean difference (MD) for primary outcomes. Heterogeneity was assessed using I2 statistics, and statistical significance was defined as p < 0.05.

RESULTS

Eight studies, including 3 randomized controlled trials, 3 prospective studies, and 2 retrospective studies, were included in this meta-analysis. The ERP group had significantly shorter LOS (MD −2.69, 95% CI −3.65 to −1.73; p < 0.00001, I2 = 87%) and lower hospitalization cost (MD −$1188 [US dollars] 95% CI −$1726 to −$650; p = 0.0008, I2 = 71%) than the non-ERP group. There were no significant differences in the incidence of perioperative complications between the two groups.

CONCLUSIONS

This study demonstrated the effectiveness of the ERP in improving postoperative outcomes for patients undergoing elective craniotomies for brain tumors. This protocol has demonstrated the ability to reduce hospital stays and costs while maintaining a low complication rate. However, the study acknowledges the presence of clinical and statistical heterogeneity among the included articles, limiting the scope of its conclusions. Further high-quality comparative studies are necessary to substantiate these findings and establish their reliability.

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Effects of a sphenopalatine ganglion block on postcraniotomy pain management: a randomized, double-blind, clinical trial

Giorgio Mantovani, Lorenzo Sgarbanti, Antonino Indaimo, Michele Alessandro Cavallo, Pasquale De Bonis, Maria Elena Flacco, and Alba Scerrati

OBJECTIVE

Postcraniotomy pain (PCP) is a common finding after neurosurgical procedures, occurring in as many 87% of patients. The sphenopalatine ganglion (SPG) has a pivotal role in several headache syndromes, and its anesthetic block is currently used in different clinical conditions with benefit. The aim of this study was to evaluate the efficacy of an SPG block (SPGB) via a transnasal approach as adjunctive therapy in reducing pain scores during the postcraniotomy period.

METHODS

In this single-center, double-blind, randomized controlled trial, patients undergoing elective surgery with a supratentorial craniotomy were randomly assigned to a scalp block, local anesthetic infiltration of the wound, and systemic analgesia during the first 48 postoperative hours (standard therapy), or to standard therapy as well as an SPGB (experimental therapy). According to the available evidence, assuming a 50% reduction in the incidence of the main outcome in patients with an SPGB (vs standard treatment), 82 patients were needed to achieve 80% statistical power in an intent-to-treat analysis. Pain intensity was recorded during the first 180 postoperative days at selective time points (5 times in the hospital, 3 times by telephone interview) with different pain rating systems (a visual analog scale [VAS], numeric rating scale [NRS], and pain assessment in advanced dementia [PAINAD] scale), together with demographic, clinical, and surgical variables and complications. Heart rate and blood pressure were recorded during surgery. Differences in all variables were evaluated using a paired t-test and confirmed through Wilcoxon matched-pairs signed-rank and Kruskal-Wallis tests.

RESULTS

No complications occurred among the 83 patients enrolled. Statistically significant differences were found in the mean VAS score at postoperative days 0 (p = 0.05), 2 (p = 0.03), and 3 (p = 0.03). The PAINAD scale score showed significant differences between groups at postoperative days 1 (p = 0.006), 2 (p = 0.001), 3 (p = 0.03), and 4 (p = 0.05). The proportion of patients reporting a VAS score ≥ 3 in the first day after surgery was lower in the SPGB group than in the standard treatment group (71.9% vs 89.5%), although this difference did not reach statistical significance. At postoperative day 180, 5 patients (2 in the control group, 3 in the treatment group) had developed chronic PCP (NRS score ≥ 3).

CONCLUSIONS

SPGB is a safe and effective procedure as an adjunctive treatment for PCP management in elective supratentorial craniotomy during the first 4 postoperative days compared with standard therapy. Further studies are needed to better define the clinical impact of SPGB use and its indications.

Clinical trial registration no.: NCT05136625 (ClinicalTrials.gov)

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Enhanced recovery after brain tumor surgery: pilot protocol implementation in a large healthcare system

Walavan Sivakumar, Jian Guan, Jean-Philippe Langevin, Garni Barkhoudarian, Daniel F. Kelly, and Neil Martin

OBJECTIVE

Enhanced recovery after surgery (ERAS) protocols have been used in numerous specialties to improve the safety, efficiency, and cost of surgical interventions. Despite these successes, implementation of ERAS in cranial neurosurgery remains limited. In this study, a comprehensive ERAS protocol was implemented at two pilot sites within the Providence Health & Services system, and groundwork was laid for systemwide adoption.

METHODS

An enhanced recovery protocol was developed and implemented through an interdisciplinary team of clinicians, executive leadership, and clinical informatics professionals across preoperative, intraoperative, and postoperative domains. Outcomes including length of stay, discharge destination, and cost were collected through systemwide databases and compared with nonprotocolized sites.

RESULTS

During the study period, both pilot sites became top performers across the regional system in all evaluated metrics. The median length of stay for elective craniotomy at site 1 was reduced to 1.25 days, with a home discharge rate of > 90%. The cost per case at the pilot sites was nearly $7000 less on average than that of the nonprotocolized sites.

CONCLUSIONS

Implementation of enhanced recovery protocols for brain tumor surgery is feasible and effective, resulting in marked improvements in healthcare efficiency. Future studies, including implementation of the current protocol across the entire Providence system, are needed to maximize the potential benefits of enhanced recovery programs.

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The Enhanced Recovery After Surgery protocol for the perioperative management of pituitary neuroendocrine tumors/pituitary adenomas

Giulia Cossu, Amani Belouaer, Julie Kloeckner, Catalina Caliman, Fabio Agri, Roy Thomas Daniel, John G. Gaudet, Georgios E. Papadakis, and Mahmoud Messerer

OBJECTIVE

Enhanced Recovery After Surgery (ERAS) is a multimodal perioperative care pathway that has radically modified the management of patients in multiple surgical specialties. Until now, no ERAS Society guidelines have been formulated for the management of cranial pathologies. During the process of ERAS certification for their neurosurgical department, the authors formulated an ERAS protocol for the perioperative care of patients with pituitary neuroendocrine tumors (PitNET), along with a compliance checklist to monitor the adherence to it and its feasibility. The authors describe the protocol and checklist and report the results, including a cost-minimization analysis, with the application of the ERAS philosophy.

METHODS

The steps that led to the development of this ERAS protocol, including items concerning the preoperative, intraoperative, and postoperative period, are detailed. The authors report their preliminary results through the comparison of the care practice of a historical cohort with a consecutive surgical cohort of patients with PitNET who underwent operation after the implementation of this ERAS protocol. A compliance checklist with key performance indicators was useful to monitor the adherence to the protocol and the changes in the perioperative management.

RESULTS

Following the introduction of this ERAS protocol, the authors significantly shortened the duration of the antibiotic therapy (p < 0.00001) and increased the use of mechanical (p < 0.00001) and pharmacological measures to prevent deep venous thrombosis (p = 0.002). The median length of hospital stay was significantly shorter for the ERAS group (p = 0.00014), and there was no increase in readmission rate or postoperative complications. The documentation and data tracking strongly improved in the ERAS cohort and the authors were more attentive in pain evaluation (p = 0.001), postoperative hormonal supplementation (p = 0.001) and early feeding and mobilization (p = 0.0008 and p < 0.00001, respectively). More patients were discharged on day 3 after surgery in the ERAS group (p < 0.00001). The compliance to the whole process increased from 64.2% to 89.5% (p = 0.016), and the compliance per patient was also found to have significantly increased (p < 0.00001).

CONCLUSIONS

The introduction of a standardized ERAS protocol for the perioperative management of patients with PitNET allowed the authors to improve the multidisciplinary management of these patients. With the application of simple cost-effective interventions and with the avoidance of unnecessary measures, gains were made in terms of early mobilization and feeding, thereby resulting in a shorter in-hospital stay.

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The Enhanced Recovery After Surgery protocol for the surgical management of craniosynostosis: Lausanne experience

Amani Belouaer, Giulia Cossu, Soulayma Al-Tayyari, Adela Bubenikova, Catalina Caliman, Fabio Agri, Maria-Helena Perez, Vivianne Chanez, Yann Boegli, Caroline Mury, Roy Thomas Daniel, and Mahmoud Messerer

OBJECTIVE

Over the past decade, the Enhanced Recovery After Surgery (ERAS) program has demonstrated its effectiveness and efficiency in improving postoperative care and enhancing recovery across various surgical fields. Preliminary results of ERAS protocol implementation in craniosynostosis surgery are presented.

METHODS

An ERAS protocol was developed and implemented for cranial pediatric neurosurgery, focusing on craniosynostosis repair. The study incorporated a pre-ERAS group consisting of a consecutive series of patients who underwent craniosynostosis repair surgery prior to the implementation of the ERAS protocol; the results were compared with a consecutive group of patients who had been prospectively collected since the introduction of the ERAS for craniosynostosis protocol. The safety, feasibility, and efficiency of the ERAS protocol in pediatric neurosurgery was evaluated, through the collection of clinical data from the pre-, intra-, and postoperative phase. Surgery-related complications were evaluated according to the Clavien-Dindo classification. Costs of the stays were obtained using a microcosting approach.

RESULTS

A total of 35 pre-ERAS patients and 10 ERAS patients were included. Scaphocephaly was the most common pathology in both groups. The overall compliance with the pre-, intra-, and postoperative criteria significantly increased—from 35.5%, 64.4%, and 54.7%, respectively, in each phase to 94%, 90%, and 84% (p < 0.001). The authors noticed a reduction in the average opioid dose used per patient in the ERAS group (p = 0.004), and they observed a trend toward a decreased mean length of stay from 5.2 days in the pre-ERAS group to 4.6 days in the ERAS group, without an increase of the rate of readmission within 30 days of surgery. The rate of complications decreased but this difference was not statistically significant. The hospital costs lowered significantly: from 21,958 Confederatio Helvetica Francs (CHF) in the pre-ERAS group to 18,936 CHF in the ERAS group (p = 0.02).

CONCLUSIONS

The ERAS protocol represents a safe and cost-effective tool for the perioperative management of craniosynostosis. It showed its positive impact on the analgesia provided and on the reduction of in-hospital costs for these patients. ERAS protocols may thus be interesting options in the pediatric neurosurgical field.

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Enhanced recovery and same-day discharge after brain tumor surgery under general anesthesia: initial experience with Hospital-at-Home–based postoperative follow-up

Cristina A. Pelaez-Sanchez, Marcos Pajaron-Guerrero, Angelina Rodríguez-Caballero, Cristina Ruiz Calderón, Carla Mora, Rubén Martín-Láez, Isabel Sampedro, and Carlos Velásquez

OBJECTIVE

The objective of this study was to describe the outcomes of outpatient oncological neurosurgery (OON) in a European clinical setting and to compare them with the conventional inpatient protocol.

METHODS

Patients who had undergone OON (either tumor removal or biopsy) at the authors’ center since 2019 were analyzed. A matched cohort of patients was selected from patients undergoing tumor surgery in the same period. Collected data included patient demographics, postoperative progress, specific location of the target lesion, and the procedure performed.

RESULTS

There were 18 patients in the case group and 59 patients in the control group. The outpatient surgeries had a same-day discharge rate of 89%, and all ambulatory patients successfully completed the Enhanced Recovery After Surgery program within 6.24 hours of the procedure. All ambulatory patients underwent Hospital-at-Home postoperative follow-up for an average of 4.12 days. Radiological complications were present in 11% of the case group and 8% of the control group. Postoperative neurological deficit occurred in 6% of the same-day discharge group and 3% of the control group. Among the patients in the control group, 3% suffered from postoperative seizures, whereas no seizures were observed in the case group. These differences were not statistically significant. General anesthesia–related complications were not observed in any of the patients.

CONCLUSIONS

The authors’ findings demonstrate that Enhanced Recovery After Surgery protocols and same-day discharge craniotomy for tumor resection and image-guided biopsy under general anesthesia, when patients are carefully selected, can be safely performed with excellent outcomes in a European clinical setting. The OON program proved to be a viable alternative to conventional hospitalization, showing comparable safety records and offering advantages in terms of patient recovery.

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An institutional experience in applying quality improvement measures to pituitary surgery: clinical and resource implications

Panayiotis E. Pelargos, Aamr Hasanjee, Benjamin Lee, Audrey Grossen, Kiana Y. Prather, Xiaochun Zhao, Prince Ohene-Nyako, Matthew P. Baier, Amanda Kate McDaniel, Kibwei A. McKinney, Christopher S. Graffeo, Edward El Rassi, and Ian F. Dunn

OBJECTIVE

The aim of this study was to report the authors’ experience developing a Lean Six Sigma clinical care pathway (CCP) for endoscopic endonasal transsphenoidal operations.

METHODS

Using Lean Six Sigma quality improvement principles—including the define, measure, analyze, improve, and control framework—the authors developed a CCP for endoscopic endonasal transsphenoidal operations, incorporating preoperative, intraoperative, and inpatient and outpatient postoperative phases of care. Efficacy and quality metrics were defined as postoperative length of stay (LOS), presentation to the emergency department (ED) or readmission within 30 days of discharge, and hospital charges. The study included all adult patients who underwent elective endoscopic endonasal resection for pituitary adenoma, Rathke’s cleft cyst, craniopharyngioma, pituicytoma, or arachnoid cyst during the sampling period (April 1, 2018, to December 31, 2022).

RESULTS

Two hundred twenty-eight patients met criteria and were included; 94 were treated before and 134 were treated after implementation of the CCP. Differences between groups in age, gender, race, BMI, American Society of Anesthesiologists classification, geographic distribution, preoperative serum sodium, tumor size, adenoma functional status, and prior surgery were not significant. The mean postoperative LOS significantly decreased from 4.5 to 1.7 days following CCP implementation (p < 0.0001); LOS variability also decreased, with the standard deviation declining from 3.1 to 1.5 days. The proportion of patients discharged on postoperative day (POD) 1 significantly increased from 0% to 61.9% (p < 0.0001). Fewer than one-quarter of the patients (23.4%) were discharged by POD 2 prior to the CCP, while 88.8% of were discharged by POD 2 after CCP implementation (p < 0.0001). Rates of 30-day ED presentations or readmissions were not significantly different (2.1% vs 6.0%, p = 0.20, and 7.5% vs 6.7%, p > 0.99, respectively). Mean per-patient hospital costs declined from $38,326 to $26,289 (p < 0.0001), with an associated change in cost variability from a standard deviation of $16,716 to $12,498.

CONCLUSIONS

CCP implementation significantly improved LOS and costs of endoscopic endonasal resection, without adversely impacting postoperative ED presentations or readmissions.

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Introduction. Developing the foundation for enhanced recovery after cranial surgery

Walavan Sivakumar, Neil Martin, Sarah T. Menacho, Randy S. D’Amico, and Luca Regli