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

Abstract

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.