Effect of the enhanced recovery after surgery protocol in patients undergoing elective craniotomies: a systematic review and meta-analysis.

Enhanced recovery after surgery protocol (ERASP) improves postoperative outcomes. However, its implementation in neurosurgery remains under explored, resulting in the absence of standard evidence-based guidelines. Thus, we compared the outcomes of ERASP and conventional perioperative care (CPC) in patients undergoing elective craniotomy for various intracranial pathologies. This systematic review and meta-analysis involved the search of PubMed, Cochrane Library, and Google Scholar until December 4, 2024. The primary outcomes were total and postoperative length of stay (LOS). Secondary outcomes included hospitalization cost, pain, analgesic use, Karnofsky performance status (KPS) score, postoperative nausea and vomiting (PONV), postoperative complications, 30-days readmission and reoperation, and mortality. A total of 15 studies, including randomized controlled trials (n = 9) as well as prospective and retrospective studies (each n = 3) were included. Compared to CPC, ERASP significantly reduced total LOS (MD -3.32, 95%CI -3.66 to -2.98; P < 0.0001, I = 34%), postoperative LOS (MD -2.80, 95%CI -3.82 to -1.79; P < 0.0001, I = 90%), hospitalization cost (MD -$1044, 95%CI -$1289 to -$800; P < 0.0001, I = 47%), postoperative pain (MD -1.55, 95%CI -1.92 to -1.19; P < 0.0001, I = 83%), analgesic use (OR 0.56, 95%CI 0.40 to 0.80; P = 0.001, I = 0%), KPS score (MD 6.68, 95%CI 0.15 to 13.21; P = 0.045, I = 93%), respiratory complications (OR 0.28, 95%CI 0.13 to 0.58; P = 0.001, I = 0%), and PONV (OR 0.39, 95%CI 0.27 to 0.57; P < 0.0001, I = 0%). While ERASP and CPC were comparable regarding other outcome measures. Thus, in elective craniotomy, ERASP shortens total and postoperative LOS, decreases hospitalization costs, improves functional recovery, decreases pain and analgesic use, with reduced incidence of PONV and respiratory complications.