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

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.

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

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.