Ummey Hani ( Department of Surgery, Section of Neurosurgery, Aga Khan University Hospital, Karachi. Pakistan )
Saqib Kamran Bakhshi ( Department of Surgery, Section of Neurosurgery, Aga Khan University Hospital, Karachi. Pakistan )
Muhammad Shahzad Shamim ( Department of Surgery, Section of Neurosurgery, Aga Khan University Hospital, Karachi. Pakistan )
Enhanced recovery after surgery (ERAS) is aimed at accelerated rehabilitation after surgery, and involves a multidisciplinary approach. Significant work has been published on this concept with regards to abdominal surgeries, however, the idea is relatively new for those undergoing neurosurgical procedures. We have reviewed literature on ERAS in patients undergoing craniotomy for brain tumours.
Keywords: ERAS, craniotomy, brain tumour.
Early, uneventful post-operative convalescence, and a quick resumption of pre-disease activities by the patient, is every surgeon’s goal after performing a major surgical procedure. Craniotomy for brain tumours is associated with significant physiological, emotional andpsychological strain, and too much stress can lead to secondary cardiovascular and cerebrovascular events and nutritional insufficiency.1,2 Postoperative nausea and vomiting, worsening neurological deficits and haemodynamic instability are some of the common conditions encountered after oncological craniotomies, and are a common hindrance in early recovery. 3 The concept of enhanced recovery after surgery (ERAS) was first introduced by Kehlet in an effort to reduce perioperative morbidity and achieve improved postoperative functional outcomes.4,5 It includes a multidisciplinary approach for preoperative, perioperative and postoperative patient care by anaesthetist, nursing staff, surgeon and home health services. 5 During the past two decades, a wide variety ofsurgical subspecialties including colorectal surgery, gynaecological and pelvic surgery, urological surgery and vascular surgery, have developed ERAS protocols that have been widely accepted. 6,7 Owing to recent developments in neuro-oncology, including awake craniotomies; early recovery and discharge from hospital are now possible. However, studies on ERAS protocol in neurosurgery, particularlyoncological craniotomies have been few. Herein, we have reviewed the existing English language literature on ERAS for elective craniotomies.
Review of Literature
We searched ERAS related keywords on PubMed and Google scholar database. ERAS in essence is a list of recommended practices, based on best evidence, and includes pre-, intra-, and post-operative interventions, that help to improve morbidity, hospital stay, recovery, cost and eventually patient outcomes. Hagan et al. 8, conducted an extensive systematic review of existing data on various aspects of oncological craniotomy, and proposed key components of ERAS protocol. These components are based on best evidence related toprinciples relevant to elective craniotomy patients, as well as those derived from other surgical specialties, but applicable to neurosurgical patients. Hagan et al., strongly recommended preoperative patient education regarding surgical procedure and its objectives, abstinence from alcohol and cigarette smoking for atleast a month before surgery and encouraged enteral nutrition with carbohydrate rich clear liquid intake upto two hours before surgery. 8 Intraoperative application of intermittent pneumatic compression and graduated compression stockings, administration of Cefazolin as prophylactic antibiotic in general population and Vancomycin in MRSA colonizers one hour before incision were also strongly advocated. 10 Scalp blocks and infiltration of local anaesthetic agent along the line of incision were proposed to reduce requirement of opioids post-operatively. 8 They cited evidence supporting use of non-opioid analgesics for good sideeffect profile in craniotomy patients and discouraged use of tramadol, gabapentin, pregabalin and NSAIDs. 8 Post-operative recommendations included avoidance ofhypothermia, removal of urinary catheter on day one after surgery or earlier, good fluid balance, early initiation of enteral nutrition and early mobilization out of bed. 8 Post-operative nausea and vomiting (PONV) is witnessed in nearly half of all post-craniotomy patients and Hagan et al., proposed Dexamethasone and Serotonin antagonists for its prevention.
They concluded that their recommendations warranted early rehabilitation and discharge from hospital, but suggested further research for improving quality of evidence. 8 In 2016, Venkatraghavanet al., reported 198 patients who had undergone craniotomy for supratentorial tumours out of which 88.4% were discharged on the day of surgery. 9 They had reported worsening of preoperative neurological exam, seizures and PONV as the main reasons for delay in discharge of remaining patients. Five of their same-day discharge patients had readmission due to seizure, worsening neurological response, wound bleeding and headache. In the other sub-group of their study, 154 patients remained admitted in the hospital after surgery and 86% of them were discharged within three post-operative days. These patients had more opioid and antiemetic consumption. Venkatraghavan et al., concluded that early, same-day discharge is feasible in patients undergoing awake craniotomy or craniotomy under general anaesthesia for procedures that are less than four hours long and there was minimal risk of developing any complications in these patients. 9 Wang et al., conducted a randomized control trial on ERAS protocol for elective craniotomy patients. 10 They recruited 140 patients of which, 70 were controls and 70 followed the ERAS protocol. They had set up a multidisciplinary working group that formulated a customized ERAS protocol that was guided by recommendations put forth by Hagan et al. 8 Their discharge criteria was similar for both groups and included tolerable pain with oral medicines, sufficient enteral nutrition, absence of fever and established mobility out of bed. They reported that ERAS protocol reduced length of stay in hospital by three days and lead to early removal of urinary catheter and initiation of enteral nutrition which were statistically significant. More patients in the ERAS group reported mild postoperative pain but the overall duration of pain was short. They concluded that implementing ERAS protocol steered relatively faster recovery after elective craniotomies, with no increase in complications.10
Despite very little specialty-specific data to support it, the larger body of evidence available for no neurosurgical patients, and the few papers available for neurosurgical patients; clearly suggest that the implementation of ERAS for neurosurgical treatment can be useful in improving at least some aspects of patient care.
1. Ren L, Zhu D, Wei Y, Pan X, Liang L, Xu J, et al. Enhanced Recovery After Surgery (ERAS) program attenuates stress and accelerates recovery in patients after radical resection for colorectal cancer: a prospective randomized controlled trial. World J Surg.2012;36:407-14.
2. Pidani AS, Rao AM, Shamim MS. Depression in adult patients with primary brain tumours: a review of independent risk factors. J Pak Med Assoc. 2018;68:672-674.
3. Lonjaret L, Guyonnet M, Berard E, Vironneau M, Peres F, Sacrista S, et al. Postoperative complications after craniotomy for brain tumor surgery. Anaesth Crit Care Pain Med. 2017;36:213-18.
4. Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg. 2002;183:630-41.
5. Ljungqvist O, Scott M, Fearon KC: Enhanced Recovery After Surgery: a review. JAMA Surg. 2017;152:292-8.
6. Scott MJ, Baldini G, Fearon KC, Feldheiser A, Feldman LS, Gan TJ, et al. Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 1: pathophysiological considerations. Acta Anaesthesiol Scand.2015;59:1212-31.
7. Cerantola Y, Valerio M, Persson B, Jichlinski P, Ljungqvist O, Hubner M, et al. Guidelines for perioperative care after radical cystectomy for bladder cancer: Enhanced Recovery After Surgery (ERAS®) Society recommendations. ClinNutr.2013;32:879-87.
8. Hagan, KB, Bhavsar S, Raza SM, Arnold B, Arunkumar R, Dang A, et al. Enhanced recovery after surgery for oncological craniotomies. J ClinNeurosci. 2016;24:10-16.
9. Venkatraghavan L, Bharadwaj S, Au K, Bernstein M, Manninen P. Same-day discharge after craniotomy for supratentorial tumour surgery: a retrospective observational single-centre study. Can J Anesth/J Can Anesth. 2016;63:1245-7.
10. Wang, Y., et al., Safety and efficacy of a novel neurosurgical enhanced recovery after surgery protocol for elective craniotomy: a prospective randomized controlled trial. J Neurosurg. 2018;22:1-12.