The global demand for hospital care, driven by population growth and medical advances, emphasizes the importance of optimized resource management. Enhanced Recovery After Surgery (ERAS) protocols aim to expedite patient recovery and reduce health care costs without compromising patient safety or satisfaction. Its principles have been adopted in various surgical specialties but have not fully encompassed all areas of neurosurgery, including craniotomy. ERAS for craniotomy has been shown to reduce the length of hospital stay and costs without increasing complications. ERAS protocols may also reduce postoperative nausea and vomiting and perioperative opioid requirements, highlighting their potential to enhance patient outcomes and health care efficiency. Despite these benefits, guidelines, and strategies for ERAS in craniotomy remain limited. This narrative review explores the current global landscape of ERAS for craniotomy, assessing existing literature and highlighting knowledge gaps. Experts from 26 countries with diverse cultural and socioeconomic backgrounds contributed to this review, offering insights about current ERAS protocol applications, implementation challenges, and future perspectives, and providing a comprehensive global overview of ERAS for craniotomy. Representatives from all 6 World Health Organization geographical world areas reported that barriers to the implementation of ERAS for craniotomy include the absence of standardized protocols, provider resistance to change, resource constraints, insufficient education, and research scarcity. This review emphasizes the necessity of tailored ERAS protocols for low and middle-income countries, addressing differences in available resources. Acknowledging limitations in subjectivity and article selection, this review provides a comprehensive overview of ERAS for craniotomy from a global perspective and underscores the need for adaptable ERAS protocols tailored to specific health care systems and countries.

Department of Anesthesia Aga Khan University Hospital Nairobi Kenya

Department of Anesthesia and Critical Care Anaesthesia Institute Cleveland Clinic Abu Dhabi UAE

Department of Anesthesia and Critical Care Hospital Kuala Lumpur Kuala Lumpur Malaysia

Department of Anesthesia and Intensive Care Medicine Charles University Prague 3rd Faculty of Medicine Prague Czech Republic

Department of Anesthesia and Intensive Care Medicine Jessa Hospital Hasselt Belgium

Department of Anesthesia and Intensive Care Medicine Perioperative Services Intensive Care Medicine and Pain Management Turku University Hospital University of Turku Turku Finland

Department of Anesthesia and Pain Medicine Toronto Western Hospital University of Toronto Toronto ON Canada

Department of Anesthesia and Surgery Aarhus University Hospital Aarhus Denmark

Department of Anesthesia Beaumont Hospital Dublin Ireland

Department of Anesthesia Beijing Tiantan Hospital Capital Medical University Beijing China

Department of Anesthesia Chris Hani Baragwanath Academic Hospital University of the Witwatersrand Johannesburg South Africa

Department of Anesthesia Cleveland Clinic Cleveland OH

Department of Anesthesia Hospital das Clínicas Faculty of Medicine University of São Paulo São Paulo Brazil

Department of Anesthesia Institute of Medicine Tribhuvan University Kathmandu Nepal

Department of Anesthesia Kilimanjaro Christian Medical Center Moshi Tanzania

Department of Anesthesia Philippine General Hospital University of the Philippines Manila Manila Philippines

Department of Anesthesia Prince Sultan Military Medical City Saudi Anaesthesia Scientific Council Riyadh Saudi Arabia

Department of Anesthesia Rambam Health Care Campus Haifa Israel

Department of Anesthesia The Aga Khan University Karachi Pakistan

Department of Anesthesia Universitas Gadjah Mada Yogyakarta Indonesia

Department of Anesthesia University Teaching Hospital Lusaka Zambia

Department of Neuro Anaesthesia The Walton Centre Liverpool UK

Department of Neuroanaesthesia and Critical Care All India Institute of Medical Sciences New Delhi India

Department of Neuroanesthesia at Hamad General Hospital Doha Qatar

Department of Neuroanesthesia Manuel Velasco Suárez National Institute of Neurology and Neurosurgery Mexico City Mexico

Department of Neurological Surgery Marqués de Valdecilla University Hospital Santander Spain

See more in PubMed

Health at a Glance 2023: OECD Indicators, Hospital beds and occupancy. Accessed April 12, 2024. https://www.oecd-ilibrary.org/sites/bdd23022-en/index.html?itemId=/content/component/bdd23022-en#:~:text=Across%20OECD%20countries%2C%20there%20were,000)%20rates%20were%20much%20higher

Colombo F, Guanais F, Haywood P, et al. Ready for the Next Crisis? Investing in Health System Resilience, OECD Health Policy Studies. Paris: OECD Publishing; 2023. doi:10.1787/1e53cf80-en. Accessed April 10, 2024. http://www.oecd-ilibrary.org/sites/1e53cf80-en/index.html?itemId=/content/publication/1e53cf80-en

Alkire BC, Raykar NP, Shrime MG, et al. Global access to surgical care: a modelling study. Lancet Glob Heal. 2015;3:e316–e323. doi: 10.1016/S2214-109X(15)70115-4

Loughlin SM, Alvarez A, Falcão LFDR, et al. The history of ERAS (enhanced recovery after surgery) society and its development in Latin America. Rev Col Bras Cir. 2020;47. doi:10.1590/0100-6991e-20202525 DOI

Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth. 1997;78:606–617. doi:10.1093/bja/78.5.606 DOI

Martins MVD de C Are we ready for the implantation of the ERAS protocol? Revista do Colégio Brasileiro de Cirurgiões. 2017. Accessed April 21, 2024. https://www.scielo.br/j/rcbc/a/8gPH3bhrWvsgBSgVDzS6sXR/?lang=pt

ERAS Society History. ERAS. Accessed April 20, 2024. https://ERASsociety.org/about/history/

Debono B, Wainwright TW, Wang MY, et al. Consensus statement for perioperative care in lumbar spinal fusion: enhanced recovery after surgery (ERAS) Society recommendations. Spine J. 2021;21:729–752. doi:10.1016/j.spinee.2021.01.001 DOI

Hagan KB, Bhavsar S, Raza SM, et al. Enhanced recovery after surgery for oncological craniotomies. J Clin Neurosci. 2016;24:10–16. doi:10.1016/j.jocn.2015.08.013 DOI

Wang Y, Xue YF, Zhao BF, et al. Real-world implementation of neurosurgical enhanced recovery after surgery protocol for gliomas in patients undergoing elective craniotomy. Front Oncol. 2022;12:860257. doi:10.3389/fonc.2022.860257 DOI

Khan HA, Hill TC, Suryadevara CM, et al. Development and implementation of an enhanced recovery after cranial surgery pathway following supratentorial tumor resection at a tertiary care center. Neurosurg Focus. 2023;55:E4. doi:10.3171/2023.9.FOCUS23552

Liu B, Liu S, Wang Y, et al. Neurosurgical enhanced recovery after surgery (ERAS) programme for elective craniotomies: are patients satisfied with their experiences? A quantitative and qualitative analysis. BMJ Open. 2019;9:e028706. doi:10.1136/bmjopen-2018-028706 DOI

Kim SH, Choi SH, Moon J, et al. Enhanced recovery after surgery for craniotomies: a systematic review and meta-analysis. J Neurosurg Anesthesiol. 2024. doi: 10.1097/ANA.0000000000000967. Epub ahead of print. DOI

Kovacs RJ, Powell-Jackson T, Kristensen SR, et al. How are pay-for-performance schemes in healthcare designed in low and middle-income countries? Typology and systematic literature review. BMC Health Serv Res. 2020;20. doi:10.1186/s12913-020-05075-y

Morrison B, Kelliher L, Jones C. The economic benefits of enhanced recovery after surgery programmes. Digest Med Res. 2019;2:20–0. doi:10.21037/dmr.2019.08.07 DOI

Carrabba G, Venkatraghavan L, Bernstein M. Day surgery awake craniotomy for removing brain tumors: technical note describing a simple protocol. Minim Invas Neurosurg. 2008;51:208–210. doi:10.1055/s-2008-1073132 DOI

Wang Y, Liu B, Zhao T, 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;130:1680–1691. doi:10.3171/2018.1.JNS171552 DOI

Elayat A, Jena SS, Nayak S, et al. Enhanced recovery after surgery—ERAS in elective craniotomies—a non-randomized controlled trial. BMC Neurol. 2021;21:127. doi:10.1186/s12883-021-02150-7 DOI

Bardach NS, Wang JJ, De Leon SF, et al. Effect of pay-for-performance incentives on quality of care in small practices with electronic health records: a randomized trial. JAMA. 2013;310:1051–1059. doi:10.1001/jama.2013.277353 DOI

Visioni A, Shah R, Gabriel E, et al. Enhanced recovery after surgery for noncolorectal surgery?: a systematic review and meta-analysis of major abdominal surgery. Ann Surg. 2018;267:57–65. doi:10.1097/SLA.0000000000002267 DOI

Petersen J, Kloth B, Konertz J, et al. Economic impact of enhanced recovery after surgery protocol in minimally invasive cardiac surgery. BMC Health Serv Res. 2021;21:254. doi:10.1186/s12913-021-06218-5 DOI

Lee L, Mata J, Ghitulescu GA, et al. Cost-effectiveness of enhanced recovery versus conventional perioperative management for colorectal surgery. Ann Surg. 2015;262:1026–1033. doi:10.1097/SLA.0000000000001019 DOI

Nelson G, Kiyang LN, Chuck A, et al. Cost impact analysis of enhanced recovery after surgery program implementation in Alberta colon cancer patients. Curr Oncol. 2016;23:e221–e227. doi:10.3747/co.23.2980 DOI

Thanh N, Nelson A, Wang X, et al. Return on investment of the enhanced recovery after surgery (ERAS) multiguideline, multisite implementation in Alberta, Canada. Can J Surg. 2020;63:E542–E550. doi:10.1503/cjs.006720 DOI

Nassiri F, Li L, Badhiwala JH, et al. Hospital costs associated with inpatient versus outpatient awake craniotomy for resection of brain tumors. J Clin Neurosci. 2019;59:162–166. doi:10.1016/j.jocn.2018.10.110 DOI

Riad AM, Barry A, Knight SR, et al. Perioperative optimisation in low- and middle-income countries (LMICs): a systematic review and meta-analysis of enhanced recovery after surgery (ERAS). J Glob Health. 2023;13:04114. doi:10.7189/jogh.13.04114 DOI

Naik BI, Dunn LK, Wanchek TN. Incremental cost-effectiveness analysis on length of stay of an enhanced recovery after spine surgery program: a single-center, retrospective cohort study. J Neurosurg Anesthesiol. 2023;35:187–193. doi:10.1097/ANA.0000000000000827 DOI

Serapioni M, Tesser C. The Brazilian Health System in the face of international typology: a prospective and inevitable discussion. [O Sistema de Saúde brasileiro ante a tipologia internacional: uma discussão prospectiva e inevitável]. Saúde em Debate. 2019;43:(spe5)44–57. doi: 10.1590/0103-11042019S504. DOI

Shafiq F, Parkash J, Enam A, et al. An awake throughout approach for awake craniotomy: a perspective from a resource-limited country. World Neurosurg. 2019;126:e1489–e1493. doi:10.1016/j.wneu.2019.03.127 DOI

Hani U, Bakhshi SK, Shamim MS. Enhanced recovery after elective craniotomy for brain tumours. J Pak Med Assoc. 2019;69:749–751. PMID: 31105305.

Shuo W, Yuguang H, Huanlong Q. Clinical practice guidelines for enhanced recovery after surgery in patients with unruptured intracranial aneurysms, The Chinese Medical Association Neurosurgery Branch, Chinese Medical Association Anesthesiology Branch and China Health Care International Exchange Promotion Association Enhanced Recovery after surgery branch. Chin Med J. 2022;102:3257–3266. doi: 10.3760/cma.j.cn112137-20220902-01863. DOI

Prasad E China Stumbles but Is Unlikely to Fall. IMF. 2023. Accessed May 2, 2024. https://www.imf.org/en/Publications/fandd/issues/2023/12/China-bumpy-path-Eswar-Prasad

Ripollés-Melchor J, Casans-Francés R, Abad-Gurumeta A, et al. Spanish survey on enhanced recovery after surgery. Rev Esp Anestesiol Reanim. 2016;63:376–383. doi:10.1016/j.redar.2015.09.007 DOI

Pelaez-Sanchez CA, Pajaron-Guerrero M, Rodríguez-Caballero A, et al. Enhanced recovery and same-day discharge after brain tumor surgery under general anesthesia: initial experience with hospital-at-home-based postoperative follow-up. Neurosurg Focus. 2023;55:E6. doi:10.3171/2023.9.FOCUS23550 DOI

Mora C, Sampedro I, Rodríguez-Caballero A, et al. Barriers and facilitators in the implementation of a telemedicine-based outpatient brain tumor surgery program. Neurosurg Focus. 2022;52:E8. doi:10.3171/2022.3.FOCUS2242 DOI

Pajarón-Guerrero M, Fernández-Miera MF, Dueñas-Puebla JC, et al. Early discharge programme on hospital-at-home evaluation for patients with immediate postoperative course after laparoscopic colorectal surgery. Eur Surg Res. 2017;58:263–273. doi:10.1159/000479004 DOI

Smith SC, Abramowicz AE. More investigations needed for enhanced recovery after anesthesia for craniotomy. J Neurosurg Anesthesiol. 2024;36:273–274. doi:10.1097/ANA.0000000000000968. DOI

Wang L, Cai H, Wang Y, et al. Enhanced recovery after elective craniotomy: a randomized controlled trial. J Clin Anesth. 2022;76:110575. doi:10.1016/j.jclinane.2021.110575 DOI

Zaed I, Marchi F, Milani D, et al. Role of enhanced recovery after surgery (ERAS) protocol in the management of elderly patients with glioblastoma. J Clin Med. 2023;12:6032. doi:10.3390/jcm12186032 DOI

Nijs K, McQueen S, Chhabra S, et al. Same-day discharge after craniotomy for tumor resection: a retrospective observational single-center study of 630 patients. J Neurosurg. 2023;140:1519–1526. doi: 10.3171/2023.9.JNS231454. DOI

Grasso G, Noto M, Pescatori L, et al. Enhanced recovery after cranial surgery in elderly: a review. World Neurosurg. 2024;185:e1013–e1018. doi:10.1016/j.wneu.2024.03.012. DOI

Yakar F, Bakirarar B, Elbir Ç, et al. Applications of enhanced recovery after surgery protocols for unruptured anterior circulation aneurysms in tertiary-level healthcare institutions: a national study. Neurosurg Focus. 2023;55:E12. doi:10.3171/2023.9.FOCUS23546 DOI

Belouaer Amani, Cossu G, Papadakis GE, et al. Implementation of the enhanced recovery after surgery (ERAS) program in neurosurgery. Acta Neurochir. 2023;165:3137–3145. doi:10.1007/s00701-023-05789-y DOI

Johnson A, Rice AN, Titch JF, et al. Identifying components necessary for an enhanced recovery after surgery pathway for elective intracranial surgery: an improvement project using the quality of recovery-15 score. World Neurosurg. 2019;130:e423–e430. doi:10.1016/j.wneu.2019.06.108 DOI

Tewarie IA, Hulsbergen AFC, Volovici V, et al. The ethical and legal status of neurosurgical guidelines: the neurosurgeon’s golden fleece or Achilles’ heel? Neurosurg Focus. 2020;49:E14. doi:10.3171/2020.8.FOCUS20597 DOI

Bharadwaj HR, Awuah WA, Adebusoye FT, et al. Awake craniotomies in South America: advancements, challenges, and future prospects. J Cent Nerv Syst Dis. 2024;16. doi:10.1177/11795735241238681 DOI

Ljungqvist O, Scott M, Fearon KC. Enhanced recovery after surgery: a review. JAMA Surg. 2017;152:292–298. doi:10.1001/jamasurg.2016.4952 DOI

Meara J, Greenberg S. The Lancet Commission on global surgery 2030: evidence and solutions for achieving health, welfare and economic development. Lancet. 2015;157:834–835. doi:10.1016/j.surg.2015.02.009 DOI

Oodit R, Biccard B, Nelson G, et al. ERAS Society recommendations for improving perioperative care in low- and middle-income countries through implementation of existing tools and programs: an urgent need for the surgical safety checklist and enhanced recovery after surgery. World J Surg. 2021;45:3246–3248. doi:10.1007/s00268-021-06279-x. DOI

Wooding DJ, Field TS, Schwarz SKW, et al. Current recommendations for perioperative brain health: a scoping review. J Neurosurg Anesthesiol. 2023;35:10. doi:10.1097/ANA.0000000000000861 DOI

Chen Y, Ni J, Li X, et al. Scalp block for postoperative pain after craniotomy: a meta-analysis of randomized control trials. Front Surg. 2022;9:1018511. doi:10.3389/fsurg.2022.1018511 DOI

Choi S, Choi YH, Lee HS, et al. Effects of scalp nerve block on the quality of recovery after minicraniotomy for clipping of unruptured intracranial aneurysms : a randomized controlled trial. J Korean Neurosurg Soc. 2023;66:652–663. doi:10.3340/jkns.2023.0010

Abhinav K, Jadhav D, Andar UB, et al. Management of post-craniotomy pain in elective cases: a randomized controlled trial. Cureus. 2023;15:e46189. doi:10.7759/cureus.46189 DOI

Vacas S, Van de Wiele B. Designing a pain management protocol for craniotomy: a narrative review and consideration of promising practices. Surg Neurol Int. 2017;8:291. doi:10.4103/sni.sni_301_17 DOI

Ban VS, Bhoja R, McDonagh DL. Multimodal analgesia for craniotomy. Curr Opin Anaesthesiol. 2019;32:592–599. doi:10.1097/ACO.0000000000000766 DOI

Sivakumar W, Guan J, Langevin JP, et al. Enhanced recovery after brain tumor surgery: pilot protocol implementation in a large healthcare system. Neurosurg Focus. 2023;55:E5. doi:10.3171/2023.9.FOCUS23563 DOI

Agarwal P, Frid I, Singer J, et al. Neurosurgery perception of enhanced recovery after surgery (ERAS) protocols. J Clin Neurosci. 2021;92:110–114. doi:10.1016/j.jocn.2021.07.044 DOI