Patient recruitment
140 patients who were admitted for elective craniotomy in our hospital between October 2016 and May 2017 were enrolled. Participants were randomly divided into two groups by computerized random number generation: the observation group (ERAS group) (n=70) and the control group (traditional treatment group) (n=70). Inclusion criteria: All patients between 18 to 65 years of age (18 and 65 were included) without sex limitation, who had a single intracranial lesion, and were medically eligible for elective craniotomy were included. Exclusion criteria: Patients with intracranial trauma, pathology requiring emergent surgery, preoperative disturbance of consciousness, and presence of a confounding condition (e.g., pregnancy) or disease that could potentially impact postoperative recovery (e.g., paralysis, spinal deformity, autoimmune diseases, myocardial infarction, severe infection, liver and renal malfunction, or severe psychological or mental illness) were excluded from this study.
Perioperative measures
Our study was supported by local institutional ethnical committee to develop a neurosurgical ERAS protocol through a quality patient care initiative. We set up a Neurosurgical ERAS Working Group in June 2016, including clinicians and ancillary staff from neurosurgery, anesthesiology, in-patient and operative nursing and clinical nutrition. This multidisciplinary working group developed and applied the neurosurgical ERAS protocol outlined in this study.
In ERAS group, patients underwent preoperative counseling, stopping smoking and alcohol consumption, nutritional risk screening and nutritional status assessment, nutritional therapy if necessary, anti-thrombotic prophylaxis, postoperative nausea and vomiting (PONV) management, glycerine enema induction if long history of constipation or ≥2 days without defecation, antimicrobial prophylaxis and skin preparation, shortening preoperative fasting and carbohydrate loading, preoperative respiratory protection, scalp blocks, minimally invasive craniotomies and endoscopic skull base approaches, non-opioid analgesia, avoiding hypothermia, early feeding after surgery, early removal of the urinary drainage within 6h, rapid de-escalation of fluids, early mobilization[7].
The perioperative care of patients in the conventional care (i.e. control) group was based on traditional neurosurgical protocols.
Nutritional risk screening (NRS-2002)
Nutritional status was assessed by NRS2002 [8]. It consists of a nutritional score, a severity of disease score and an age-adjustment for patients aged over 70 years. Nutritional score was calculated as the total score of the nutritional state, severity of disease and the age adjustment. Patients with NRS2002 score <3 were classified as having no nutritional risk, and NRS2002 score ≥3 were classified as existing nutritional risk.
Anthropometric measurement and bioelectrical impedance analysis before and after surgery
Height was measured with an accordant tool accurate to 0.1centimeter. BIA measurement was taken using Healthy Keeper body composition analyzer (Korea). Patients were on an empty stomach, emptying urine and feces, calming down if exercising or sweating. Shoes, socks and metal accessories were removed. Pelmas attached to the two electrodes while thumb and forefinger squeezed the other two electrodes. Whole-body resistance and reactance between frequencies of 1 kHz and 1 MHz were measured. Body mass (BM), body mass index (BMI), fat mass (FM), free-fat mass (FFM), muscle mass (MM), body fat percentage (BFP), total body water (TBW), intracellular fluid (ICF) and extracellular fluid (ECF) values of patients were recorded. Body fat mass (BCM), fat mass index (FMI) and fat-free mass index (FFMI) were calculated by the following formulas: FMI(kg/m2)=FFM(kg)/height2(m2), FFMI(kg/m2)=(BM-FM)(kg)/height2(m2) [9], BCM(kg)=ICF(kg)/0.7, BCMI(kg/m2)=BCM(kg)/height2(m2) [10].
Perioperative nutritional support
In the ERAS group, patients were permitted solid food 6 hours before surgery and given 400 mL of 12.5% carbohydrate-rich beverage 2-3 hours before induction of anaesthesia to whom without suffering diabetes mellitus. The program of early feeding after surgery is as follows: feeding was started 4-6 hours after operation with water, when most of patients revived from anesthesia. During 6-24 hours after operation, patients could drink oral nutritional supplement (250 kcal/day) and other liquid diet. On POD 2, patients were suggested to drink oral nutritional supplement (500 kcal/day) and feed with some soft diet. From POD 3 until discharge, patients were allowed to eat regular diet, and ONS were given only if subjects were unable to eat 1000kcal/day from normal food. As ONS, we used homogenized diet (Leskon, Xi’an Li Bang clinical nutrition Co, LTD, China). The composition per 100 mL is: kcal, 104; carbohydrates, 14.6 g; proteins, 4.28 g; lipids, 2.82 g.
While, in control group, fasting is from midnight before surgery, no carbohydrate loading, no early feeding after surgery. Feeding was started 24h or more after surgery with the return of passing wind and faeces.
Discharge criteria
All the patients in ERAS and control group were discharged if they met our predefined discharge criteria: adequate pain management with oral analgesia, adequate intake of solid food, no need for intravenous fluids, no fever, independent mobility and a safe disposition at home. The decision of discharge was made by the consensus of two senior attending physicians in the department of Neurosurgery, who were instructed to follow the discharging criteria, and were independent of the researchers involved in this study.
Statistical analysis
All data were analyzed using the SPSS software (version 20.0). Data were shown as mean ± standard deviation for normally distributed variables and as median for distributed continuous variables. Normally distributed continuous variables were analyzed using paired and un-paired t-test and ANOVA. Non-normally distributed variables were compared by Mann-Whitney U-test test. A two-sided level of p<0.05 was considered as statistically significant.