Development of an enhanced recovery after laser ablation surgery protocol: a preliminary analysis

Abstract

Background

Enhanced recovery after surgery (ERAS) programs are a model of care that aim to improve patient outcomes, reduce complications, and facilitate recovery while reducing healthcare-associated costs and admission length. While such programs have been developed in other surgical subspecialties, there have yet to be guidelines published specifically for laser interstitial thermal therapy (LITT). Here we describe the first multidisciplinary ERAS preliminary protocol for LITT for the treatment of brain tumors.

Methods

Between the years 2013 and 2021, 184 adult patients consecutively treated with LITT at our single institution were retrospectively analyzed. During this time, a series of pre, intra, and postoperative adjustments were made to the admission course and surgical/anesthesia workflow with the goal of improving recovery and admission length.

Results

The mean age at surgery was 60.7 years with a median preoperative Karnofsky performance score of 90 ± 13. Lesions were most commonly metastases (50%) and high-grade gliomas (37%). The mean length of stay was 2.4 days, with the average patient being discharged 1.2 days after surgery. There was an overall readmission rate of 8.7% with a LITT-specific readmission rate of 2.2%. Three of 184 patients required repeat intervention in the perioperative period, and there was one perioperative mortality.

Conclusions

This preliminary study shows the proposed LITT ERAS protocol to be a safe means of discharging patients on postoperative day 1 while preserving outcomes. Although future prospective work is needed to validate this protocol, results show the ERAS approach to be promising for LITT.

Enhanced recovery after surgery (ERAS), formerly known as fast-track surgery programs, is a model of care that aims to improve patient outcomes, reduce admission length, limit complications, and lower healthcare-associated costs.¹ Central to the ERAS model is reducing the physiologic reaction to stress associated with surgery. This model relies on heightened interdepartmental collaboration, and the implementation of data-driven improvement measures.²

While ERAS protocols have become increasingly popular among surgical subspecialties, the model has only recently gained traction among the neurosurgical community. In fact, to the authors’ knowledge, there are no ERAS society guidelines for any brain neurosurgical procedure, although there are preliminary protocols published by different groups, such as those by Elayat and Wang et al. for elective craniotomies.^3,4 Early neurosurgery ERAS efforts were pioneered by Wang et al. in spinal fusions.^3,5,6 However, as the repertoire of surgical and procedural interventions broadens in this field, the development of new ERAS protocols specific to such novel interventions should follow.

Here we describe the first multidisciplinary ERAS preliminary protocol for laser interstitial thermal therapy (LITT) for the treatment of brain tumors. The study aims to retrospectively analyze the effect this ERAS protocol has on perioperative outcomes and hospital course for brain tumor patients undergoing this procedure.

Methods

The authors retrospectively reviewed the interventions applied pre, intra, and postoperatively to brain tumor patients treated with laser ablation from February 2013 to June 2021 in the Department of Neurosurgery at the University of Miami Hospital. Inclusion criteria were: 1) Adults ≥ 18 years old, and 2) primary or metastatic brain tumor treated with LITT. Exclusion criteria included 1) Incomplete patient data, and 2) LITT for management of nontumor lesions (ie, Radiation necrosis). Aiming for a more homogenous cohort is why it was decided to only analyze brain lesions with a tumoral component. The review process was multidisciplinary. Each recommendation was individually identified and assessed by the working group for its appropriateness for enhancing recovery of the population included. A post hoc focused literature review was carried out with an evaluation of the quality of evidence for each recommendation. Table 1a–c lists the interventions proposed for the preliminary development of an ERAS program. Based on this review the following ERAS protocol is being proposed for prospective studies.

Table 1.

Pre, Intra, and Postoperative Recommendations Preoperative Recommendations

Intervention	Summary
Multidisciplinary team discussion	Tumor board for multidisciplinary treatment decisions and follow-up.
Patient education	Oral and written consent. Detailed explanation to patient and family of what to expect.
Smoking and alcohol	Abstinence recommended, not imposed.
Mental state assessment
Admission a day prior to procedure	Suggested when possible.
Preoperative fasting and oral carbohydrate loading	NPO 8 h for solids. Allowed clear liquids w/high carbs (preselected drink given to patient in out-patient setting) until 2 h before surgery. If patient noncollaborative: NPO 8 h for liquids.
Prophylactic antithrombotic therapy	Graduated compression stockings.
Skin preparation	Hibiclens in the morning of surgery.
Intraoperative recommendations
Prophylactic antithrombotic therapy	Graduated compression stockings and intermittent pneumatic compression pump.
Antimicrobial prophylaxis	Cefazolin 1 h prior to skin incision, 2nd dose if surgery >6 h. If allergic: clindamycin 500 mg 1 h prior.
Steroid prohylaxis	Dexamethasone 10 mg at the beginning of the procedure.
Antiepileptic prophylaxis	During anesthesia prep: levetiracetam 1 g (if already on levetiracetam, keep same dose).
Skin preparation	Chlorhexidine prep.
Local anesthesia	Do not used for ROSA pins
Urinary catheters	Used in every case longer than 3 h. Removed at the end of procedure.
Arterial line	Always used.
Central venous line	Not used. Only used if there were peripheral access issues.
MRI scan	The usage of 3T shortens that stage of procedure (45 min vs 90 min with a 1.5T MRI, approximately).
General Anesthesia details and management
Standard of care of all general anesthesia procedures	End-tidal capnography, noninvasive monitoring (ECG, BP, and pulse oximetry).
CO2 management	Range: 28–31. Aiming for midrange (“not too high, not too low”).
O2 management	We try to get them off supplement oxygen as soon as possible. The need of O2 delays discharge.
EEG monitoring	BIS used. Aim: 44–55. Key element as too much anesthesia = longer PACU time. Must be removed before the MRI. During surgery, it is seen case by case the doses needed to maintain de BIS between 44 and 55 during the MRI part.
Hypothermia avoidance
BP management	BP within 20% of baseline, no lower or higher than that. MAP no lower than 60–65 mmHg.
Mannitol	Usually avoided.
Fluid management: Goal-directed, restriction strategy guided by PPV.	Avoid fluid overload. Keep PPV (pulse pressure variation) below 15%.
Anesthesia protocol	Induction: propofol/fentanyl PRN. No long-acting opiates used. Fentanyl dose: 1 mg/kg early, 1 mg/kg/hs intermittently. Until the patient goes to MRI. We want to be in the low end of opiate doses because in the MRI we canno use pump, just gas. Anesthetic infusion pumps cannot enter this sector. Relaxant: Rocuronium for intubation. Need to know how often you need to redose. We have to establish the dose in the OR because we can’t measure it in the MRI. Doses slightly varies with each pt. Use of Sugammadex, to revert Rocuronium. Maintenance: Sevoflurane ± intermittent boluses of fentanyl (only in the OR, try to minimize the dose of fentanyl). Emergence: bring up CO2 (45 mmHg). Sevoflurane is fast enough to not delay emergence. BIS guides the dose in the OR, so you don’t give too much Sevoflurane, so you don’t delay extubation. We do not reverse the relaxant till the closure is nearly finished.
PONV management	One hour prior to end: ondansetron 4 mg. In addition, we add another antiemetic of another class for every added risk factor such as: hx of motion sickness, non-smoking, plan use for postop opioids, hx PONV: for example, low dose propofol at the end of the case; Promethazine; Aprepitant; Amisulpride (new drug).
Absorbable skin sutures
Postoperative recommendations
Extubation in MRI scanner room
PACU	Observation for 45 min to 1 h.
PACU Analgesia	Small incremental doses of fentanyl + IV acetaminophen.
Routine used of ICU	Artery line kept during ICU stay. Fluid balance measurement. BP control.
Early mobilization
Early fluid de-escalation
Early intake of fluids and solids	6 h postop restart.
MRI control scan	6 h postop.
Prophylactic antithrombotic therapy	Unfractionated heparin 5000 qd during hospital stay.
Discharge criteria standardization
Antiepileptic prophylaxis	Levetiracetam: if < 65 y 1000 mg bid for 2 weeks. If > 65 y 500 mg bid. If already with levetiracetam, keep it the same.
Steroids prophylaxis	Dexamethasone 4 mg q 6 h and taper. If supratentorial benign lesion or metastasis: taper off over 1 week. For supratentorial GBM: taper to 2 mg bid over 1 week. Infratentorial benign or metastasis: taper off over 2 weeks. Infratentorial GBM: taper to 2 mg bid over 2 weeks.
Rescue analgesia at discharge	Paracetamol w/ or w/out Oxycodone.
Discharge	POD 1–2.
Follow-up	Two weeks postop.

ECG = electrocardiogram, BP = blood pressure, EEG = electroencephalogram, BIS = Bispectral Index, MAP = mean arterial pressure, PONV = postoperative nausea and vomiting, Hx = history, PACU = postanesthesia care unit; ICU = intensive care unit; BP = blood pressure; MRI = magnetic resonance imaging; GBM = glioblastoma; POD = postoperative day.

The medical records of 184 consecutive patients treated with LITT were retrospectively analyzed. Institutional review board approval was obtained for this study. Because all identifying information was censored, informed consent from patients was not required. Demographics and clinical information were collected. Tumor volume was calculated using the formula for analyzing ellipsoids: (length × width × height)/2. Likewise, length of hospital stay (LOS), disposition, perioperative complications, and readmissions within 30 days after surgery were analyzed. We divided readmissions into medical and neurosurgical causes. In the latter, we discriminated between complications related directly to surgery (infections, bleeding, cerebral edema, etc.) and those related to the tumor itself (symptomatic progression, regional brain syndromes, etc.). An analysis of patients with LOS > 5 days was done to identify variables that hinder early discharge.

Surgical Laser Ablation Technique

The surgical technique used was described in previous publications by our group.^7,8 In brief, it’s a three-stage procedure: 1) Presurgical trajectory planning, 2) Surgical procedure performed in the operating room (OR), and 3) MRI (magnetic resonance imaging)-guided laser ablation. The current technique is described using the Robotic Surgical Assistant (ROSA) robot that was acquired in March 2019. The same ablation technique was used before that, but with the Stealth Vertek (Medtronic, Dublin) system. The day before surgery an MRI is performed and the surgical planning of the trajectory is carried out. In the OR, after sedation and intubation, five fiduciaries are placed in the skull. Next, an O-arm CT scan is performed and fused with the previously acquired MRI. The head is fixed via a head clamp and attached to the ROSA robot. After registration is performed, the entry point is chosen according to the chosen trajectory using the robot. Next, a small burr hole is made, the robot calculates the depth at which the target is located, a needle biopsy is inserted and several tissue samples are taken. The needle is removed and a guidance bolt is placed that is then used to introduce the laser catheter, always assisted by the ROSA arm. The patient is transferred to the MRI, which (at our institution) is located on the same floor, approximately 40 m away from the OR. A 3T MRI is used. Anesthetic infusion pumps cannot enter this MRI suite, and as such the ablation is carried out using only anesthetic gases. This restriction also applies to certain monitoring elements such as Bispectral index (BIS) or to heaters that prevent the patient’s core temperature to drop. The doses of the drugs used during this last stage must be calculated in the OR according to the particular characteristics of the patient. The ablation strategy is created and carried out controlled entirely by MRI thermography. When the procedure is finished, the patient is extubated in the MRI suite and then taken to the postanesthesia care unit (PACU).

Statistical Analysis

Continuous variables were reported as means, medians, and standard deviations. Categorical variables were reported as frequencies and percentages. Chi-squared test of independence was used to evaluate relationships between categorical variables, and t-test or Analysis of Variance was used to evaluate relationships among continuous variables. Spearman rank correlation coefficient was calculated for variables found to have significant relationships on univariate analysis. In this study, we report findings using 95% confidence intervals and P-values. Analyses were performed using R for Statistical Computing (Vienna, Austria: R Core Team) utilizing a significance value of α= 0.05.⁹ Univariate and multivariate logistic regression analyses were done with GraphPad Prism software (Version 9, GraphPad Software Inc, San Diego, California).

Results

Patient Population

Between February 2013 and July 2021, 184 LITT procedures were performed for the treatment of intracranial tumors at our institution. Clinical and demographic data are shown in Table 2. The average age was 60.7 ± 13.5 years, 35% male. Lesions were most commonly metastases (50%) and high-grade gliomas (HGG) (37%). All metastatic lesions were recurrent, with the patient having undergone prior resection, stereotactic radiosurgery, and/or chemotherapy. The majority of HGG were recurrent from prior disease (72.2%). Lesions were most commonly supratentorial and cortical (88%). Average lesion diameter was 1.84 ± 1.04 cm, with a mean tumor volume of 7.87 ± 11.71 cm ³. Median preoperative (KPS) and Modified Rankin Score (mRS) were 90 and 1, respectively.

Table 2.

Patient Demographics

aracteristic	Value
Age in years
Mean	60.7 ± 13.5
Range	19–86
Sex, % male	35
Location
Supratentorial	167
Cortical	162
Subcortical	5
Infratentorial	17
Lesion type
Metastasis	92
HGG	68
LGG	11
Meningioma	5
Other	8
Tumor diameter, mean (cm)	1.84 ± 1.04
Tumor volume, mean (cm3)	7.87 ± 11.71
Recurrent lesion	72.2%
% presenting with deficit	64.1%
% presenting with seizure	23.5%
Preop KPS, median	90 ± 13
Preop mRS, median	1 ± 0.7
Frailty index, mean	0.0798

Clinical Outcome Measures

Mean hospital LOS was 2.4 ± 1.3 days, with 87.5% of patients discharged by day 3 of admission. Outcomes and complications are summarized in Table 3. Eight patients had a LOS over 5 days (Table 4). Six were held for prolonged inpatient rehabilitation and/or coordination of care. Of the remaining 2, one was admitted initially for workup of suspected stroke leading to the incidental discovery of an intracranial mass subsequently treated with LITT. The second patient underwent elective vertebroplasty after LITT during his admission, prolonging his stay. None with LOS >5 days were readmitted within 30 days of LITT. Spearman rank correlation testing revealed a negative weak, significant correlation between LOS and preoperative KPS (r = −0.211, P = .012) as well as a positive weak correlation between LOS and preoperative frailty index (r = 0.213, P = .004). No relationship was identified between LOS and age at surgery (P = .921), maximum tumor diameter (P = .986), lesion type (P = .162), or location (P = .954).

Table 3.

Postoperative Outcomes

Length of stay
Mean (days)	2.4 ± 1.3
Range (days)	0–11
LOS > 5 days	8 (4.3%)
POD discharge
Mean (days)	1.2 ± 0.8
POD discharge > 5 days	1
Disposition
Home	181
Rehabilitation (short term)	3
Nursing home	0
Long-term acute care	0
Readmissions (within 30 days)	16 (8.7%)
Tumor-related complications (non-LITT)	6 (3.3%)
Neurosurgery readmissions (LITT-related)	4 (2.2%)
Surgical site infection	1
Repeat neurosurgical intervention	3
EVD placement (ICH, hydrocephalus)	2
Mechanical thrombectomy for stroke	1
Medical complications	4 (2.2%)
Repeat elective LITT	2 (1.1%)
Median follow-up (days)	122
Median overall survival (days)	733

Table 4.

Summary of Prolonged Admissions

Patient	LOS	POD discharge	Disposition	30-day readmission	Reason for prolonged LOS
1	6	2	Home	No	Postop weakness and inpatient PT
2	6	5	Short-term rehab	Yes (elective repeat LITT)	Held until bed opened for rehab
3	6	5	Short-term rehab	No	Kept for inpatient PT/OT
4	7	3	Home	No	Psychosocial
5	8	1	Home	No	Tumor discovered incidentally on admission for stroke workup, patient kept for LITT
6	8	6	Home	No	Coordination of care with oncology
7	10	4	Home	No	Patient kept for a second unrelated spinal surgery
8	11	5	Short-term rehab	No	Kept for inpatient PT/OT

Mean postoperative discharge (POD) day was 1.2 ± 0.8 days, with 92.9% of patients discharged by POD 2 (Figure 1). Just one patient was discharged on POD >5 (6 days) due to prolonged inpatient medical oncology and psychiatry care unrelated to LITT. Univariate binary logistic regression revealed a significant relationship between those discharged on < POD 2 and previous radiation therapy (Odds Ratio [OR] = 0.3592, 95% CI = 0.1421–0.9050, P = .0285), tumor volume (OR 0.9706, 95% CI 0.9428–1.000, P = .0412), and preoperative KPS (OR 1.069; 95% CI 1.024–1.121; P = .0032). However, statistical significance was lost in the multivariate analysis. There were no intraoperative complications. No significant relationship was found between POD discharge and age at surgery, BMI, lesion type, or location. Further, there was no significant relationship between POD discharge and date of surgery (ie, no change in POD discharge over time) (P = .0546).

Fig. 1.

Postoperative discharge day distribution. LITT, laser interstitial thermal therapy.

Three of the 184 patients in this cohort were discharged to short-term rehabilitation, all three of which were among the prolonged LOS group. The other 181 patients were discharged home.

Among 184 patients, 16 (8.7%) were readmitted within the perioperative period (30 days) following LITT (Table 3). Of those, 4 (2.2%) were admitted by neurosurgery for complications related to LITT. One admission was due to surgical site infection in a patient with metastatic adenocarcinoma of the lung, which resolved after 2 weeks of antibiotics. The remaining three admissions involved repeat neurosurgical intervention. Two cerebrospinal fluid diversion procedures were performed, the first being a ventriculoperitoneal shunt 3 weeks after LITT. The second patient underwent external ventricular drain placement for management of intraventricular hemorrhage (ICH) 4 days after LITT. This patient’s condition rapidly declined, and she expired on day 6 of readmission, representing the only perioperative mortality in this cohort. The third perioperative neurosurgical intervention involved a mechanical thrombectomy for an MCA (middle cerebral artery) infarction 4 days after LITT.

Among the remaining 12 readmissions, 6 (3.3%) were for tumor-related complications not associated with LITT and included encephalopathy (4), hydrocephalus (1), and progressive motor deficit (1). The one patient with the progressive motor deficit was readmitted for evaluation of generalized worsening weakness and suspected seizure activity. The patient was treated with dexamethasone, levetiracetam, and IV fluids and was discharged home after 4 days with near-complete resolution of the symptoms. Of the remaining six patients, four were readmitted for medical reasons (2.2%) (anemia, pulmonary embolism, and delirium), and 2 (1.1%) for repeat elective LITT. Both patients who underwent repeat elective LITT did so for a second intracranial lesion.

Discussion

Here we discuss the first report of an ERAS protocol for patients undergoing LITT for brain tumor ablation. Our findings suggest that the interventions proposed in this protocol may correlate with a safe and effective way of preserving outcomes while attaining an average 2.4-day hospital stay. The protocol described here is standard of care at our institution and has allowed the typical patient to be discharged on POD 1–2. Given that the ERAS society recommends developing an initial framework prior to definitive guidelines, our group proposes that this design be used in developing a future formal ERAS protocol.¹⁰ These results are comparable to the postoperative course observed at outside institutions with LOS ranging from 2 to 3 days.^11,12 This is, to the best of our knowledge, the first detailed description of an ERAS protocol for LITT, so there is no group within the literature for protocol comparison. Just 4.3% of patients remained in the hospital for a time greater than the acceptable upper limit after a neurosurgical intervention of 5 days.¹³ Further, three of the eight patients with LOS >5 were held for LITT admission-related treatment (prolonged inpatient physical and occupational therapy). The remainder were held for prolonged coordination of care, psychosocial reasons, or unrelated surgical treatment.

In this study, there were no intraoperative complications, and the perioperative complication rate was 2.2%, with three patients requiring repeat neurosurgical intervention. This falls below the average major complication rate of 2.7% cited in the literature for LITT, with rates ranging from 0% to 12%.^11,12,14 The single mortality in this study was secondary to an ICH four days after surgery. Intracranial hemorrhage is a known complication of LITT outlined by Jethwa et al.¹⁵ and Pruitt et al.,¹⁶ who recommend the selection of the safest trajectory regardless of the length from the entry point to target for reducing the probability of intracranial bleeds. Nevertheless, the rate of perioperative mortality in our study (0.05%) is still below that of 1.5%–2.2% stated in the literature.^17,18 Although an early single-center study, this reduced rate suggests ERAS protocols may carry perioperative mortality benefit for brain tumor patients undergoing LITT.

Preoperative Intervention

The LITT ERAS protocol presented here begins with patient selection and entails a multidisciplinary tumor board discussion (Figure 2). Although costly in time and effort, this practice has improved patient care and provider satisfaction.¹⁹ It should be noted here that not every patient is an ideal candidate for ERAS and early discharge. Our population presented with a median preoperative KPS of 90 and a low median frailty index of 0.09, which are correlated to a shorter LOS. Ahluwalia et al. report a less-stable preoperative population with median KPS of 80.¹¹ Although the LOS reported by Ahluwalia et al. is comparable to that reported here, a LITT-specific (ie, nonmedical) complication rate of 15% was reported.¹¹ While patients with lower functional status may still benefit from ERAS and early discharge after LITT, the results presented here suggest such patients are more prone to perioperative complications.

Fig. 2.

Admission timeline of proposed enhanced recovery after laser ablation surgery protocol⁶. ICU, intensive care unit; MRI, magnetic resonance imaging; NPO, nil per os; OR, operating room; PACU, post-anesthesia care unit; POD, postoperative day; PONV, postoperative nausea and vomiting; ppx, prophylaxis. Adopted from “Gantt Chart”, by Biorender.com 2022. Retrieved from https://app.biordender.com/biorender-templates.

On selection of LITT candidates, patients are educated on the procedure itself as well as on its risks and benefits. The positive effect patient education has on patient satisfaction and recovery has been well documented across surgical specialties.²⁰ Although patient satisfaction was not measured in this study given its retrospective design, further investigation should address it.

Patients were ideally admitted 1 day prior to scheduled surgery. Once admitted, patients are placed on a nil per os (NPO) diet 8 hours prior to surgery with allowance for high-carb clear liquids, and fully NPO 2 hours prior. This practice has been shown to curb insulin resistance, perioperative hunger and thirst, and postoperative fatigue.²¹

Intraoperative Intervention

Several measures were employed to reduce surgical site infection, many of which are considered standard of care, as described in "Table 1a and b. The incidence of surgical site infection was low at just 1 in 184. The infection rate after LITT for brain tumor ablation is poorly described in the literature. However, Shao et al. suggest infection to be related to center and surgeon experience where they report a reduced infection rate of 3.1% to 0% over a 9-year period.¹⁷

A logistic advantage specific to our institution is having the MRI suite located very close to the OR, as well as utilizing a 3T MRI, whose main advantage in the context of the ERAS program is a reduction in the intraoperative imaging stage compared to the 1.5T MRI.

Anesthesia-Specific Interventions

Anesthesia care is central to ERAS protocols. Its goal is to provide adequate analgesia and sedation while keeping time for recovery and the need for postoperative anesthesia care at a minimum.²² Much of the guidelines employed in this study are standard of care. Other interventions aim to improve the pace of emergence such as keeping BIS between 44 and 45 and limiting the use of opioids that contribute to postanesthesia “hangover” and reduced gastric motility.²³ An important late development in this protocol regarding emergence was the implementation of Sugammadex for rocuronium reversal (when applicable) which began at this institution in early 2021. Of note, sugammadex has recently been proposed to harbor potential neuroprotective effects and enhanced cognitive recovery in select surgeries, although these findings require further investigation.²⁴

Another area of interest is that of reduction in postoperative nausea and vomiting (PONV).²² PONV is very common with an incidence of 47% and can prolong a given hospital stay.²¹ This postoperative sequelae is of special concern after any intracranial procedure given the risk of Valsalva leading to increased intracranial pressure.²¹ This protocol employed ondansetron 1 hour prior to emergence with additional antiemetics per every PONV risk factor present as summarized in Table 1b. A similar strategy was employed by Wang et al. who reported a significantly lower incidence of PONV with preoperative administration of 5-HT₃ receptor agonists and dexamethasone accompanied by preoperative carb loading and reduced perioperative fasting time.⁴

Postoperative Intervention

A key tenet of postoperative care in ERAS protocols is efficiency of logistics and systems. Anesthesia begins this process with extubation in the MRI suite. This detail allows for rapid turnaround, frees up an OR, and mitigates the risk associated with transporting an anesthetized patient.²⁵

Limiting the use of opioids continues in the postoperative period as it has been shown to reduce the time to discharge.^21,26 In this reported protocol, opioid use is kept to a minimum (ie, small stepwise doses of fentanyl in the PACU) and pain control is ideally multimodal, favoring the use of acetaminophen.

From a neurosurgical perspective, patients were safe for discharge after clearance from physical and occupational therapy, when they were in stable medical condition, without new neurological findings, and had completed postoperative imaging without concerning findings (MRI at 6 hours postop). Discharge protocols in this study closely mirrored those described by Vallejo et al. for same-day discharge after brain tumor resection.²⁷

A goal of discharge at POD 1 or 2 was outlined as a part of this protocol, however, patients were not rushed to discharge if they were not comfortable returning home. The preoperative KPS may serve as a predictor to be used when discussing expected hospital stay.

Future Directions

Although the ERAS protocol for LITT reported in this initial investigation supports expedited recovery and early discharge with a potential benefit in perioperative mortality, deeper investigation is warranted for validation of the findings presented here. Given this is the first report of an ERAS protocol for LITT to the best of our knowledge, a comparative analysis was not possible. In future studies, the focus should be placed on the collection of qualitative details such as patient satisfaction, comfort with early discharge, and quality of pain management. Attention should also be given to patient’s financial burden. Lastly, a future prospective study is expected in order to assess the applicability and rate of compliance of the proposed protocol.

Limitations

Given the retrospective design of this project, total compliance with the ERAS interventions recommended here cannot be guaranteed as some interventions were added to this institution’s practice at varying times over the life of this study (ie, the availability of sugammadex to anesthesia). However, there is evidence that these small variations in this protocol did not affect its efficacy given no significant change in POD discharge was observed.

Conclusion

This report proposes the first ERAS preliminary protocol for LITT in the treatment of brain tumors. The protocol relies heavily on close cooperation at the pre, intra, and postoperative phases of the admission course. Through a combination of evidence-based interventions and multidisciplinary management, this study has shown this institution’s protocol to be a safe mean for discharging patients on POD 1 while preserving outcomes.

Funding

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

Conflicts of Interest

M. Ivan, MD, MBS is a consultant and grant recipient from Medtronic and a consultant for Invenio. The other authors have no relevant financial or non-financial interests to disclose.

Data Availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Code Availability

No code for cleaning or analysis was utilized in this study. Not applicable.

Ethics Approval

This is a retrospective study. The University of Miami Ethics Committee has confirmed that no ethical approval is required.

Consent to Participate

This is a retrospective study approved by the University of Miami IRB, and all data is deidentified. There are no prospective human or animal participants, and there are no new participants included in this study.

Consent for Publication

This is a retrospective study with no new or retrospective human or animal participants. No individual details, images, or videos are included in this manuscript. All participant data has been deidentified.

Authors Contributions

All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Adam S Levy, Tiffany Eatz, Alexis A Morell, and Martin Merenzon. The first draft of the manuscript was written by Adam S Levy and Martin Merenzon, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.