Enhanced recovery after surgery in major oncologic head and neck surgery: A systematic review and meta-regression.

Abstract

e13616 Background: Major oncologic head and neck surgery (OHN) is associated with complex hospitalization and perioperative morbidity. Enhanced Recovery After Surgery (ERAS) pathways aim to standardize multimodal perioperative care and improve recovery; however, evidence in OHN is variable, and the impact of protocolized ERAS bundles has not been comprehensively synthesized. Methods: A systematic review and random-effects meta-analysis were conducted per PRISMA guidelines. MEDLINE, Embase, Emcare, CENTRAL, and trial registries were searched from 2000 to 2026. Randomized controlled trials (RCTs) and observational studies comparing protocolized ERAS with usual care in adults undergoing major OHN were included. Mean differences (MD) were pooled for hospital length of stay (LOS) and risk ratios (RR) for postoperative complications. Meta-regression evaluated associations between LOS & ERAS domains. Sensitivity analyses excluded studies with approximated variance estimates. Results: Twenty-five studies were included overall; 17 studies (1 RCT and 16 nonrandomized studies) contributed to the primary analyses. In sensitivity analyses restricted to studies with reported standard deviations, ERAS was associated with a significant reduction in LOS across all designs (MD −0.77 days; 95%CI −1.50 to −0.04; i 2 = 69.2%). Across all designs, ERAS was associated with fewer postoperative complications (RR 0.74; 0.56 to 1.00; i 2 = 83.6%). No significant association was observed for major complications (RR 1.18; 0.75 to 1.85; i 2 = 0%). Higher ERAS protocol intensity was associated with greater LOS reduction. High-intensity ERAS (≥11 domains) was associated with larger LOS reductions (MD −2.68 days; −4.11 to −1.25) compared with low-intensity ERAS ( < 11 domains; MD −1.05 days; −2.22 to 0.13). In domain-level random-effects meta-regression, select postoperative components were associated with shorter LOS. Standardized flap monitoring was associated with a 2.02-day shorter LOS (95%CI −3.72 to −0.31; p = 0.020). ICU management protocols were associated with a 2.25-day shorter LOS (95%CI −4.19 to −0.31; p = 0.023). Conclusions: ERAS implementation in OHN is associated with shorter hospital LOS, with clinically significant benefits in high-intensity ERAS protocols. Postoperative components, including standardized flap monitoring and ICU management protocols, were associated with shorter LOS. Consistent reporting methodology in ERAS studies is integral to deciphering which domains hold priority and may support refining low- to moderate-intensity protocol bundles that may lead to significant recovery and perioperative optimization with less domain steps to implement.