Enhanced recovery after surgery protocols in adrenal surgery. A systematic review and meta-analysis

Background: Enhanced recovery after surgery (ERAS) protocols aim to attenuate the physiological stress of surgery and accelerate postoperative recovery. While widely adopted in several surgical fields, their role in adrenal surgery remains less defined. The aim of this systematic review and meta-analysis was to evaluate the impact of ERAS protocols on perioperative outcomes in patients undergoing adrenalectomy compared with conventional care. Methods: Eligible studies included randomized controlled trials (RCTs), prospective cohorts, and retrospective comparative analyses involving adult patients undergoing adrenalectomy managed with ERAS versus standard care. A systematic literature search was conducted in PubMed, Scopus, ScienceDirect, and the Cochrane Library, without time restrictions, with the last search performed in August 2025. Primary outcomes were postoperative length of stay (LOS), pain, and complication rates. Secondary outcomes included functional recovery, gastrointestinal recovery, and hospital costs. Risk of bias (RoB) was assessed using the RoB 2.0 tool for RCTs and the ROBINS-I tool for non-randomized studies. Quantitative synthesis was performed using a random-effects meta-analysis, with standardized mean differences (SMDs) and risk ratios used to summarize continuous and dichotomous outcomes, respectively. Results: Six comparative studies, including a total of 429 patients, met the inclusion criteria. ERAS protocols were associated with a significant reduction in postoperative LOS, postoperative complications, and pain scores. ERAS pathways also resulted in faster functional recovery, including earlier mobilization, urinary catheter removal, and gastrointestinal recovery, without an increase in major complications. Although individual studies reported cost savings with ERAS implementation, pooled analysis did not demonstrate a statistically significant reduction in hospitalization costs. Conclusions: ERAS protocols in adrenalectomy are associated with improved perioperative outcomes, faster recovery, and reduced postoperative morbidity without compromising safety. However, the available evidence is limited by heterogeneity and methodological quality. Further high-quality prospective studies are needed to develop and validate standardized ERAS guidelines tailored specifically to adrenal surgery.