Impact of ERAS pathway-based perioperative management on postoperative recovery and psychological status in thyroid cancer surgery patients: A retrospective study.

Impact of ERAS pathway-based perioperative management on postoperative recovery and psychological status in thyroid cancer surgery patients: A retrospective study - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Search Log in Primary site navigation Search Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice Medicine (Baltimore) . 2026 May 29;105(22):e49029. doi: 10.1097/MD.0000000000049029 Impact of ERAS pathway-based perioperative management on postoperative recovery and psychological status in thyroid cancer surgery patients: A retrospective study Hui Xu a , Miao Pan b , Lin Zhu c, * Author information Article notes Copyright and License information a Department of Otolaryngology, The First People’s Hospital of Jiangxia District, Wuhan, Hubei University of Medicine, Wuhan, Hubei, China b Department of Nephrology, The First People’s Hospital of Jiangxia District, Wuhan, Hubei University of Medicine, Wuhan, Hubei, China c Department of Hepatobiliary, Thyroid and Breast Surgery, The First People’s Hospital of Jiangxia District, Wuhan, Hubei University of Medicine, Wuhan, Hubei, China. * Correspondence: Lin Zhu, Department of Hepatobiliary, Thyroid and Breast Surgery, The First People’s Hospital of Jiangxia District, Wuhan, Hubei University of Medicine, Wuhan 430200, Hubei, China (e-mail: zl20251112@163.com ). Received 2025 Nov 25; Revised 2026 Feb 24; Accepted 2026 May 8; Collection date 2026 May 29. Copyright © 2026 the Author(s). Published by Wolters Kluwer Health, Inc. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC) , where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially without permission from the journal. PMC Copyright notice PMCID: PMC13225497  PMID: 42216346 Abstract Enhanced recovery after surgery (ERAS) protocols have demonstrated benefits in various surgical specialties, but their impact on psychological outcomes in thyroid cancer patients remains underexplored. This study comprehensively evaluated the effects of ERAS implementation on both postoperative recovery and psychological well-being in thyroid cancer surgery patients. This retrospective cohort study included 278 thyroid cancer patients undergoing thyroidectomy after 1:1 propensity score matching. Patients treated from January 2024 to December 2024 were managed according to the ERAS protocol (ERAS group, n = 139), while those treated from January 2023 to December 2023 received conventional perioperative care (control group, n = 139). The ERAS protocol comprised multimodal perioperative interventions including patient education, optimized anesthesia, early mobilization, and psychological support. Primary outcome was length of hospital stay. Secondary outcomes included early recovery metrics, pain scores (Visual Analog Scale), opioid consumption, hospitalization costs, psychological status (Self-rating Anxiety Scale, Self-rating Depression Scale), quality of life (36-Item Short Form Survey), and complications. The ERAS group demonstrated significantly shorter hospital stay and superior early recovery outcomes including earlier oral intake, mobilization, and drain removal (all P < .001). Pain scores were consistently lower at all postoperative timepoints, with reduced opioid consumption ( P < .001). Total hospitalization costs were significantly reduced in the ERAS group ( P < .001). ERAS patients showed significantly lower anxiety and depression scores throughout recovery ( P < .001) and higher quality of life scores at discharge and 1 month postoperatively ( P < .05). Total complication rates were reduced (23.74% vs 35.97%, P = .026), with significant decreases in transient hypocalcemia, postoperative nausea and vomiting, and hypothermia. ERAS implementation in thyroid cancer surgery is associated with improved postoperative recovery, reduced complications, decreased costs, and enhanced psychological well-being, supporting its adoption as a comprehensive perioperative care strategy addressing both physical and psychological dimensions of recovery. Keywords: enhanced recovery after surgery (ERAS), perioperative management, postoperative recovery, psychological status, thyroid cancer 1. Introduction Thyroid cancer has emerged as one of the most rapidly increasing malignancies worldwide, with significant implications for public health systems globally. According to the GLOBOCAN database, approximately 586,000 new cases of thyroid cancer were reported globally in 2020, making it the 10th most common cancer worldwide. [ 1 ] In 2022, the global age-standardized incidence rate reached 10.1 per 100,000 in women and 3.1 per 100,000 in men, with projections suggesting a 34% increase in new cases by 2050. [ 2 ] This epidemiological landscape underscores the growing burden of thyroid cancer management and the critical need for optimized perioperative care strategies. Enhanced recovery after surgery (ERAS) represents a multimodal, evidence-based perioperative care pathway designed to reduce surgical stress, accelerate functional recovery, and minimize postoperative complications. [ 3 ] Since its introduction in the early 2000s, ERAS protocols have demonstrated significant benefits across various surgical specialties, including colorectal, orthopedic, and gynecologic surgery. [ 4 – 6 ] The fundamental principles of ERAS encompass preoperative patient education and optimization, intraoperative standardization of care, and early postoperative mobilization, and accelerated return to normal diet and activities. [ 7 ] A systematic review and meta-analysis by Chorath et al demonstrated growing evidence supporting the implementation of ERAS protocols in thyroidectomy, showing significant reductions in hospital length of stay and costs without increasing complication or readmission rates. [ 8 ] Similarly, a prospective study at Shanghai Ruijin Hospital demonstrated that ERAS protocols significantly reduced pain scores, length of stay, and hospitalization costs compared to conventional management, while maintaining comparable complication rates. [ 9 ] Beyond physical recovery outcomes, emerging evidence suggests that perioperative management may significantly impact patients’ psychological well-being. Thyroid surgery, particularly for cancer, has been associated with increased risk of anxiety and depression. [ 10 ] A large population-based study by Choi et al revealed that patients undergoing total thyroidectomy faced a 27% increased risk of depression before surgery, with postoperative risk escalating by 81% and remaining significantly elevated for over a year. [ 11 ] Furthermore, A study demonstrated that approximately 10% of thyroid surgery patients experienced psychological morbidity during the perioperative period, with somatic symptoms positively correlated with psychological status. [ 12 ] The psychological burden associated with cancer diagnosis, surgical stress, and concerns about postoperative outcomes can substantially impair patients’ quality of life and recovery trajectory. [ 13 ] However, limited research has specifically examined whether ERAS protocols can mitigate these psychological effects in thyroid cancer patients. Most existing studies have focused primarily on traditional surgical metrics such as length of stay, complication rates, and pain scores, with limited attention to the psychological dimensions of recovery. [ 8 , 9 ] Therefore, this retrospective cohort study aimed to comprehensively evaluate the impact of an ERAS protocol on both postoperative recovery and psychological status in thyroid cancer patients undergoing thyroidectomy. We hypothesized that ERAS pathway implementation would not only accelerate physical recovery but also improve patients’ psychological well-being and overall quality of life compared to conventional perioperative management. 2. Methods 2.1. Study design and participants This single-center retrospective cohort study was conducted at the Department of Thyroid Surgery, The First People’s Hospital of Jiangxia District, Wuhan, Hubei University of Medicine, from January 2023 to December 2024. The study protocol was approved by the Institutional Ethics Committee, and the requirement for informed consent was waived due to the retrospective nature of the study. Patients who underwent thyroidectomy for thyroid carcinoma between January 2023 and December 2024 were consecutively enrolled. The inclusion criteria were: age 18 to 75 years; pathologically confirmed thyroid carcinoma (papillary or follicular carcinoma); first-time thyroidectomy (unilateral or bilateral thyroidectomy with or without lymph node dissection); American Society of Anesthesiologists (ASA) physical status I-III; [ 14 ] and complete medical records and follow-up data. The exclusion criteria were: concurrent other malignancies; severe cardiopulmonary dysfunction; psychiatric disorders requiring active treatment or cognitive impairment; preoperative radiotherapy or chemotherapy; emergency or revision surgery. Patients treated from January 2024 to December 2024 were managed according to the ERAS protocol (ERAS group), while those treated from January 2023 to December 2023 received conventional perioperative care (Control group). Between January 2023 and December 2024, 360 patients underwent thyroidectomy for thyroid cancer. After applying the inclusion and exclusion criteria, 339 patients were eligible, with 178 in the ERAS group and 161 in the control group. After 1:1 propensity score matching (PSM), 139 patients in each group were included in the final analysis. 2.2. ERAS protocol The ERAS protocol was developed based on the ERAS Society guidelines for head and neck cancer surgery with adaptations for thyroidectomy, [ 15 ] in conjunction with the systematic review evidence for thyroid surgery [ 8 ] and the Chinese Expert Consensus on ERAS in Thyroid Surgery. [ 16 ] The protocol comprised the following key elements: 2.2.1. Preoperative phase First, patient education and psychological support. Multimodal health education through videos, printed materials, and one-on-one counseling covered ERAS concepts, surgical procedures, and recovery expectations. The teach-back method verified comprehension while nursing staff addressed concerns to alleviate anxiety, integrated as fundamental ERAS components recognizing psychological stress reduction as intrinsic to the pathway. Second, medical optimization. Comprehensive assessment evaluated cardiovascular risk, thyroid function, respiratory status, and nutritional status using Nutritional Risk Screening 2002. Patients received targeted interventions including pulmonary therapy, thyroid hormone normalization, and smoking/alcohol cessation counseling for minimum 2 weeks. Third, preoperative preparation. Optimized fasting permitted solids until 6 hours and clear liquids until 2 hours before surgery. Carbohydrate loading (800 mL at 10 hours, 400 mL at 2 hours preoperatively) reduced insulin resistance and anxiety. Skin preparation involved cleansing without routine hair removal. Patients performed respiratory training including diaphragmatic breathing 3 times daily for 10 to 20 minutes. 2.2.2. Intraoperative phase First, anesthetic management. General anesthesia was induced using short-acting agents (propofol, remifentanil, rocuronium) to facilitate rapid emergence. Ultrasound-guided bilateral superficial cervical plexus block or local anesthetic infiltration was routinely performed, which effectively reduced opioid consumption and the incidence of postoperative nausea and vomiting (PONV). The depth of anesthesia was monitored with the Bispectral Index and maintained between 40 and 60. Second, fluid management and hemodynamic optimization. A goal-directed fluid therapy strategy was adopted, primarily utilizing balanced crystalloid solutions to maintain euvolemia and avoid fluid overload. This approach aimed to ensure tissue perfusion, promote wound healing, and reduce cardiopulmonary complications. Third, hypothermia prevention and organ preservation. Active warming measures, including forced-air warming blankets, were used to maintain core body temperature ≥ 36°C. Meticulous surgical techniques were emphasized to preserve the recurrent and superior laryngeal nerves, with intraoperative neuromonitoring employed when necessary. Parathyroid glands were preserved in situ or autotransplanted when necessary, utilizing carbon nanoparticle imaging for enhanced identification. Lymphatic structures were carefully managed to prevent chylous fistula formation. 2.2.3. Postoperative phase First, early recovery. Patients received water after awakening, advancing to cool liquids at 6 hours then regular diet targeting 25 to 30 kcal/kg/day. Early mobilization began with in-bed exercises, progressing to ambulation for minimum 2 hours on postoperative day 1. Second, complication management. Multimodal PONV prophylaxis combined antiemetics with non-pharmacological approaches. Prophylactic calcium and vitamin D supplementation prevented symptomatic hypocalcemia. Vigilant 12 to 48 hour monitoring detected hemorrhage, respiratory difficulty, nerve injury, and hypocalcemia. Nursing staff provided continuous emotional support through proactive communication throughout recovery. Third, rehabilitation. Individualized neck functional exercises began on postoperative day 1, including neck rotation and shoulder movements performed 5 to 10 repetitions 3 times daily. Thyroid hormone replacement initiated based on surgical extent. Drains were removed when criteria met. Structured follow-up provided guidance with thyroid function testing at 4 to 6 weeks and ultrasound at 3 to 6 months. The control group received conventional perioperative care including preoperative fasting from midnight, restriction of oral intake for 6 hours after surgery, encouraged ambulation starting from 10 to 12 hours postoperatively, and routine postoperative monitoring. 2.3. Outcome measures 2.3.1. Primary outcome The primary outcome was length of hospital stay, defined as days from surgery to discharge meeting standard discharge criteria. 2.3.2. Secondary outcomes Secondary outcomes encompassed multiple domains of recovery and safety: Early recovery metrics: time to first postoperative oral intake (hours from surgery completion to first liquid or food consumption), time to first postoperative ambulation (hours from surgery completion to first out-of-bed walking), time to drain removal (days from surgery to removal of surgical drains), total drainage volume (cumulative output in milliliters from all drains until removal), and 30-day readmission rate (proportion of patients requiring hospital readmission within 30 days of discharge for any cause related to the surgery). Postoperative pain intensity was e evaluated preoperatively and at 6, 24, and 48 hours postoperatively using a 0 to 10 Visual Analog Scale, where 0 represented “no pain” and 10 represented “worst possible pain.” [ 17 ] Total opioid consumption during hospitalization was calculated and converted to morphine equivalents (mg), the proportion of patients requiring opioid analgesia was also recorded, and total hospitalization costs were recorded. Healthcare utilization outcomes included total hospitalization costs, medication costs, and nursing care costs. Psychological status was assessed by Self-rating Anxiety Scale (SAS) and Self-rating Depression Scale (SDS) preoperatively, on postoperative day 3, and at discharge. The SAS (Cronbach α = 0.82) is a 20-item scale used to measure the frequency of anxiety symptoms, with each item scored on a 4-point Likert scale. [ 18 , 19 ] The total raw score (ranging from 20–80) is converted to a standard index score by multiplying by 1.25, with a standard score of 50 as the cutoff point for clinically significant anxiety; higher scores indicate more severe anxiety. The SDS (Cronbach α = 0.78) similarly contains 20 items assessing depressive symptoms, and its total raw score is converted to a standard index score using the same method, with a standard score of 53 as the cutoff for clinically significant depression; [ 20 , 21 ] higher scores indicate more severe depressive symptoms. Quality of life was evaluated by 36-Item Short Form Survey (SF-36) preoperatively, at discharge, and 1 month postoperatively. The SF-36 (Cronbach α > 0.85 across subscales) is a generic quality of life instrument comprising 36 items that measure health across 8 domains, which can be aggregated into a Physical Component Summary and a Mental Component Summary score. [ 22 , 23 ] The scores for each domain and summary component are transformed to a scale from 0 to 100, with higher scores indicating better health status and quality of life. Postoperative complications including PONV, bleeding, infection, recurrent laryngeal nerve injury, hypoparathyroidism, neck hematoma, and wound healing problems. Overall complications represent the number of patients who experienced any complication during the perioperative period (a patient with multiple complications was counted once). 2.4. Data collection Data were retrospectively extracted from the hospital electronic medical record system by 2 independent researchers who were blinded to the study objectives. Extracted data included demographic information, clinical characteristics, surgical details, laboratory results, postoperative outcomes, and follow-up information. Discrepancies were resolved by consensus with a third senior investigator. 2.5. Statistical analysis Analyses were performed using IBM SPSS Statistics (IBM Corp.) and R software version 4.2.0 (R Foundation for Statistical Computing). Continuous variables were tested for normality using the Shapiro–Wilk test. Normally distributed data were expressed as mean ± standard deviation and compared using independent t -tests; non-normal data as median (interquartile range) and compared using Mann-Whitney U tests. Categorical variables were expressed as n (%) and compared using chi-square or Fisher exact tests. Repeated measures data (pain scores, psychological assessments, quality of life) were analyzed using linear mixed-effects models with random intercepts for subjects, fixed effects for time, group, and time × group interaction, and unstructured covariance matrix. Post hoc pairwise comparisons were performed using estimated marginal means with Bonferroni correction for multiple comparisons. To minimize selection bias and balance baseline characteristics between groups, PSM was performed using a 1:1 nearest-neighbor matching algorithm with a caliper width of 0.02. Propensity scores were calculated using logistic regression including covariates: age, sex, body mass index, ASA classification, smoking history, alcohol consumption, hypertension, diabetes mellitus, surgical procedure type (lobectomy/total thyroidectomy), and lymph node dissection extent. The C -statistic for the propensity score model was 0.73 (95% confidence interval: 0.68–0.78), indicating good discriminative ability. Matching quality was assessed by standardized mean differences (< 0.10 indicating adequate balance). Missing data < 10% were handled by multiple imputation; otherwise complete case analysis was performed. Two-tailed P < .05 was considered significant. Given the multiple secondary endpoints examined, results should be interpreted with appropriate consideration of the exploratory nature of some analyses. 3. Results 3.1. Patient characteristics A total of 278 patients were included in the final analysis after 1:1 PSM (139 per group). The baseline characteristics are presented in Table 1 . Briefly, the mean age was approximately 46 years, with a female predominance (approximately 79%). Most patients were ASA class I-II (> 95%) with low comorbidity burden. Papillary thyroid carcinoma was the predominant histological type (> 92%), and the majority presented with stage I disease (approximately 75%). Bilateral thyroidectomy was performed in approximately 68% of patients, with central lymph node dissection in approximately 55%. After PSM, all baseline characteristics were well-balanced between groups, with all standardized mean differences < 0.10, confirming adequate matching quality. Table 1. Baseline characteristics after PSM. Variable Before PSM After PSM ERAS (n = 178) Control (n = 161) SMD ERAS (n = 139) Control (n = 139) SMD Demographic characteristics Age (yrs), mean ± SD 45.32 ± 11.20 46.81 ± 12.53 0.13 45.84 ± 11.42 45.60 ± 11.82 0.02 Female, n (%) 142 (79.78) 124 (77.02) 0.07 110 (79.14) 111 (79.86) 0.02 BMI (kg/m 2 ), mean ± SD 23.83 ± 3.43 24.24 ± 3.63 0.12 23.91 ± 3.53 24.00 ± 3.42 0.03 ASA classification, n (%) 0.15 0.05 I 98 (55.06) 82 (50.93) 76 (54.68) 77 (55.40) II 72 (40.45) 68 (42.24) 58 (41.73) 57 (41.01) III 8 (4.49) 11 (6.83) 5 (3.60) 5 (3.60) Current smoker, n (%) 15 (8.43) 18 (11.18) 0.09 11 (7.91) 12 (8.63) 0.03 Alcohol consumption, n (%) 12 (6.74) 15 (9.32) 0.09 9 (6.47) 10 (7.19) 0.03 Comorbidities Hypertension, n (%) 28 (15.73) 32 (19.88) 0.11 23 (16.55) 24 (17.27) 0.02 Diabetes mellitus, n (%) 14 (7.87) 18 (11.18) 0.11 12 (8.63) 13 (9.35) 0.03 Tumor characteristics Tumor size (cm), mean ± SD 1.62 ± 0.68 1.70 ± 0.79 0.11 1.60 ± 0.63 1.63 ± 0.69 0.04 Multifocality, n (%) 52 (29.21) 54 (33.54) 0.09 42 (30.22) 43 (30.94) 0.02 Extrathyroidal extension, n (%) 24 (13.48) 28 (17.39) 0.11 20 (14.39) 21 (15.11) 0.02 TNM stage, n (%) 0.11 0.03 I 135 (75.84) 116 (72.05) 104 (74.82) 105 (75.54) II 32 (17.98) 33 (20.50) 27 (19.42) 26 (18.71) III 11 (6.18) 12 (7.45) 8 (5.76) 8 (5.76) Pathological type, n (%) 0.06 0.02 Papillary 165 (92.70) 148 (91.93) 129 (92.81) 128 (92.09) Follicular 11 (6.18) 11 (6.83) 9 (6.47) 10 (7.19) Others 2 (1.12) 2 (1.24) 1 (0.72) 1 (0.72) Surgical procedure Unilateral thyroidectomy, n (%) 58 (32.58) 48 (29.81) 0.06 44 (31.65) 45 (32.37) 0.02 Bilateral thyroidectomy, n (%) 120 (67.42) 113 (70.19) 0.06 95 (68.35) 94 (67.63) 0.02 Central LN dissection, n (%) 95 (53.37) 92 (57.14) 0.08 76 (54.68) 77 (55.40) 0.01 Lateral LN dissection, n (%) 18 (10.11) 21 (13.04) 0.09 15 (10.79) 16 (11.51) 0.02 Surgical approach, n (%) 0.05 0.01 Open 156 (87.64) 138 (85.71) 122 (87.77) 121 (87.05) Endoscopic 22 (12.36) 23 (14.29) 17 (12.23) 18 (12.95) Open in a new tab After PSM, all SMD < 0.10, indicating adequate balance between groups. ASA = American Society of Anesthesiologists, BMI = body mass index, LN = lymph node, n = number of partcipants, NRS2002 = Nutritional Risk Screening 2002, PSM = propensity score matching, SD = standard deviation, SMD = standardized mean difference, TNM = tumor-node-metastasis. 3.2. Primary outcome The ERAS group demonstrated significantly shorter hospital stay compared to the control group (3.00 [2.00–4.00] vs 4.00 [3.00–5.00] days, P < .001), representing a 25% reduction in median length of stay (Table 2 ). Table 2. Primary outcome and early recovery metrics. Variable ERAS (n = 139) Control (n = 139) P value Primary Outcome Length of hospital stay (d), median (IQR) 3.00 (2.00–4.00) 4.00 (3.00–5.00) < .001 Secondary Outcomes - Early Recovery Time to first oral intake (h), median (IQR) 2.50 (2.00–4.00) 6.00 (4.00–8.00) < .001 Time to first ambulation (h), median (IQR) 6.00 (4.00–8.00) 10.00 (8.00–12.00) < .001 Time to drain removal (d), median (IQR) 2.00 (1.00–2.00) 3.00 (2.00–4.00) < .001 Total drainage volume (mL), mean ± SD 156.32 ± 52.18 189.45 ± 61.23 < .001 30-day readmission, n (%) 3 (2.16) 9 (6.47) .076 Open in a new tab ERAS = enhanced recovery after surgery, IQR = interquartile range, SD = standard deviation. 3.3. Secondary outcomes 3.3.1. Early recovery metrics Patients in the ERAS group demonstrated significantly superior outcomes across all early recovery endpoints (Table 2 ). Time to first ambulation ( P < .001), with the ERAS group achieving mobilization within 6 hours compared to 10 hours in the control group. Drains were removed earlier in the ERAS group ( P < .001), with significantly lower total drainage volume ( P < .001). The 30-day readmission rate showed a trend toward reduction in the ERAS group (2.16 vs 6.47%), though this difference did not reach statistical significance ( P = .076). 3.3.2. Pain management and healthcare utilization The ERAS group consistently reported significantly lower Visual Analog Scale pain scores at all postoperative time points compared to the control group (all P < .001 for post hoc comparisons) (Fig. 1 A). Mixed-effects model analysis revealed significant main effects of time ( F = 244.70, P < .001), group (F = 179.10, P < .001), and time × group interaction ( F = 27.88, P < .001) on postoperative pain scores. The multimodal analgesia approach in the ERAS protocol resulted in significantly reduced opioid consumption ( P < .001) and fewer patients requiring opioid analgesia ( P < .001). The ERAS protocol was associated with substantial cost savings, with significant reductions in total hospitalization costs, medication costs, and nursing care costs ( P < .001) (Table 3 ) Figure 1. Open in a new tab Postoperative recovery outcomes in the ERAS and control groups. (A) Change in VAS pain score. (B) Change in SAS anxiety score. (C) Change in SDS depression score. (D) Change in SF-36 quality of life score. Data are presented as mean ± SD. & P < .05, && P < .01, &&& P < .001 compared to preoperative within each group; * P < .05, ** P < .01, *** P < .001 ERAS group vs Control group at the same time point. 1m postop = 1 month postoperative, 24h postop = 24 hours postoperative, 3d postop = 3 days postoperative, 48h postop = 48 hours postoperative, 6h postop = 6 hours postoperative, ERAS = enhanced recovery after surgery, SAS = Self-rating Anxiety Scale, SD = standard deviation, SDS = Self-rating Depression Scale, SF-36 = 36-Item Short Form Survey, VAS = Visual Analog Scale. Table 3. Opioid consumption, and hospitalization costs. Variable ERAS (n = 139) Control (n = 139) P value Opioid consumption Total morphine equivalent (mg), median (IQR) 6.00 (3.00–10.00) 12.00 (8.00–18.00) < .001 Patients requiring opioids, n (%) 81 (58.27) 112 (80.58) < .001 Hospitalization costs Total cost (USD), mean ± SD 3245.45 ± 528.68 3856.78 ± 645.34 < .001 Medication cost (USD), mean ± SD 420.35 ± 82.45 540.67 ± 98.76 < .001 Nursing care cost (USD), mean ± SD 324.68 ± 58.23 404.58 ± 72.45 < .001 Open in a new tab ERAS = enhanced recovery after surgery, IQR = interquartile range, n = number of partcipants, SD = standard deviation, USD = United States dollars, VAS = Visual Analog Scale. 3.3.3. Psychological status and quality of life Baseline anxiety and depression scores were comparable between groups (Figs. 1 B and 1 C). Mixed-effects model analysis of anxiety scores revealed significant main effects of time ( F = 76.60, P < .001), group ( F = 56.15, P < .001), and time × group interaction ( F = 15.22, P < .001). Post hoc comparisons demonstrated that SAS scores decreased significantly over time in both groups, with the ERAS group showing greater improvement at all postoperative time points (all P < .001). (Fig. 1 B) Similarly, for SDS scores, significant effects were observed for time ( F = 22.62, P < .001), group ( F = 73.30, P < .001), and time × group interaction ( F = 5.76, P = .003), indicating superior psychological recovery in the ERAS group. (Fig. 1 C) SF-36 scores were comparable between groups preoperatively. Mixed-effects model analysis showed significant effects of time ( F = 11.97, P < .001), group ( F = 88.83, P < .001), and time × group interaction ( F = 4.47, P = .012), with the ERAS group demonstrating significantly higher SF-36 scores at discharge and 1 month postoperatively (both P < .05) (Fig. 1 D) 3.4. Postoperative complications The overall complication rate was significantly lower in the ERAS group compared to the control group (Table 4 ). Among surgical complications, the incidence of transient hypocalcemia was significantly reduced in the ERAS group ( P = .020), while permanent hypoparathyroidism rates showed no significant difference between groups ( P > .05). Transient recurrent laryngeal nerve injury occurred less frequently in the ERAS group, though this difference did not reach statistical significance, and no permanent recurrent laryngeal nerve injuries occurred in the ERAS group compared to 2 cases in the control group. Other surgical complications, including hemorrhage requiring intervention, surgical site infection, chylous fistula, and seroma formation, all occurred less frequently in the ERAS group without reaching statistical significance ( P > .05). Table 4. Postoperative complications. Complication ERAS (n = 139) n (%) Control (n = 139) n (%) P value Overall complications 33 (23.74) 50 (35.97) .026 Surgical complications Hemorrhage requiring intervention 3 (2.16) 6 (4.32) .307 Transient hypocalcemia 18 (12.95) 33 (23.74) .020 Permanent hypoparathyroidism 1 (0.72) 4 (2.88) .180 Transient RLN injury 6 (4.32) 12 (8.63) .126 Permanent RLN injury 0 (0.00) 2 (1.44) .156 Surgical site infection 2 (1.44) 5 (3.60) .245 Chylous fistula 1 (0.72) 2 (1.44) .561 Seroma formation 2 (1.44) 4 (2.88) .406 Anesthesia-related complications PONV 15 (10.79) 36 (25.90) .001 Perioperative hypothermia 9 (6.47) 27 (19.42) .001 Prolonged emergence (> 30 min) 4 (2.88) 11 (7.91) .063 Medical complications Urinary retention 3 (2.16) 7 (5.04) .194 Respiratory complications 2 (1.44) 5 (3.60) .245 Cardiovascular events 1 (0.72) 2 (1.44) .561 Open in a new tab Overall complications represent the number of patients who experienced any complication during the perioperative period (a patient with multiple complications was counted once). ERAS = enhanced recovery after surgery, n = number of partcipants, PONV = postoperative nausea and vomiting, RLN = recurrent laryngeal nerve. Anesthesia-related complications were markedly reduced in the ERAS group, particularly PONV and perioperative hypothermia ( P = .001). Prolonged emergence from anesthesia showed a trend toward reduction in the ERAS group ( P > .05). Medical complications, including urinary retention, respiratory complications, and cardiovascular events, occurred infrequently in both groups without significant differences ( P > .05). 4. Discussion This retrospective cohort study evaluated the impact of an ERAS protocol on postoperative recovery and psychological outcomes in thyroid cancer patients undergoing thyroidectomy. Our findings demonstrated that ERAS implementation was associated with significant improvements in both physical recovery metrics and psychological well-being compared to conventional perioperative care. The primary outcome of reduced hospital stay in our ERAS group aligns with previous systematic reviews and meta-analyses. A recent multi-institutional study by Machado et al reported significant reductions in total length of stay following ERAS implementation for thyroid and parathyroid surgery, Though their median stay reduction was more modest (9.2 vs 7.5 hours for same-day discharge patients), [ 24 ] Our study focused on inpatient thyroidectomy with more complex cases, explaining the longer absolute stay times but similar relative improvements. Similarly, Zheng and Zhang prospective study in Shanghai demonstrated a mean hospital stay reduction of approximately 1.5 days with ERAS protocols. [ 9 ] In our study, the reduction in hospital stay observed in the ERAS group may reflect differences in baseline practices across institutions as well as the comprehensiveness of our ERAS protocol, which incorporated extensive preoperative patient education, optimized anesthesia management, and structured early mobilization strategies. However, it is important to note that baseline conventional care practices varied across institutions, and direct comparisons should be interpreted cautiously. The significant reduction in postoperative pain scores observed in our ERAS group is consistent with emerging evidence on multimodal analgesia in thyroid surgery. [ 25 ] Yip et al [ 26 ] 2020 landmark study demonstrated that implementation of enhanced recovery protocols specific to cervical endocrine surgery resulted in substantial reductions in opioid consumption, with some patients requiring no opioids during their postoperative hospitalization. Our finding of reduced morphine equivalents supports this trend toward opioid-sparing strategies. The incorporation of regional anesthesia techniques, such as superficial cervical plexus blocks, likely contributed to improved pain control in our cohort, though we acknowledge that the relative contribution of individual ERAS components cannot be determined from our study design. Perhaps most notably, our study demonstrates that ERAS implementation conferred significant psychological benefits, as evidenced by substantially lower anxiety and depression scores throughout the postoperative period. This focus on psychological well-being is particularly warranted given the established burden of psychological distress in thyroid cancer survivors. Longitudinal studies indicate that anxiety and depression can persist for years after treatment, [ 27 , 28 ] a finding underscored by a 2025 systematic review emphasizing the high prevalence of psychological distress, fear of recurrence, and impaired quality of life in this population despite a favorable prognosis. [ 29 ] The Chinese Expert Consensus on ERAS in Thyroid Surgery explicitly recognizes this challenge, advocating for integrated psychological support as a fundamental component of perioperative care. [ 16 ] Our results empirically affirm the value of this recommendation. The mechanisms underlying the psychological benefits observed in our ERAS cohort likely involve multiple interrelated factors. Preoperative education and psychological support, which were integral components of our ERAS protocol, may have reduced preoperative anxiety and established realistic postoperative expectations. Evidence from other surgical specialties supports the psychological benefits of ERAS protocols. Ji et al [ 30 ] retrospective cohort study in patients undergoing percutaneous kyphoplasty demonstrated that ERAS protocols significantly reduced both depression and anxiety scores at postoperative follow-up periods, with the intervention group achieving faster psychological recovery and maintaining psychological stability compared to the control group. In total hip arthroplasty, a recent study by Xing et al [ 31 ] showed that ERAS protocols exerted beneficial influences on patient satisfaction while significantly mitigating pain catastrophizing and reducing surgery-related anxiety and depression, with these improvements persisting through 6 months postoperatively. Furthermore, a randomized controlled study by Zhang et al [ 32 ] in andrological surgery patients demonstrated that psychological care combined with ERAS management significantly improved SAS and SDS scores at discharge compared with baseline and control groups, while also shortening postoperative hospital stay and reducing pain scores. In our study, reduced postoperative pain through multimodal analgesia, earlier mobilization facilitating return to normal activities, and expedited recovery minimizing hospitalization duration may have collectively contributed to improved mood and reduced distress. The structured emotional support provided by nursing staff throughout the ERAS pathway, as an integral component of our protocol, may have further enhanced psychological resilience during the recovery period. Consistent with these psychological improvements, our study also demonstrated superior quality of life outcomes in the ERAS group, with significantly higher SF-36 scores observed at discharge and maintained at 1 month postoperatively, suggesting sustained benefits beyond the immediate perioperative period. Regarding complications, our study demonstrated a significant reduction in overall complication rates, particularly for transient hypocalcemia and PONV. Based on the systematic review and meta-analysis, the incidence of post-thyroidectomy hypocalcemia can reach up to 38% for transient cases and 3% for permanent cases under specific high-risk conditions, and a comprehensive approach integrating risk factor assessment and biochemical monitoring can effectively mitigate the burden of this complication. [ 33 ] Our observed rate of transient hypocalcemia (12.95% in the ERAS group) falls within the lower end of this reported range. The reduced incidence may be attributable to prophylactic calcium and vitamin D supplementation protocols and meticulous parathyroid preservation techniques, though the retrospective nature of our study precludes definitive causal inference. A 2025 comprehensive review by Liu et al identified multiple risk factors for post-thyroidectomy hypocalcemia, including surgical extent, inadvertent parathyroidectomy, and patient-specific factors such as vitamin D status. [ 34 ] Our ERAS protocol’s emphasis on careful surgical technique and standardized supplementation likely contributed to the favorable outcomes observed. The reduction in PONV represents an important quality of care improvement. PONV not only causes significant patient discomfort but can also increase the risk of cervical hematoma formation and prolong hospital stay. [ 35 ] Our multimodal PONV prophylaxis strategy, incorporating both pharmacological and non-pharmacological approaches, appears effective and aligns with contemporary best practices in perioperative care. The cost reductions observed in our study demonstrate the economic value of ERAS implementation. Shorter hospital stays, reduced complication rates, and decreased opioid requirements all contributed to these savings. These findings support the value proposition of ERAS protocols in an era of increasing healthcare cost consciousness, [ 36 ] though institution-specific cost structures may influence the magnitude of savings achieved. Several limitations warrant consideration when interpreting our results. The retrospective, single-center design limits generalizability and introduces potential for selection bias despite PSM. Temporal changes in surgical technique, anesthesia practices, or institutional protocols between the control period (2023) and ERAS period (2024) may have influenced outcomes independent of the ERAS protocol itself. The study population comprised predominantly low-risk, early-stage thyroid cancer patients with relatively low comorbidity burden, which may limit applicability to more complex patient populations. In addition, we could not assess the relative contributions of individual ERAS components to the observed outcomes. Future prospective studies with factorial designs would be valuable to identify the most impactful elements of ERAS protocols for thyroid surgery. While our psychological assessments demonstrated statistically significant improvements, the clinical significance of the observed differences and their long-term persistence beyond hospital discharge require further investigation.The relatively short follow-up period (30 days for readmissions, 1 month for quality of life) precluded assessment of longer-term outcomes such as cancer recurrence, permanent complications, or sustained psychological benefits. Despite these limitations, our study provides valuable evidence supporting the implementation of ERAS protocols in thyroid cancer surgery, with the novel addition of demonstrating significant psychological benefits. The integration of psychological support and patient education within perioperative care pathways represents an important holistic approach to cancer care. Future multicenter, prospective studies are needed to validate these findings, assess long-term outcomes, and identify optimal ERAS protocol configurations for different patient populations and surgical indications. 5. Conclusion In conclusion, this study demonstrates that ERAS pathway implementation for thyroid cancer surgery is associated with improved postoperative recovery, reduced complications, decreased healthcare costs, and enhanced psychological well-being. While these results are encouraging, they should be interpreted within the context of our study’s limitations. The observed benefits suggest that comprehensive ERAS protocols addressing both physical and psychological aspects of recovery may enhance the quality of care for thyroid cancer patients. Notably, tailored psychological interventions for thyroid cancer surgery patients are vital for addressing their unique challenges, including depression and anxiety; customizing these strategies to individual risk factors may further enhance their effectiveness. However, careful patient selection, individualized risk assessment, and ongoing quality monitoring remain essential components of optimal thyroid cancer management. Further research is needed to establish evidence-based guidelines for ERAS implementation across diverse clinical settings and to elucidate the mechanisms underlying the psychological benefits observed. Acknowledgments The authors would like to thank the nursing staff and colleagues in the Department of Thyroid Surgery at The First People’s Hospital of Jiangxia District, Wuhan, Hubei University of Medicine for their support in data collection and patient care. Author contributions Conceptualization: Hui Xu, Miao Pan. Data curation: Hui Xu, Miao Pan. Formal analysis: Hui Xu, Miao Pan. Investigation: Hui Xu, Miao Pan, Lin Zhu. Methodology: Hui Xu. Resources: Miao Pan, Lin Zhu. Supervision: Lin Zhu. Validation: Miao Pan, Lin Zhu. Writing – original draft: Hui Xu. Writing – review & editing: Hui Xu, Lin Zhu. Abbreviations: AMA American Society of Anesthesiologists ERAS enhanced recovery after surgery PONV postoperative nausea and vomiting PSM propensity score matching SAS Self-rating Anxiety Scale SDS Self-rating Depression Scale SF-36 36-Item Short Form Survey This study was approved by the Institutional Ethics Committee of The First People’s Hospital of Jiangxia District, Wuhan, Hubei University of Medicine. The requirement for informed consent was waived by the ethics committee due to the retrospective nature of the study. All procedures performed were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The authors have no funding and conflicts of interest to disclose. The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request. How to cite this article: Xu H, Pan M, Zhu L. Impact of ERAS pathway-based perioperative management on postoperative recovery and psychological status in thyroid cancer surgery patients: A retrospective study. Medicine 2026;105:22(e49029). HX and MP contributed to this article equally. Contributor Information Hui Xu, Email: 676936237@qq.com. Miao Pan, Email: 670061774@qq.com. References [1]. Shank JB, Are C, Wenos CD. Thyroid cancer: global burden and trends. Indian J Surg Oncol. 2022;13:40–5. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] [2]. 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