An enhanced recovery pathway reduces duration of stay and complications after open pulmonary lobectomy

Impact of a standardized protocol for chest tube management after VATS pulmonary resections on post-operative outcomes and complications

Chest tube management represents a major issue after lung surgery as no protocol is widely accepted and tube management is generally based on local or personal habits. Aim of this study is to evaluate the impact of a standardized protocol for chest tube management after pulmonary resections on the post-operative outcomes. We performed a single center retrospective analysis of all adult patients undergoing thoracoscopic pulmonary resection from January 2020 to December 2021. Starting from January 2021 a standardized protocol of chest tube management was applied after all procedures. Patients were divided into two groups according to the chest tube management strategy. he two groups had similar pre-operative characteristics and the extent of lung resection was comparable. Intervention group had significantly shorter time to chest tube removal (median 1 vs 3 days, p < 0.001) and post-operative length of stay (median 3 vs 4 days, p < 0.001). Despite earlier chest tube removal, there was not an increased incidence of post-removal complications. On multivariable analysis, the new chest drain management strategy was an independent predictor of earlier chest tube removal. A standardized protocol of chest tube management allows for an earlier chest tube removal and a shorter hospital stay, without an increase in post-operative complications.

Strict compliance to a thoracic enhanced recovery after surgery protocol is associated with improved outcomes compared with partial compliance: A prospective cohort study

BACKGROUND

Benefits of thoracic enhanced recovery after surgery programs have been described. However, there is ongoing discussion on the importance of full protocol compliance. The objective of this study was to determine whether strict adherence to an enhanced recovery after surgery protocol leads to further improvement in outcomes compared with less strict compliance.

METHODS

This was a multihospital prospective cohort study of all consecutive anatomic lung resection patients on the thoracic enhanced recovery after surgery pathway from May 2021 to March 2023, with comparison with a historical control from January 2019 to April 2021. Compliance to 5 key protocol elements was tracked. Patients were grouped into high- and low-compliance cohorts, defined as adherence to 4-5/5 or 0-3/5 elements, respectively. The primary outcome was overall morbidity; secondary outcomes included cardiac, respiratory, and infectious morbidity and length of stay.

RESULTS

Of the 960 patients, 429 (44.7%) were enhanced recovery after surgery patients and 531 (55.3%) were in the historical control group. Across all patients, 250 (26.0%) were considered high compliance and 710 (74.0%) were considered low compliance. After adjustment for enhanced recovery after surgery status and confounders, the association between high compliance and improved outcomes persisted for all but infectious morbidity. Compared with low compliance, high compliance was associated with decreased odds of any morbidity (0.41 [95% CI, 0.22-0.77]), cardiac morbidity (0.31 [0.11-0.91]), respiratory morbidity (0.46 [0.23-0.90]) and decreased length of stay (0.38 [0.18-0.87]).

CONCLUSION

Enhanced recovery after surgery protocols improve outcomes after anatomic lung resection. Increasing compliance to individual elements (>80%) further improves patient outcomes. Continued efforts should be directed at increasing compliance to individual protocol elements.

Does Enhanced Recovery After Surgery Protocols Reduce Complications and Length of Stay After Thoracic Surgery: A Systematic Review of the Literature

Enhanced recovery after surgery (ERAS) has an increasingly important role in the perioperative management of thoracic surgical patients. It has been extensively studied in multiple surgical specialties, particularly colorectal surgery, where ERAS protocols have been shown to reduce postoperative length of stay and postoperative complications. Electronic searches of two research databases were performed: PubMed (1972 to October 2023) and Ovid MEDLINE (1946 to October 2023). The literature search was completed on January 4, 2024. Search terms included: "thoracic surgery" and "ERAS" or "Enhanced Recovery After Surgery". The search was limited to studies evaluating humans undergoing thoracic surgery for any indication. The primary outcome was overall morbidity, with secondary outcomes including mortality, length of stay, and pulmonary complications. The search yielded a total of 794 records, of which 30 (four meta-analyses and 26 observational trials) met the relevant inclusion and exclusion criteria. This review suggested the implementation of ERAS protocols can lead to a reduction in postoperative morbidity; however, this was not a consistent finding. The majority of studies included demonstrated a reduction in the length of stay with the implementation of ERAS. Overall, ERAS/ERATS is an important adjunct to the management of patients requiring thoracic surgery, consistently leading to shorter lengths of stay and likely contributing to reduced rates of postoperative morbidity. Further research will be required to determine the impact of the recently released ERATS guidelines.

Enhanced recovery after surgery in elderly patients with non-small cell lung cancer who underwent video-assisted thoracic surgery

BACKGROUND

This study was designed to investigate the clinical outcomes of enhanced recovery after surgery (ERAS) in the perioperative period in elderly patients with non-small cell lung cancer (NSCLC).

AIM

To investigate the potential enhancement of video-assisted thoracic surgery (VATS) in postoperative recovery in elderly patients with NSCLC.

METHODS

We retrospectively analysed the clinical data of 85 elderly NSCLC patients who underwent ERAS (the ERAS group) and 327 elderly NSCLC patients who received routine care (the control group) after VATS at the Department of Thoracic Surgery of Peking University Shenzhen Hospital between May 2015 and April 2017. After propensity score matching of baseline data, we analysed the postoperative stay, total hospital expenses, postoperative 48-h pain score, and postoperative complication rate for the 2 groups of patients who underwent lobectomy or sublobar resection.

RESULTS

After propensity score matching, ERAS significantly reduced the postoperative hospital stay (6.96 ± 4.16 vs 8.48 ± 4.18 d, P = 0.001) and total hospital expenses (48875.27 ± 18437.5 vs 55497.64 ± 21168.63 CNY, P = 0.014) and improved the satisfaction score (79.8 ± 7.55 vs 77.35 ± 7.72, P = 0.029) relative to those for routine care. No significant between-group difference was observed in postoperative 48-h pain score (4.68 ± 1.69 vs 5.28 ± 2.1, P = 0.090) or postoperative complication rate (21.2% vs 27.1%, P = 0.371). Subgroup analysis showed that ERAS significantly reduced the postoperative hospital stay and total hospital expenses and increased the satisfaction score of patients who underwent lobectomy but not of patients who underwent sublobar resection.

CONCLUSION

ERAS effectively reduced the postoperative hospital stay and total hospital expenses and improved the satisfaction score in the perioperative period for elderly NSCLC patients who underwent lobectomy but not for patients who underwent sublobar resection.

Initial Results of the Enhanced Recovery After Surgery (ERAS) Program in Patients Undergoing Lobectomy in the Treatment of Lung Cancer: An Experience From the University Medical Center Ho Chi Minh City

BACKGROUND

Lobectomy is a standard surgical method in the treatment of early stages of non-small cell lung cancer (NSCLC). The enhanced recovery after surgery (ERAS) program aims to reduce the postoperative length of hospital stay (PLOS) in major surgeries. This study evaluated the impact of the ERAS program on PLOS and identified related factors in patients undergoing lobectomy for NSCLC.

METHODS

This prospective observational study was conducted at the University Medical Center Ho Chi Minh City, Vietnam, from February 2022 to December 2023. We included patients diagnosed with NSCLC scheduled for lobectomy. The ERAS protocol was applied according to guidelines from the ERAS Society and the French Society of Anaesthesia and Intensive Care Medicine. We collected data on patient demographics, surgical details, adherence to the ERAS protocol, and postoperative outcomes, including the PLOS.

RESULTS

Among the 98 patients enrolled, the median PLOS after ERAS intervention was 4.1 days (interquartile range: 3.7 to 5.2 days). Adherence to ERAS protocols significantly correlated with reduced PLOS (p<0.001). Notably, smoking status was identified as a related factor of PLOS (p=0.002). Complications (p<0.001), surgical method (p=0.007), operation time (p<0.001), duration of postanesthesia care unit (p=0.006), duration of thoracic drainage (p<0.001), and urinary catheter retention time (p=0.023) were also associated with PLOS variations.

CONCLUSION

Implementing the ERAS program in patients undergoing lobectomy for NSCLC at our center reduced PLOS and highlighted the importance of protocol adherence for optimizing surgical outcomes. These findings supported the broader adoption of ERAS protocols in thoracic surgery to enhance patient recovery. Future research should focus on multi-center studies to generalize these results and further dissect the impact of individual ERAS components.

Factors associated with safe and successful postoperative day 1 discharge after lung operations: a systematic review and meta-analysis

BACKGROUND

A shorter length of stay (LOS) is associated with fewer hospital-acquired adverse conditions and decreased utilization of hospital resources. While modern perioperative care protocols have enabled some ambitious surgical teams to achieve discharge as early as within postoperative day 1 (POD1), most other teams remain cautious about such an approach due to the perceived risk of missing postoperative complications and increased readmission rates. We aimed to identify factors that would help guide surgical teams aiming for safe and successful POD1 discharge after lung resection.

METHODS

We searched the PubMed, Embase, Scopus, Web of Science and CENTRAL databases for articles comparing perioperative characteristics in patients discharged within POD1 (DWPOD1) and after POD1 (DAPOD1) following lung resection. Meta-analysis was performed using a random-effects model.

RESULTS

We included eight retrospective cohort studies with a total of 216,887 patients, of which 22,250 (10.3%) patients were DWPOD1. Our meta-analysis showed that younger patients, those without cardiovascular and respiratory comorbidities, and those with better preoperative pulmonary function are more likely to qualify for DWPOD1. Certain operative factors, such as a minimally invasive approach, shorter operations, and sublobar resections, also favor DWPOD1. DWPOD1 appears to be safe, with comparable 30-day mortality and readmission rates, and significantly less postoperative morbidity than DAPOD1.

CONCLUSIONS

In select patients with a favorable preoperative profile, DWPOD1 after lung resection can be achieved successfully and without increased risk of adverse outcomes such as postoperative morbidity, mortality, or readmissions.

Application on perioperative ERAS concept in elderly lung cancer patients undergoing surgery

Investigating the applying effects of the enhanced recovery after surgery (ERAS) in the perioperative period of elderly lung cancer patients undergoing the surgery. We randomly selected 98 elderly patients with lung cancer who were admitted to our hospital and underwent surgery from January 2022 to September 2023 as study subjects. The control group received conventional care during the perioperative period, and the intervention group received ERAS-guided care measures. The differences in perioperative-related indices, pulmonary function, pain level, inflammatory factors, and postoperative complication rates between these 2 groups were compared. The postoperative extubation time, the activity time since getting out of bad and hospital stay were lower in the observation group than those in the control group (P  < .05). At 3 days postoperatively, the FEV1, forced vital capacity and maximum ventilation volume of these 2 groups were lower than those of their same groups before surgery, and those of the observation group were higher than those of the control group (P  < .05). At 3 days postoperatively, the numerical rating scale in both groups were lower than those of their same groups at 6 hours postoperatively, and the numerical rating scale of the observation group was lower than that of the control group (P  < .05). At 3 days postoperatively, tumor necrosis factor-α, IL-6, and CRP in both groups were higher than those in their same groups before surgery, and those of the observation group was lower than those of the control group (P  < .05). The incidence of postoperative complications in the observation group was lower than that in the control group (P  < .05). ERAS applied in the perioperative period of elderly lung cancer patients undergoing surgery can shorten the hospital stay, promote the postoperative recovery on pulmonary function, alleviate inflammation, and reduce the risk of postoperative complications.

Rapid Discharge After Anatomic Lung Resection: Is Ambulatory Surgery for Early Lung Cancer Possible?

BACKGROUND

Given resource constraints during the coronavirus disease 2019 pandemic, we explored whether minimally invasive anatomic lung resections for early-stage lung cancer could undergo rapid discharge.

METHODS

All patients with clinical stage I-II non-small cell lung cancer from September 2019 to June 2022 who underwent minimally invasive anatomic lung resection at a single institution were included. Patients discharged without a chest tube <18 hours after operation, meeting preset criteria, were considered rapid discharge. Demographics, comorbidities, operative details, and 30-day outcomes were compared between rapid discharge patients and nonrapid discharge "control" patients. Multivariable logistic regression was performed for predictors of nonrapid discharge.

RESULTS

Overall, 430 patients underwent resection (200 lobectomies and 230 segmentectomies); 162 patients (37%) underwent rapid discharge and 268 patients (63%) were controls. The rapid discharge group was younger (66.5 vs 70.0 years; P < .001), was assigned to lower American Society of Anesthesiologists class (P = .02), had more segmentectomies than lobectomies (P = .003), and had smaller tumors (P < .001). There were no differences between groups in distance from home to hospital (P = .335) or readmission rates (P = .39). Increasing age had higher odds for nonrapid discharge (odds ratio, 1.04; 95% CI, 1.02-1.07), whereas segmentectomy had decreased odds (odds ratio, 0.46; 95% CI, 0.28-0.75).

CONCLUSIONS

Approximately 37% of the patients underwent rapid discharge after operation with similar readmission rate to controls. Increasing age had higher odds for nonrapid discharge; segmentectomy was likely to lead to rapid discharge. Consideration of rapid discharge minimally invasive lung resection for early-stage lung cancer can result in significant reduction in inpatient resources without adverse patient outcomes.

Enhanced recovery after surgery, current, and future considerations in head and neck cancer

Objectives

Review of the current and relevant literature to develop a list of evidence-based recommendations that can be implemented in head and neck surgical practices. To provide rationale for the multiple aspects of comprehensive care for head and neck surgical patients. To improve postsurgical outcomes for head and neck surgical patients.

Methods

Extensive review of the medical literature was performed and relevant studies in both the head and neck surgery and other surgical specialties were considered for inclusion.

Results

A total of 18 aspects of perioperative care were included in this review. The literature search included 276 publications considered to be the most relevant and up to date evidence. Each topic is concluded with recommendation grade and quality of evidence for the recommendation.

Conclusion

Since it's conception, enhanced recovery after surgery (ERAS) protocols have continued to push for comprehensive and evidence based postsurgical care to improve patient outcomes. Head and neck oncology is one of the newest fields to develop a protocol. Due to the complexity of this patient population and their postsurgical needs, a multidisciplinary approach is needed to facilitate recovery while minimizing complications. Current and future advances in head and neck cancer research will serve to strengthen and add new principles to a comprehensive ERAS protocol.

Level of Evidence

2a.

Effects of mobilization within the first 4 h following anatomical lung resection with thoracotomy

Thoracic incisions are very painful and complicated incisions. Many analgesic drugs including opioids are used to relieve pain in patients. We hypothesized that early mobilization and patient-centered strategy after lung resection reduce the incidence of perioperative complications and postoperative pain. We conducted a retrospective study on patients who underwent lung resection via thoracotomy and were mobilized in the first 4 h postoperatively. Mobilization was defined as standing and walking at least 100 m from the bed. If orthostatic hypotension occurred, mobilization was postponed for 30 min. Analgesic treatment needs, walking distance, co-morbidity, hospitalization, postoperative complications within 30 days, and drainage and discharge times of patients were analyzed. The lobectomy with thoracotomy was performed in 48 patients. Thirty-six patients were male. The rate of additional systemic diseases was 58.3%. Forty patients walked in the first 3 h postoperatively. The mean walking distance was 140 ± 38.5 m. The rate of orthostatic hypotension was 8.3%. The routine analgesic treatment included intravenous paracetamol 3 g and dexketoprofen 100 mg daily. In this study, 18% of patients received narcotic analgesics. Thromboembolic event and arrhythmia did not develop in any patient. The most common complication was prolonged air leaks (18.8%). Mobilization within the first 4 h following anatomical lung resection is feasible and safe. Early mobilization provided pain relief after lung surgery and reduced the use of narcotic analgesics and cardiovascular complications. The article is the first study about walking in first hours after pulmonary lobectomy with thoracotomy in the thoracic surgery literature.

The efficacy of three-ball breathing apparatus exercise based on the concept of pulmonary rehabilitation in patients after lung cancer surgery

BACKGROUND

Postoperative patients with lung cancer mostly experience different degrees of dyspnea and decreased activity tolerance, and these symptoms all significantly affect postoperative quality of life. The concept of pulmonary rehabilitation applicable to patients with chronic respiratory diseases is also applicable to patients with postoperative lung cancer. The current application of postoperative pulmonary rehabilitation for lung cancer is inconsistent, and reliable guidelines are lacking. The purpose of this study was to further verify the efficacy and feasibility of postoperative pulmonary rehabilitation for lung cancer patients, and to find a suitable local pulmonary rehabilitation program for postoperative patients with lung cancer that is clinically promoted in our department through this study.

METHODS

We collected the clinical data of patients undergoing video-assisted thoracoscopic surgery (VATS) wedge resection or lobectomy. The patients were divided into rehabilitation group (using three-ball breathing apparatus after discharge) and control group (routine follow-up after discharge) according to whether the patients were trained with three-ball breathing apparatus after operation. The detailed method using three-ball apparatus is as follows. To begin with, patients are required to put themselves in a comfortable position. Then, after the three-ball breathing apparatus put on the same plane of their eyes, patients hold the tube in their mouth closely and control their breath slowly. When patients inhale to their largest extent, the balls will rise up accordingly. Then they exhale. The evaluation results of pulmonary function, activity tolerance, anxiety scores and others were collected. All data was gathered at the First Affiliated Hospital of Soochow University. The effects of pulmonary rehabilitation training on wedge resection and lobectomy were compared.

RESULTS

A total of 210 patients were included in this study, including 126 patients with VATS wedge resection and 84 patients with VATS lobectomies. No discrepancy was noticed when FEV₁ loss between two groups were compared in the wedge resection patients, and the same results were also shown in patients undergoing lobectomy (12.8% ± 2.0% vs. 12.7% ± 1.9%, P = 0.84, wedge resection; 12.6% ± 2.9% vs. 12.1% ± 1.8%, P = 0.37, lobectomy). The loss of FVC in the control group was greater than that in the rehabilitation group for patients undergoing lobectomy (11.7% ± 5.2%, vs. 17.1% ± 5.6%, P < 0.001, lobectomy). No difference was found in the wedge resection patients between the control and rehabilitation groups (6.6% ± 2.8%, vs. 6.4% ± 3.2%, P = 0.76, lobectomy). Moreover, all patients showed no significant difference in 6MWD regardless of surgical procedure and with or without breathing exercises at T3 (392.6 ± 50.6 m, rehabilitation group vs. 394.0 ± 46.6 m, control group. P = 0.87, wedge resection; 381.3 ± 38.9 m, rehabilitation group vs. 369.1 ± 49.3 m, control group. P = 0.21, lobectomy).

CONCLUSIONS

For patients after thoracoscopic pulmonary wedge resection, the use of three-ball apparatus did not significantly improve postoperative pulmonary function and activity tolerance, dyspnea, and anxiety symptoms. In patients after thoracoscopic lobectomy, respiratory trainers were able to improve postoperative lung function but were unable to significantly improve dyspnea and anxiety symptoms. There was a significant benefit for the use of three-ball apparatus in patients after thoracoscopic lobectomy, whereas there was no significant benefit for the use of respiratory trainers after wedge resection. Registry: Medical Ethics Committee of the First Affiliated Hospital of Soochow University.

REGISTRATION NUMBER

no. 2022455.

Enhanced recovery of postoperative nursing for single-port thoracoscopic surgery in lung cancer patients

Lung cancer is a common clinical malignant tumor, and the number of new lung cancer patients is increasing year by year. With the advancement of thoracoscopy technology and equipment, the scope of application of minimally invasive surgery has expanded to almost all types of lung cancer resection, making it the mainstream lung cancer resection surgery. Single-port thoracoscopic surgery provides evident advantages in terms of postoperative incision pain since only a single incision is required, and the surgical effect is similar to those of multi-hole thoracoscopic surgery and traditional thoracotomy. Although thoracoscopic surgery can effectively remove tumors, it nevertheless induces variable degrees of stress in lung cancer patients, which eventually limit lung function recovery. Rapid rehabilitation surgery can actively improve the prognosis of patients with different types of cancer and promote early recovery. This article reviews the research progress on rapid rehabilitation nursing in single-port thoracoscopic lung cancer surgery.

Efficacy and safety of early chest tube removal after selective pulmonary resection with high-output drainage: A systematic review and meta-analysis

BACKGROUND

There is controversy over the drainage threshold for removal of chest tubes in the absence of significant air leakage after selective pulmonary resection.

METHODS

A comprehensive search of online databases (PubMed, Web of Science, Embase, Cochrane Library, Scopus, Ovid, Elsevier, Ebsco, and Wiley) and clinical trial registries (WHO-ICTRP and ClinicalTrials.gov) was performed to investigate the efficacy and safety of early chest tube removal with high-output drainage. Primary outcome (postoperative hospital day) and secondary outcomes (30-day complications, rate of thoracentesis, and chest tube placement) were extracted and synthesized. Subgroup analysis, meta-regression, and sensitivity analysis were used to explore the potential heterogeneity. Study quality was assessed with the Newcastle-Ottawa Scale, and evidence was graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessment by the online GRADEpro Guideline Development Tool.

RESULTS

Six cohort studies with a total of 1262 patients were included in the final analysis. The postoperative hospital stay in the high-output group was significantly shorter than in the conventional treatment group (weighted mean difference: -1.34 [-2.34 to -0.34] day, P = .009). While there was no significant difference between 2 groups in 30-day complications (relative ratio [RR]: 0.92 [0.77-1.11], P = .38), the rate of thoracentesis (RR: 1.93 [0.63-5.88], P = .25) and the rate of chest tube placement (RR: 1.00 [0.37-2.70], P = .99). According to the sensitivity analysis, the relative impacts of the 2 groups had already stabilized. Subgroup analysis revealed that postoperative hospital stay was modified by Newcastle-Ottawa Scale score. The online GRADEpro Guideline Development Tool presented very low quality of evidence for the available data.

CONCLUSIONS

This meta-analysis revealed that it is feasible and safe to remove a chest tube with high-output drainage after pulmonary resection for selected patients.

Evaluation of an enhanced recovery after lung surgery (ERALS) program in lung cancer lobectomy: An eight-year experience

INTRODUCTION

Enhanced recovery after lung surgery (ERALS) protocols have proven useful in reducing postoperative stay (POS) and postoperative complications (POC). We studied the performance of an ERALS program for lung cancer lobectomy in our institution, aiming to identify which factors are associated with a reduction of POC and POS.

METHODS

Analytic retrospective observational study conducted in a tertiary care teaching hospital involving patients submitted to lobectomy for lung cancer and included in an ERALS program. Univariable and multivariable analysis were employed to identify factors associated with increased risk of POC and prolonged POS.

RESULTS

A total 624 patients were enrolled in the ERALS program. The median POS was 4 days (range 1-63), with 2.9% of ICU postoperative admission. A videothoracoscopic approach was used in 66.6% of cases, and 174 patients (27.9%) experienced at least one POC. Perioperative mortality rate was 0.8% (5 cases). Mobilization to chair in the first 24h after surgery was achieved in 82.5% of cases, with 46.5% of patients achieving ambulation in the first 24h. Absence of mobilization to chair and preoperative FEV1% less than 60% predicted, were identified as independent risk factors for POC, while thoracotomy approach and the presence of POC predicted prolonged POS.

CONCLUSIONS

We observed a reduction in ICU admissions and POS contemporaneous with the use of an ERALS program in our institution. We demonstrated that early mobilization and videothoracoscopic approach are modifiable independent predictors of reduced POC and POS, respectively.

The impact of an enhanced recovery after surgery pathway for video-assisted and robotic-assisted lobectomy on surgical outcomes and costs: a retrospective single-center cohort study

To determine the impact of enhanced recovery after surgery (ERAS) pathway implementation on outcomes and cost of robotic- and video-assisted thoracoscopic (RATS and VATS) lobectomy. Retrospective review of 116 consecutive VATS and RATS lobectomies in the pre-ERAS (Oct 2018-Sep 2019) and ERAS (Oct 2019-Sep 2020) period. Multivariate analysis was used to determine the impact of ERAS and operative approach alone, and in combination, on length of hospital stay (LOS) and overall cost. Operative approach was 49.1% VATS, 50.9% RATS, with 44.8% pre-ERAS, and 55.2% ERAS (median age 68, 65.5% female). ERAS patients had shorter LOS (2.22 vs 3.45 days) and decreased total cost ($15,022 vs $20,155) compared with non-ERAS patients, while RATS was associated with decreased LOS (2.16 vs 4.19 days) and decreased total cost ($14,729 vs $20,484) compared with VATS. The combination of ERAS + RATS showed the shortest LOS and the lowest total cost (1.35 days and $13,588, P < 0.001 vs other combinations). On multivariate analysis, ERAS significantly decreased LOS (P = 0.001) and total cost (P = 0.003) compared with pre-ERAS patients; RATS significantly decreased LOS (P < 0.001) and total cost (P = 0.004) compared with VATS approach. ERAS implementation and robotic approach were independently associated with LOS reduction and cost savings in patients undergoing minimally invasive lobectomy. A combination of ERAS and RATS approach synergistically decreases LOS and overall cost.

AM-PAC mobility scores predict non-home discharge following adult spinal deformity surgery

BACKGROUND CONTEXT

Adult spinal deformity (ASD) surgery requires an extended recovery period and often non-routine discharge. The Activity Measure for Post-Acute Care (AM-PAC) Basic Mobility Inpatient Short Form (6-Clicks) is a prediction tool, validated for other orthopedic procedures, to assess a patient's ability to mobilize after surgery.

PURPOSE

To assess the thresholds of AM-PAC scores that determine non-home discharge disposition in patients who have undergone ASD surgery.

STUDY DESIGN

Retrospective review PATIENT SAMPLE: Ninety consecutive ASD patients with ≥5 levels fused who underwent surgery from 2015 to 2018, with postoperative AM-PAC scores measured before discharge, were included.

OUTCOME MEASURES

Non-home discharge disposition METHODS: Patients with routine home discharge were compared to those with non-home discharge. Bivariate analysis was first conducted to compare these groups by preoperative demographics, comorbidities, radiographic alignment, surgical characteristics, HRQOLs, and AM-PAC measurements. Threshold linear regression with Bayesian information criteria was utilized to identify the optimal cutoffs for AM-PAC scores associated with increased likelihood of non-home discharge. Finally, multivariable analysis controlling for age, sex, comorbidities, levels fused, perioperative complication, and home support was conducted to assess each threshold.

RESULTS

Thirty-six (40%) of 90 patients analyzed had non-home discharge. On bivariate analysis, first AM-PAC score (13.5 vs. 17), last AM-PAC score (17 vs. 20), and AM-PAC change per day (+.387 vs. +1) were all significantly associated with non-home discharge. Threshold regression identified that cutoffs of ≤15 for first AM-PAC score, <17 for last AM-PAC score, and <+0.625 for daily AM-PAC change were associated with non-home discharge. On multivariable analysis, first AM-PAC score ≤15 (odds ratio [OR] 11.28; confidence interval [CI] 2.96-42.99; p<.001), last AM-PAC score <17 (OR 33.57; CI 5.85-192.82; p<.001), and AM-PAC change per day <+0.625 (OR 6.24; CI 2.01-19.43; p<.001) were all associated with increased odds of non-home discharge.

CONCLUSIONS

First AM-PAC score of 15 or less can help predict non-home discharge. A goal of daily AM-PAC increases of 0.625 points toward a final AM-PAC score of 17 can aid in achieving home discharge. The early AM-PAC mobility threshold of ≤15 may help prepare for non-home discharge, while AM-PAC daily changes per day <0.625 and final AM-PAC <17 may provide goals for mobility improvement during the early postoperative period in order to prevent non-home discharge.

Analysis of Outcomes for Robotic-Assisted Lobectomy with an Enhanced Recovery after Surgery Protocol

BACKGROUND

The impact on cost relative to clinical efficacy of Enhanced Recovery after Surgery (ERAS) protocols for patients who undergo robotic-assisted lobectomy is currently unknown. The objective of this study was to compare cost and perioperative outcomes of robotic-assisted lobectomy before and after implementation of an ERAS protocol.

METHODS

This is a retrospective analysis of 574 patients who underwent robotic-assisted lobectomy for primary lung carcinoma from May 1, 2017 - June 1, 2021. The ERAS protocol was implemented on October 17, 2019. Inverse probability of treatment weighting (IPTW) of propensity scores was used to balance baseline characteristics. The primary outcomes of the study were mean direct and indirect hospital costs, complication rates, and hospital length of stay.

RESULTS

A total of 315 patients underwent robotic-assisted lobectomy prior to implementation of the ERAS protocol and 259 patients were enrolled on the protocol. A significantly higher percentage of patients were discharged home in less than 3 days following the ERAS protocol implementation [24.5% vs 9.8% (p =0.001)]. There was a significant decrease in the IPTW adjusted mean direct hospital costs (p< 0.001) and mean indirect costs (p= 0.018) for the total hospital stay after ERAS protocol implementation. The mean initial discharge opioid medication dose (Morphine Equivalent Dose) was significantly lower (p< 0.001) following the ERAS protocol.

CONCLUSIONS

Increased early discharge and decreased hospital costs were observed for robotic-assisted lobectomy after implementation of an ERAS protocol. There was also an observed significant decrease in the discharge opioid medication doses prescribed.

Perioperative Protocol of Ankle Fracture and Distal Radius Fracture Based on Enhanced Recovery after Surgery Program: A Multicenter Prospective Clinical Controlled study

Background. The enhanced recovery after surgery (ERAS) program is aimed to shorten patients’ recovery process and improve clinical outcomes. This study aimed to compare the outcomes between the ERAS program and the traditional pathway among patients with ankle fracture and distal radius fracture. Methods. This is a multicenter prospective clinical controlled study consisting of 323 consecutive adults with ankle fracture from 12 centers and 323 consecutive adults with distal radial fracture from 13 centers scheduled for open reduction and internal fixation between January 2017 and December 2018. According to the perioperative protocol, patients were divided into two groups: the ERAS group and the traditional group. The primary outcome was the patients’ satisfaction of the whole treatment on discharge and at 6 months postoperatively. The secondary outcomes include delapsed time between admission and surgery, length of hospital stay, postoperative complications, functional score, and the MOS item short form health survey-36. Results. Data describing 772 patients with ankle fracture and 658 patients with distal radius fracture were collected, of which 323 patients with ankle fracture and 323 patients with distal radial fracture were included for analysis. The patients in the ERAS group showed higher satisfaction levels on discharge and at 6 months postoperatively than in the traditional group ( $P<0.001$ ). In the subgroup analysis, patients with distal radial fracture in the ERAS group were more satisfied with the treatment ( $P=0.001$ ). Furthermore, patients with ankle fracture had less time in bed ( $P<0.001$ ) and shorter hospital stay ( $P<0.001$ ) and patients with distal radial fracture received surgery quickly after being admitted into the ward in the ERAS group than in the traditional group ( $P=0.001$ ). Conclusions. Perioperative protocol based on the ERAS program was associated with high satisfaction levels, less time in bed, and short hospital stay without increased complication rate and decreased functional outcomes.

Outcomes of enhanced recovery after surgery in lung cancer: A systematic review and meta-analysis

Objective

Methods

Results

Conclusions

Implementation of an enhanced recovery after surgery protocol for head and neck cancer patients: Considerations and best practices

Enhanced recovery after surgery (ERAS) protocols have been developed in numerous surgical specialties as a means of systematically improving patient recovery, functional outcomes, cost savings, and resource utilization. Such multidisciplinary initiatives seek to minimize variability in several aspects of perioperative patient care, helping to reduce inpatient length of hospital stay, complications, and the overall resource and financial burden of surgical care. Head and neck oncology patients stand to benefit from the implementation of comprehensive ERAS protocols, as these patients have complex medical needs that may dramatically impact multiple aspects of their recovery, including breathing, eating, nutrition, pain, speech, swallowing, and communication. Implementing ERAS protocols for head and neck cancer patients may present unique challenges, and require significant interdisciplinary coordination and collaboration. We therefore sought to provide a comprehensive guide to the planning and institution of such ERAS systems at institutions undertaking care of head and neck cancer patients. Key elements to consider in the implementation of successful ERAS protocols for this population include organizing a team consisting of frontline leaders such as nursing staff, medical specialists, and associated health professionals; designing interventions based on systematically evaluated, high-quality literature; and instituting a clear methodology for regularly updating protocols and auditing the success or potential limitations of a given intervention. Potential obstacles to the success of ERAS interventions for head and neck cancer patients include challenges in systematically tracking progress of the protocol, as well as resource limitations in a given health system.

Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program

In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyzes, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.

Enhanced Recovery Pathway in Lung Resection Surgery: Program Establishment and Results of a Cohort Study Encompassing 1243 Consecutive Patients

Simple Summary

Enhanced Recovery Pathways (ERP) have been scarcely assessed in lung cancer surgery. We performed a two-step audit for our experience: the first dealing with our initial experience focusing on patients undergoing segmentectomies and lobectomies, the second including all subsequent consecutive patients undergoing all kind of lung resections for NSCLC. The first step aimed at auditing results of ERP on occurrence of postoperative complications and at assessing which ERP components were associated with improved short-term outcomes. We also audited late results by assessing long-term survival of patients in the first step of our study. The second step aimed at auditing on large-scale short-term results of the ERP in a real-life setting. In total, 166 patients were included in the first period. No postoperative death occurred. The overall adverse events rate was 30%. In multivariate analyzes, the only element associated with reduced adverse postoperative events was chest tube withdrawal within POD2. The 1-, 3- and 5-year survival rates were 97%, 86.1%, and 76.3%, respectively. In the second period, 1077 patients were included; 11 patients died during the postoperative period. The overall postoperative adverse event rate was 30.3%. Thoracoscore independently predicted postoperative death, the occurrence of complications (all-kind, minor, major, or respiratory ones). We conclude that compliance to ERP procedures and early chest tube removal are associated with reduced postoperative events in patients with lung resection surgery. Thoracoscore is a useful tool in predicting mortality and postoperative adverse events.

Abstract

Introduction: In spite of increasing diffusion, Enhanced Recovery Pathways (ERP) have been scarcely assessed in large scale programs of lung cancer surgery. The aim of this study was auditing our practice. Methods: A two-step audit program was established: the first dealing with our initial ERP experience in patients undergoing non-extended anatomical segmentectomies and lobectomies, the second including all consecutive patients undergoing all kind of lung resections for NSCLC. The first step aimed at auditing results of ERP on occurrence of postoperative complications and at assessing which ERP components are associated with improved short-term outcomes. We also audited late results by assessing long-term survival of patients in the first step of our study. The second step aimed at auditing on large-scale short-term results of the ERP in a real-life setting. Results: Over a one-year period, 166 patients were included. The median number of ERP procedures per patient was three (IQR 3–4). No postoperative death occurred. The overall adverse events rate was 30%. In multivariate analyzes, the only element associated with reduced adverse postoperative events was chest tube withdrawal within POD2 (OR = 0.21, 95% CI (0.10–0.46)). The 1-, 3-, and 5-year survival rates were 97%, 86.1%, and 76.3%, respectively. In the second period, 1077 patients were included in our ERP; 11 patients died during the postoperative period or within 30 days of operation (1.02%). The overall postoperative adverse event rate was 30.3%, major complication occurring in 134 (12.4%), and minor ones in 192 (17.8%). Respiratory complications occurred in 64 (5.9%). Thoracoscore independently predicted postoperative death, the occurrence of complications (all-kind, minor, major, or respiratory ones). Conclusions: Compliance to ERP procedures and early chest tube removal are associated with reduced postoperative events in patients with lung resection surgery. In a large setting scale, ERP can be applied with satisfactory results in terms of mortality and morbidity. Thoracoscore is a useful tool in predicting mortality and postoperative adverse events.

Optimization of an Enhanced Recovery After Surgery protocol for opioid-free pain management following robotic thoracic surgery

Objectives

Our Enhanced Recovery After Thoracic Surgery protocol was implemented on February 1, 2018, and firmly established 7 months later. We instituted protocol modifications on January 1, 2020, aiming to further reduce postoperative opioid consumption. We sought to evaluate the influence of such efforts on clinical outcomes and the use of both schedule II and schedule IV opioids following robotic thoracoscopic procedures.

Methods

A retrospective study of patients undergoing elective robotic procedures between September 1, 2018, and December 31, 2020, was conducted. Essential components of pain management in the original protocol included nonopioid analgesics, intercostal nerve blocks with long-acting liposomal bupivacaine diluted with normal saline, and opioids (ie, scheduled tramadol administration and as-needed schedule II narcotics). Protocol optimization included replacing saline diluent with 0.25% bupivacaine and switching tramadol to as needed, keeping other aspects unchanged. Demographic characteristics, type of robotic procedures, postoperative outcomes, and in-hospital and postdischarge opioids prescribed (ie, milligrams of morphine equivalent [MME]) were extracted from electronic medical records.

Results

Three hundred twenty-four patients met the inclusion criteria (159 in the original and 183 in the optimized protocol). There was no difference in postoperative outcomes or acute postoperative pain; there was a significant reduction of in-hospital and postdischarge opioid requirements in the optimized cohort. For anatomic resections: mean, 60.0 MME (range, 0-60.0 MME) versus mean, 105.0 MME (range, 60.0-150.0 MME), and other procedures: mean, 0 MME (range, 0-60 MME) versus mean, 140.0 (range, 60.0-150.0 MME) (P < .00001) with median schedule II opioids prescribed = 0.

Conclusions

Small modifications to our protocol for pain management strategies are safe and associated with significant decrease of opioid requirements, particularly schedule II narcotics, during the postoperative period without influencing acute pain levels.

Evolution of Process and Outcome Measures during an Enhanced Recovery after Thoracic Surgery Program

Background

A time course analysis was undertaken to evaluate how perioperative process-of-care and outcome measures evolved after implementation of an enhanced recovery after thoracic surgery (ERATS) program.

Methods

Outcome and process-of-care measures were compared between patients undergoing major elective thoracic surgery during a 9-month pre-ERATS implementation period to those at 1–3, 4–6, and 7–9 months post-ERATS implementation. Outcome measures included length of stay, the 30-day readmission rate, 30-day emergency department visits, and minor and major adverse events. Process measures included first time to activity, out-of-bed, ambulation, fluid diet, diet as tolerated, as well as removal of the first and last chest tube, epidural, patient-controlled analgesia, and Foley and intravenous catheters.

Results

In total, 704 patients (352 pre-ERATS, 352 post-ERATS) were included. Mobilization-related process measures, including time to first activity (16.5 vs. 6.8 hours, p<0.001), out-of-bed (17.6 vs. 8.9 hours, p<0.001), and ambulation (32.4 vs. 25.4 hours, p=0.04) saw statistically significant improvements by 1–3 months post-ERATS implementation compared to pre-ERATS. Time to Foley removal improved by 4–6 months post-ERATS (19.5 vs. 18.2 hours, p=0.003). Outcome measures, including the 30-day readmission rate and emergency department visits, steadily decreased post-ERATS. By 7–9 months post-ERATS, both minor (18.2% vs. 7.9%, p=0.009) and major (13.6% vs. 4.4%, p=0.007) adverse events demonstrated statistically significant improvements. Length of stay trended towards improvement from 6.2 days pre-ERATS to 4.8 days by 7–9 months post-ERATS (p=0.06).

Conclusion

The adoption of ERATS led to improvements in multiple process-of-care measures, which may collectively and gradually achieve optimization of clinical outcomes.

A Preoperative Spinal Education intervention for spinal fusion surgery designed using the Rehabilitation Treatment Specification System is safe and could reduce hospital length of stay, normalize expectations, and reduce anxiety

Aims

Psychoeducative prehabilitation to optimize surgical outcomes is relatively novel in spinal fusion surgery and, like most rehabilitation treatments, they are rarely well specified. Spinal fusion patients experience anxieties perioperatively about pain and immobility, which might prolong hospital length of stay (LOS). The aim of this prospective cohort study was to determine if a Preoperative Spinal Education (POSE) programme, specified using the Rehabilitation Treatment Specification System (RTSS) and designed to normalize expectations and reduce anxieties, was safe and reduced LOS.

Methods

POSE was offered to 150 prospective patients over ten months (December 2018 to November 2019) Some chose to attend (Attend-POSE) and some did not attend (DNA-POSE). A third independent retrospective group of 150 patients (mean age 57.9 years (SD 14.8), 50.6% female) received surgery prior to POSE (pre-POSE). POSE consisted of an in-person 60-minute education with accompanying literature, specified using the RTSS as psychoeducative treatment components designed to optimize cognitive/affective representations of thoughts/feelings, and normalize anxieties about surgery and its aftermath. Across-group age, sex, median LOS, perioperative complications, and readmission rates were assessed using appropriate statistical tests.

Results

In all, 65 (43%) patients (mean age 57.4 years (SD 18.2), 58.8% female) comprised the Attend-POSE, and 85 (57%) DNA-POSE (mean age 54.9 years (SD 15.8), 65.8% female). There were no significant between-group differences in age, sex, surgery type, complications, or readmission rates. Median LOS was statistically different across Pre-POSE (5 days ((interquartile range (IQR) 3 to 7)), Attend-POSE (3 (2 to 5)), and DNA-POSE (4 (3 to 7)), (p = 0.014). Pairwise comparisons showed statistically significant differences between Pre-POSE and Attend-POSE LOS (p = 0.011), but not between any other group comparison. In the Attend-POSE group, there was significant change toward greater surgical preparation, procedural familiarity, and less anxiety.

Conclusion

POSE was associated with a significant reduction in LOS for patients undergoing spinal fusion surgery. Patients reported being better prepared for, more familiar, and less anxious about their surgery. POSE did not affect complication or readmission rates, meaning its inclusion was safe. However, uptake (43%) was disappointing and future work should explore potential barriers and challenges to attending POSE. Cite this article: Bone Jt Open 2022;3(2):135–144.

Efficacy of multi-groove silicone drains in single-port video-assisted thoracoscopic lung cancer surgery and their effect on C-reactive protein: a single-center experience

Background

The purpose of this study was to systematically evaluate the effectiveness and safety of a multi-groove silicone drain in single-port video-assisted thoracoscopic lung cancer surgery and its effect on postoperative serum C-reactive protein (CRP) levels.

Methods

We retrospectively analyzed 122 surgical cases who underwent standard lobectomy and lymph node dissection for primary lung cancer between May 2020 and December 2020. A total of 62 patients received 19-F multi-groove silicone drains (experimental group) and 60 patients received 24-F conventional chest drains (control group). According to the different thoracic drainage approaches, the clinical efficacy in the perioperative period, postoperative complications, and postoperative serum CRP levels were compared between the 2 groups.

Results

In this study, thoracic drainage volume, the average visual analog scale (VAS) pain scores in incisions, the rate of primary healing at the site of incisions, and the pulmonary infection rate in the multi-groove silicone drain group were significantly lower than those in the conventional chest drain group (P<0.05), but there was no significant difference in the average hospital stay time, arrhythmia rates, and chest tube removal time between the 2 groups. At postoperative day 1, the levels of serum CRP in the 2 groups were further increased (P>0.05), and the comparison between the 2 groups showed that the levels of serum CRP in the multi-groove silicone drain group at 72 h after the operation were significantly lower than those in the conventional drain group (P<0.05).

Conclusions

Our results showed that a multi-groove silicone drain is feasible and relatively safe in single-port video-assisted thoracoscopic lung cancer surgery for most patients. However we should take cautious in those patients with higher susceptibility of postoperative active bleeding. In patients undergoing lung cancer surgery in the clinical treatment process, the use of a multi-groove silicone drain can improve the quality of life of patients. Due to a small number of included studies and unclear bias, the above results should be verified by high-quality, large-sample randomized controlled studies.

Keywords

Video-assisted thoracoscopic lung cancer surgery; multi-groove silicone drains; conventional chest drains

Impact of enhanced pathway of care in uniportal video-assisted thoracoscopic surgery

Enhanced Recovery After Surgery (E.R.A.S.) is a multimodal, evidence-based and patient-centered pathway designed to minimize surgical stress, enhancing recovery and improving perioperative outcomes. However, considering that the potential clinical implication of E.R.A.S. on patients undergoing video-assisted thoracic surgery (V.A.T.S.) has not properly defined, we proposed to implement our minimally invasive program with a specific clinical pathway able to enhance recovery after lung resection. Aim of this study was to assess the impact of this integrated program of Enhanced Pathway of Care (E.P.C.) in Uniportal V.A.T.S. patients undergoing lung resection, in terms of efficiency and safety. We conducted a retrospective, observational study enrolling patients undergoing uniportal V.A.T.S. resections from January 2015 to May 2020. Two groups were created: pre-E.P.C. and E.P.C. Propensity score matching analysis was performed to evaluate length of stay (LOS), postoperative cardiopulmonary complications (CPC) and readmission rate (READM). We analyzed 1167 patients (E.P.C. group: 182; pre-E.P.C. group: 985). E.P.C. group has a mean LOS shorter compared to pre-E.P.C. group (3.13 vs 4.19 days, p < 0.0001) without increasing on CPC (E.P.C. 12% vs pre-E.P.C. 11%, p = 0.74) and READM rate (E.P.C. 1.6% vs pre-E.P.C. 4.9%, p = 0.07). In particular, the LOS was shortened in the E.P.C. patients submitted to lobectomy, segmentectomy and wedge resection. Moreover, the three subgroups had similar CPC and READM rates for E.P.C. and control patients. In conclusion, this study demonstrated the benefits and safety of E.P.C. program showing a reduction of LOS for patients undergoing uniportal V.A.T.S. resection.

Enhanced recovery after thoracic anesthesia

In recent years, the concept of “Perioperative Medicine” has been evolved to a more concrete and sophisticated approach called “Enhanced Recovery After Surgery” (ERAS). ERAS has been first introduced in colorectal surgery by a dedicated leading ERAS® society, ERAS-criteria has been subsequently extended into several types of surgery, including thoracic surgery. Anesthesiology has always been one of the most important components of the multidisciplinary perioperative approaches, which is also valid for ERAS. There are several guidelines published on the enhanced recovery after thoracic surgery (ERATS). This article focuses on the “official” ERATS protocols of a joint consensus of two different societies. Regarding thoracic anesthesia, there are some challenges to be dealt with. The first challenge, although there is a large number of studies published on thoracic anesthesia, only a very few of them have studied the overall outcome and quality of recovery; and only few of them were powered enough to provide sufficient evidence. This has led to the fact that some components of the protocol are debatable. The second challenge, the adherence to individual elements and the overall compliance are poorly reported and also hard to apply even in the best organized centers. This article explains and discusses the debatable viewpoints on the elements of the ERATS protocol published in 2019 aiming to achieve a list for the future steps required for a more effective and evidence-based ERATS protocol.

Health education for hospitalized patient in nursing care: a conceptual analysis

OBJECTIVES

to define the concept of Health Education of Hospitalized Patient.

METHODS

the study used the conceptual analysis based on Walker and Avant strategies: Derivation, Synthesis, and Analysis of the concept. Researchers conducted 35 interviews with nurses who worked in direct care to patients admitted to a Hospital-School, and a bibliographic search on the CINAHL, Medline/PubMed®, Scopus, Web of Science, LILACS, and BDENF databases.

RESULTS

the study identified the antecedents, attributes, and consequences of the concept and defined the concept of Health Education of Hospitalized Patient as "the action of sharing knowledge about the promotion, prevention, recovery and rehabilitation concerning to health based on reciprocity between nurses and patients, family members and companions, in a systematized or unsystematic way".

FINAL CONSIDERATIONS

the identification of antecedents, attributes, consequences, and empirical references enabled the theoretical definition unprecedented of this concept and its applicability in practice, contributing to science and hospital nursing care.

Enhanced recovery after surgery (ERAS®) protocol adapted to the Brazilian reality: a prospective cohort study for thoracic patients

Background

In Low-Middle Income Countries (LMICs), resource optimization and infrastructure availability are recurrently in debate. In order to assist the development and implementation of guidelines, LMICs often exemplify from High-Income Countries protocols. At the final, it will be: content adaption is often needed. In this study, we demonstrated the preliminary analysis of the Brazilian experience by adapting the ERAS^® Protocol for thoracic surgery patients (PROSM).

Methods

Patients’ data were extracted from the surgical group database that operated in the city of Sao Paulo. Patients’ data were organized for analysis after the institution’s ethics committee gave their approval. Patients’ variables were analyzed and compared to a control group. Subgroup analysis included patients without ICU Admission.

Results

PROSM patients had reduced ICU length of stay (LOS) (Mean of 0.3±0.58 days, 1.2±1.65 days, P=0.001), Hospital LOS (Mean of 1.6±1.32 days, 3.9±3.25 days, P=0.001) and Chest Drain duration (Median 1.0±1.00 days, 3.0±3.00 days, P=0.001). Analyses of patients that were not admitted to the ICU demonstrated reduced Hospital LOS and Chest drain duration. Cost analysis, such as procedure, daily, and post-surgical costs were also significantly lower towards PROSM group.

Conclusions

This study revealed important aspects for improvement of the delivered care quality and opportunity for expenditure management. We expect to assist more countries to improve knowledge under the implementation of enhanced protocols.

Association Between Gabapentinoids and Postoperative Pulmonary Complications in Patients Undergoing Thoracic Surgery

OBJECTIVE

Perioperative gabapentinoids in general surgery have been associated with an increased risk of postoperative pulmonary complications (PPCs), while resulting in equivocal pain relief. This study's aim was to examine the utilization of gabapentinoids in thoracic surgery to determine the association of gabapentinoids with PPCs and perioperative opioid utilization.

DESIGN

A multicenter retrospective cohort study.

SETTING

Hospitals in the Premier Healthcare Database from 2012 to 2018.

PARTICIPANTS

A total of 70,336 patients undergoing elective open thoracotomy, video-assisted thoracic surgery, and robotic-assisted thoracic surgery.

INTERVENTIONS

Propensity score analyses were used to assess the association between gabapentinoids on day of surgery and the primary composite outcome of PPCs, defined as respiratory failure, pneumonia, reintubation, pulmonary edema, and noninvasive and invasive ventilation. Secondary outcomes included invasive and noninvasive ventilation, hospital mortality, length of stay, opioid consumption on day of surgery, and average daily opioid consumption after day of surgery.

RESULTS

Overall, 8,142 (12%) patients received gabapentinoids. The prevalence of gabapentin on day of surgery increased from 3.8% in 2012 to 15.9% in 2018. Use of gabapentinoids on day of surgery was associated with greater odds of PPCs (odds ratio [OR] 1.19, 95% CI 1.11-1.28), noninvasive mechanical ventilation (OR 1.30, 95% CI 1.16-1.45), and invasive mechanical ventilation (OR 1.14, 95% CI 1.02-1.28). Secondary outcomes indicated no clinically meaningful associations of gabapentinoid use with opioid consumption, hospital mortality, or length of stay.

CONCLUSIONS

Perioperative gabapentinoid administration in elective thoracic surgery may be associated with a higher risk of PPCs and no opioid-sparing effect.

Enhanced Recovery after Surgery: Perspective in Elder Women

Enhanced recovery after surgery (ERAS) is a multimodal convention first reported for colorectal and gynecologic procedures. The main benefits have been a shorter length of stay and reduced complications, leading to improved clinical outcomes and cost savings substantially. With increase in life expectancy, recent years has shown a significant rise in advanced age population, and similarly, a rise in age-related disorders requiring surgical management. Due to pathophysiological and metabolic changes in geriatric age group with increased incidence of medical comorbidities, there is higher risk of enhanced surgical stress response with undesirable postoperative morbidity, complications, prolonged immobility, and extended convalescence. The feasibility and effectiveness of ERAS protocols have been well researched and documented among all age groups, including the geriatric high-risk population.^[1] Adhering to ERAS protocols after colorectal surgery showed no significant difference in postoperative complications, hospital stay, or readmission rate among various age groups.^[2] A recent report mentions the safety and benefits following ERAS guidelines with reduced length of stay in elderly patients with short-level lumbar fusion surgery.^[3] The concept of prehabilitation has evolved as an integral part of ERAS to build up physiological reserve, especially in geriatric high-risk group, and to adapt better to surgical stress.^[4] High levels of compliance with ERAS interventions combined with prehabilitation can be achieved when a dedicated multidisciplinary team is involved in care of these high-risk patients.

Optimizing Discharge After Shorter Hospitalizations: Lessons Learned Through After-Hours Calls with Thoracic Surgical Patients

OBJECTIVE

Minimally invasive procedures coupled with enhanced recovery pathways enable faster postoperative recovery and shorter hospitalizations. However, patients may experience unexpected concerns after return home, prompting after-hours calls. We aimed to characterize concerns prompting after-hours calls to improve discharge strategies.

METHODS

A single-institution, retrospective review was conducted of thoracic surgical patients from 11/4/2019 to 6/14/2020. Records were reviewed and elements of patient demographics, surgical procedures, postoperative courses, reasons for calls, and outcome of calls were collected. We compared characteristics of patients who made after-hours calls to those who did not, and performed multivariable analysis to identify characteristics associated with making an after-hours call.

RESULTS

During the study period, 379 patients underwent thoracic surgical procedures, among whom 88 (23.2%) initiated after-hours calls. Of these, 62 (70%) addressed patient symptoms, while 26 (30%) addressed patient questions including drain management, medications, and hospital policy questions. Patients making after-hours calls more frequently had undergone complex operations (26.1% vs 8.2%, P = 0.001), and were less likely to have received a standardized, clinician-initiated post-discharge telephone follow-up (29.5% vs 54.3%, P < 0.001). Complex operations increased likelihood of after-hours calls (OR: 3.33, 95% CI: 1.69-6.57, P < 0.001), while receipt of clinician-initiated telephone follow-up decreased likelihood of after-hours calls (OR: 0.38, 95% CI: 0.22-0.64, P < 0.001). There were no differences in emergency visits between the 2 groups (11% vs 8%, P = 0.370).

CONCLUSIONS

Despite efforts to optimize patient symptoms and knowledge prior to discharge, a substantial number of patients still have concerns after discharge. Many after-hours calls are related to knowledge gaps that may be addressed with improved predischarge education. Moreover, clinician-initiated telephone follow-up shows benefit in reducing after-hours calls.

Effect of Lowest Postoperative Pre-albumin on Outcomes after Robotic-Assisted Pulmonary Lobectomy

Objective:

Lower pre-albumin levels have been associated with increased rates of post-surgical complications, prolonged hospital length of stay (LOS), and death. This study aims to investigate the effect of postoperative pre-albumin levels on perioperative and long-term outcomes following robotic-assisted video thoracoscopic (RAVT) pulmonary lobectomy.

Methods:

We retrospectively reviewed 459 consecutive patients who underwent RAVT pulmonary lobectomy by one surgeon for known or suspected lung cancer. The lowest pre-albumin values during the postoperative hospital stay were recorded. Twenty-three patients with no pre-albumin levels available were excluded from analysis. Patients were grouped as having normal (≥ 15 mg/dL) versus low (< 15mg/dL) pre-albumin. Outcomes and demographics were compared between groups using Pearson χ², Student’s t, or Kruskal-Wallis tests. Univariate and multivariate generalized linear regression, logistic regression, or Cox proportional hazard ratio models were used to assess the association between outcomes and variables of interest. Kaplan-Meier analyses were performed to estimate and depict survival probabilities for each group.

Results:

Our study population comprised 436 patients. Lowest postoperative pre-albumin below 15 mg/dL was associated with more postoperative complications (44.2% vs 24.9%, p < 0.001), longer chest tube duration (6.9 vs 4.6 days, p = 0.001), and longer LOS (7.0 vs. 4.4 days, p < 0.001). In survival analysis, lowest perioperative pre-albumin levels were found to correlate with decreased 1 year (p = 0.012), 3-year (p = 0.001), and 5-year survival (p = 0.001).

Conclusion:

Lower pre-albumin levels postoperatively are associated with more postoperative complications, longer chest tube duration and LOS, and decreased overall survival following robotic-assisted pulmonary lobectomy.

Enhanced recovery after thoracic surgery: Systematic review and meta-analysis

ERATS decreased length of stay, postoperative complications, and readmission.

Implementation of an enhanced recovery after thoracic surgery care pathway for thoracotomy patients-achieving better pain control with less (schedule II) opioid utilization

Background

Enhanced recovery after surgery protocols incorporate evidence-based practices of pre-, intra- and post-operative care to achieve the most optimal surgical outcome, safe on-time discharge, and surgical cost efficiency. Such protocols have been adapted for specialty-specific needs and are implemented by a variety of surgical disciplines including general thoracic surgery. This study aims to evaluate the impact of our enhanced recovery after thoracic surgery (ERATS) protocol on postoperative outcomes, pain, and opioid utilization following thoracotomy.

Methods

This is a retrospective analysis of patients undergoing elective resection of intrathoracic neoplasms via posterolateral thoracotomy between 1/1/2016 and 3/1/2020. Our enhanced recovery protocol, with a focus on multimodal pain management (opioid-sparing analgesics, infiltration of local anesthetics into intercostal spaces and surgical wounds, and elimination of thoracic epidural analgesia) was initiated on 2/1/2018. Demographics, clinicopathology data, subjective pain levels, peri-operative outcomes, in-hospital and post-discharge opioid utilization were obtained from the electronic medical record.

Results

A total of 98 patients (43 pre- and 55 post-protocol implementation) were included in this study. There was no difference in perioperative outcomes or percentage of opioid utilization between the two cohorts. The enhanced recovery group had significantly less acute pain. A significant reduction of in-hospital potent schedule II opioid use was noted following ERATS implementation [average MME: 10.5 (3.5–16.5) (ERATS) vs. 19.5 (12.6–36.0) (pre-ERATS), P<0.0001]. More importantly, a drastic reduction of total and schedule II opioids dispensed at discharge was noted in the ERATS group [total MME: 150 (100.0–330.0) vs. 800.0 (450.0–975.0), P<0.0001 and schedule II MME: 90.0 (0–242.2) vs. 800.0 (450.0–975.0), P<0.0001; ERATS vs. pre-ERATS respectively]. A shorter hospital stay (median difference of 1 day, P=0.0012 and a mean difference of 2.4 days, P=0.0054) was observed in the enhanced recovery group.

Conclusions

Implementation of an enhanced recovery protocol for thoracotomy patients is safe and associated with elimination of thoracic epidural analgesia, decreased postoperative pain, shorter hospitalization, drastic reduction of post-discharge opioid dispensed and decreased dependence on addiction-prone schedule II narcotics.

Enhanced Recovery After Surgery Protocol Minimizes Intensive Care Unit Utilization and Improves Outcomes Following Pulmonary Resection

Background

Enhanced recovery after surgery (ERAS) protocols have been associated with improved postoperative outcomes but require further validation in thoracic surgery. This study evaluated outcomes of patients undergoing pulmonary resection before and after implementation of an ERAS protocol.

Methods

Electronic medical records were queried for all patients undergoing pulmonary resection between April 2017 and April 2019. Patients were grouped into pre- and post-ERAS cohorts based on dates of operation. The ERAS protocol prioritized early mobilization, limited invasive monitoring, euvolemia, and non-narcotic analgesia. Primary outcome measures included intensive care unit (ICU) utilization, postoperative pain metrics, and perioperative morbidity. Regression analyses were performed to identify predictors of morbidity. Subgroup analyses were performed by pulmonary risk profile and surgical approach.

Results

A total of 64 pre- and 67 post-ERAS patients were included in the study. ERAS implementation was associated with reduced postoperative ICU admission (pre: 65.6% vs. post: 19.4%, p < 0.0001), shorter ICU median length of stay (LOS) (pre: 1 vs. post: 0, p < 0.0001), and decreased opioid usage measured by median morphine milligram equivalents (pre: 40.5 vs. post: 20.0, p < 0.0001). Post-ERAS patients also reported lower visual analog scale (VAS) pain scores on postoperative days (POD) 1 and 2 (pre: 6.3/5.6 vs. post: 5.3/4.2, p = 0.04/0.01) as well as average VAS pain score over POD0-2 (pre: 6.2 vs. post: 5.2, p = 0.005).

Conclusions

Implementation of an ERAS protocol for pulmonary resection, which dictated reduced ICU admissions, did not increase major postoperative morbidity. Additionally, ERAS-enrolled patients reported improved postoperative pain control despite decreased opioid utilization.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00268-021-06259-1.

Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program

In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyses, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.

Conversion from video-assisted thoracic surgery (VATS) to thoracotomy during major lung resection: how does it affect perioperative outcomes?

OBJECTIVES

Since video-assisted thoracic surgery (VATS) was first performed in the early 1990s, there have been many developments, and the conversion rate has decreased over the years. This article highlights the specific outcomes of patients undergoing conversion to thoracotomy despite initially scheduled VATS lung resection.

METHODS

We retrospectively reviewed 501 patients who underwent thoracoscopic anatomic lung resection (i.e. lobectomy, segmentectomy or bilobectomy) between 1 January 2012 and 1 August 2017 at our institution. We explored the risk factors for surgical conversion and adverse events occurring in patients who underwent conversion to thoracotomy.

RESULTS

A total of 44/501 patients underwent conversion during the procedure (global rate: 8.8%). The main reasons for conversion were (i) anatomical variation, adhesions or unexpected tumour extension (37%), followed by (ii) vascular causes (30%) and (iii) unexpected lymph node invasion (20%). The least common reason for conversion was technical failure (13%). We could not identify any specific risk factors for conversion. The global complication rate was significantly higher in converted patients (40.9%) than in complete VATS patients (16.8%) (P = 0.001). Postoperative atrial fibrillation was a major complication in converted patients (18.2%) [odds ratio (OR) 5.09, 95% confidence interval (CI) 1.80-13.27; P = 0.001]. Perioperative mortality was higher in the conversion group (6.8%) than in the VATS group (0.2%) (OR 33.3, 95% CI 3.4-328; P = 0.003).

CONCLUSIONS

Through the years, the global conversion rate has dramatically decreased to <10%. Nevertheless, patients who undergo conversion represent a high-risk population in terms of complications (40.9% vs 16.8%) and perioperative mortality (6.8% vs 0.2%).

Delayed Discharge after Thoracic Surgery under the Guidance of ERAS Protocols

BACKGROUND

 Enhanced recovery after surgery (ERAS) protocols have been applied in thoracic surgery and are beneficial to patients. However, some issues about ERAS are still pending.

METHODS

 A total of 1,654 patients who underwent thoracic surgery under the guidance of ERAS protocols were enrolled in this study. We set the length of postoperative stay (LOPS) as our key research indicator. Patients were divided into routine discharge group and delayed discharge group based on LOPS. Causes of delayed discharge were analyzed to improve management of postoperative recovery.

RESULTS

 Male, old age, underlying disease (coronary artery disease, chronic kidney disease, old cerebral infarction, chronic obstructive pulmonary disease, and arrhythmia), intensive care unit (ICU) stay, type of insurance, and lower forced expiratory volume in one second (FEV1) are the independent impact factors causing delayed discharge. Increased nonchylous drainage (INCD) and prolonged air leakage were the two leading causes for delayed discharge.

CONCLUSION

 Patients should have personalized recovery goal under the same ERAS protocols. We should accept that patients in poor general condition have a prolonged LOPS. More stringent ICU stay indications should be developed to increase postoperative patients' ERAS protocols compliance. Further research on chest tube management will make a contribution to ERAS protocols.

A Narrative Review on Perioperative Pain Management Strategies in Enhanced Recovery Pathways-The Past, Present and Future

Effective pain management is a key component in the continuum of perioperative care to ensure optimal outcomes for surgical patients. The overutilization of opioids in the past few decades for postoperative pain control has been a major contributor to the current opioid epidemic. Multimodal analgesia (MMA) and enhanced recovery after surgery (ERAS) pathways have been repeatedly shown to significantly improve postoperative outcomes such as pain, function and satisfaction. The current review aims to examine the history of perioperative MMA strategies in ERAS and provide an update with recent evidence. Furthermore, this review details recent advancements in personalized pain medicine. We speculate that the next important step for improving perioperative pain management could be through incorporating these personalized metrics, such as clinical pharmacogenomic testing and patient-reported outcome measurements, into ERAS program.

The effect of the enhanced recovery after surgery program on lung cancer surgery: a systematic review and meta-analysis

BACKGROUND

Lung cancer is one of the most common causes of cancer-related death worldwide. The enhanced recovery after surgery (ERAS) program is an effective evidence-based multidisciplinary protocol of perioperative care. However, the roles of ERAS in lung cancer surgery remain unclear. This systematic review and meta-analysis aimed to investigate the short-term impact of the ERAS program on lung resection surgery, especially in relation to postoperative complications.

METHODS

A systematic literature search of PubMed, EMBASE, and the Cochrane Library databases until October 2020 was performed to identify the studies that implemented an ERAS program in lung cancer surgery. The studies were selected and subjected to data extraction by 2 reviewers independently, which was followed by quality assessment. A random effects model was used to calculate overall effect sizes. Risk ratio (RR), risk difference (RD), and standardized mean difference (SMD) with 95% confidence interval (CI) served as the summary statistics for meta-analysis. Subgroup analysis and sensitivity analysis were subsequently performed.

RESULTS

A total of 21 studies with 6,480 patients were included. The meta-analysis indicated that patients in the ERAS group had a significantly reduced risk of postoperative complications (RR =0.64; 95% CI: 0.52 to 0.78) and shortened postoperative length of stay (SMD=-1.58; 95% CI: -2.38 to -0.79) with a significant heterogeneity. Subgroup analysis showed that the risks of pulmonary (RR =0.58; 95% CI: 0.45 to 0.75), cardiovascular (RR =0.73; 95% CI: 0.59 to 0.89), urinary (RR =0.53; 95% CI: 0.32 to 0.88), and surgical complications (RR =0.64; 95% CI: 0.42 to 0.97) were significantly lower in the ERAS group. No significant reduction was found in the in-hospital mortality (RD =0.00; 95% CI: -0.01 to 0.00) and readmission rate (RR =1.00; 95% CI: 0.76 to 1.32). In the qualitative review, most of the evidence reported significantly decreased hospitalization costs in the ERAS group.

CONCLUSIONS

The implementation of an ERAS program for surgery of lung cancer can effectively reduce risks of postoperative complications, length of stay, and costs of patients who have undergone lung cancer surgery without compromising their safety.

Implementation of an ERAS program in patients undergoing thoracic surgery at a third-level university hospital: an ambispective cohort study

OBJECTIVE

To analyze the effects of an ERAS program on complication rates, readmission, and length of stay in patients undergoing pulmonary resection in a tertiary university hospital.

METHODS

Ambispective cohort study with a prospective arm of 50 patients undergoing thoracic surgery within an ERAS program (ERAS group) versus a retrospective arm of 50 patients undergoing surgery before the protocol was implemented (Standard group). The primary outcome was the number of patients with 30-day surgical complications. Secondary outcomes included ERAS adherence, non-surgical complications, mortality, readmission, reintervention rate, pain, and hospital length of stay. We performed a multivariate logistic analysis to study the correlation between outcomes and ERAS adherence.

RESULTS

In the univariate analysis, we found no difference between the two groups in terms of surgical complications (Standard 18 [36%] vs. ERAS 12 [24%], p=0.19). In the ERAS group, only the readmission rate was significantly lower (Standard 15 [30%] vs. ERAS 6 [12%], p=0.03). In the multivariate analysis, ERAS adherence was the only factor associated with a reduction in surgical complications (OR [95% CI]=0.02 [0.00, 0.59], p=0.03) and length of stay (HR [95% CI]=18.5 [4.39, 78.4], p<0.001).

CONCLUSIONS

The ERAS program significantly reduced the readmission rate at our hospital. Adherence to the ERAS protocol reduced surgical complications and length of stay.