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Comacchio GM, Mammana M, Cannone G, Zambello G, Silvestrin S, Rebusso A, Nicotra S, Rea F. Impact of a standardized protocol for chest tube management after VATS pulmonary resections on post-operative outcomes and complications. Updates Surg 2024; 76:1493-1500. [PMID: 38007703 DOI: 10.1007/s13304-023-01704-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 11/07/2023] [Indexed: 11/28/2023]
Abstract
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.
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Affiliation(s)
- Giovanni M Comacchio
- Thoracic Surgery and Lung Transplant Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University Hospital of Padua, Via Giustiniani 2, 35128, Padua, Italy.
| | - Marco Mammana
- Thoracic Surgery and Lung Transplant Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University Hospital of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Giorgio Cannone
- Thoracic Surgery and Lung Transplant Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University Hospital of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Giovanni Zambello
- Thoracic Surgery and Lung Transplant Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University Hospital of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Stefano Silvestrin
- Thoracic Surgery and Lung Transplant Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University Hospital of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Alessandro Rebusso
- Thoracic Surgery and Lung Transplant Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University Hospital of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Samuele Nicotra
- Thoracic Surgery and Lung Transplant Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University Hospital of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Federico Rea
- Thoracic Surgery and Lung Transplant Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University Hospital of Padua, Via Giustiniani 2, 35128, Padua, Italy
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Sun MH, Wu LS, Qiu YY, Yan J, Li XQ. Enhanced recovery after surgery in elderly patients with non-small cell lung cancer who underwent video-assisted thoracic surgery. World J Clin Cases 2024; 12:2040-2049. [PMID: 38680260 PMCID: PMC11045500 DOI: 10.12998/wjcc.v12.i12.2040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 02/25/2024] [Accepted: 03/15/2024] [Indexed: 04/16/2024] Open
Abstract
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.
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Affiliation(s)
- Mei-Hua Sun
- Department of Thoracic Surgery, Peking University Shenzhen Hospital, Shenzhen 518036, Guangdong Province, China
| | - Liu-Sheng Wu
- School of Medicine, Tsinghua University, Beijing 100084, China
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Ying-Yang Qiu
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Jun Yan
- School of Medicine, Tsinghua University, Beijing 100084, China
| | - Xiao-Qiang Li
- Department of Thoracic Surgery, Peking University Shenzhen Hospital, Shenzhen 518036, Guangdong Province, China
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Bottet B, Piton N, Selim J, Sarsam M, Guisier F, Baste JM. Beyond the Frontline: A Triple-Line Approach of Thoracic Surgeons in Lung Cancer Management-State of the Art. Cancers (Basel) 2023; 15:4039. [PMID: 37627067 PMCID: PMC10452134 DOI: 10.3390/cancers15164039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 07/26/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
Non-small cell lung cancer (NSCLC) is now described as an extremely heterogeneous disease in its clinical presentation, histology, molecular characteristics, and patient conditions. Over the past 20 years, the management of lung cancer has evolved with positive results. Immune checkpoint inhibitors have revolutionized the treatment landscape for NSCLC in both metastatic and locally advanced stages. The identification of molecular alterations in NSCLC has also allowed the development of targeted therapies, which provide better outcomes than chemotherapy in selected patients. However, patients usually develop acquired resistance to these treatments. On the other hand, thoracic surgery has progressed thanks to minimally invasive procedures, pre-habilitation and enhanced recovery after surgery. Moreover, within thoracic surgery, precision surgery considers the patient and his/her disease in their entirety to offer the best oncologic strategy. Surgeons support patients from pre-operative rehabilitation to surgery and beyond. They are involved in post-treatment follow-up and lung cancer recurrence. When conventional therapies are no longer effective, salvage surgery can be performed on selected patients.
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Affiliation(s)
- Benjamin Bottet
- Department of General and Thoracic Surgery, Hospital Center University De Rouen, 1 Rue de Germont, F-76000 Rouen, France; (B.B.); (M.S.)
| | - Nicolas Piton
- Department of Pathology, UNIROUEN, INSERM U1245, CHU Rouen, Normandy University, F-76000 Rouen, France;
| | - Jean Selim
- Department of Anaesthesiology and Critical Care, CHU Rouen, F-76000 Rouen, France;
- INSERM EnVI UMR 1096, University of Rouen Normandy, F-76000 Rouen, France
| | - Matthieu Sarsam
- Department of General and Thoracic Surgery, Hospital Center University De Rouen, 1 Rue de Germont, F-76000 Rouen, France; (B.B.); (M.S.)
| | - Florian Guisier
- Department of Pneumology, CHU Rouen, 1 Rue de Germont, F-76000 Rouen, France;
- Clinical Investigation Center, Rouen University Hospital, CIC INSERM 1404, 1 Rue de Germont, F-76000 Rouen, France
| | - Jean-Marc Baste
- Department of General and Thoracic Surgery, Hospital Center University De Rouen, 1 Rue de Germont, F-76000 Rouen, France; (B.B.); (M.S.)
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Zhu J, Xia X, Li R, Song W, Zhang Z, Lu H, Li Z, Guo Q. Efficacy and safety of early chest tube removal after selective pulmonary resection with high-output drainage: A systematic review and meta-analysis. Medicine (Baltimore) 2023; 102:e33344. [PMID: 36961179 PMCID: PMC10036022 DOI: 10.1097/md.0000000000033344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 03/01/2023] [Indexed: 03/25/2023] Open
Abstract
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.
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Affiliation(s)
- Junwei Zhu
- Department of Thoracic Surgery, Zhoukou Central Hospital, Zhoukou, China
| | - Xueyang Xia
- Department of Thoracic Surgery, Zhoukou Central Hospital, Zhoukou, China
| | - Rongyao Li
- Department of Thoracic Surgery, Zhoukou Central Hospital, Zhoukou, China
| | - Weikang Song
- Department of Thoracic Surgery, Zhoukou Central Hospital, Zhoukou, China
| | - Zhiqiang Zhang
- Department of Thoracic Surgery, Zhoukou Central Hospital, Zhoukou, China
| | - Huawei Lu
- Department of Thoracic Surgery, Zhoukou Central Hospital, Zhoukou, China
| | - Zhiwei Li
- Department of Thoracic Surgery, Zhoukou Central Hospital, Zhoukou, China
| | - Qingwei Guo
- Department of Thoracic Surgery, Zhoukou Central Hospital, Zhoukou, China
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5
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Zhang W, Zhang Y, Qin Y, Shi J. Outcomes of enhanced recovery after surgery in lung cancer: A systematic review and meta-analysis. Asia Pac J Oncol Nurs 2022; 9:100110. [PMID: 36158708 PMCID: PMC9500517 DOI: 10.1016/j.apjon.2022.100110] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 06/13/2022] [Indexed: 11/02/2022] Open
Abstract
Objective Methods Results Conclusions
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Bagan P, Zaimi R, Dakhil B. [Patient outcomes after lung resection. The impact of unplanned readmission]. Rev Mal Respir 2022; 39:34-39. [PMID: 35034830 DOI: 10.1016/j.rmr.2021.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 11/11/2021] [Indexed: 11/28/2022]
Abstract
Unplanned readmissions after lung cancer surgery impair normal postoperative recovery and are associated with increased postoperative mortality. The objective of this review was to compile a detailed and comprehensive dataset on unplanned readmissions after pulmonary resection so as to better understand the associated factors and how they may be attenuated. Based on the identified risk factors, prevention involves improved preoperative preparation of at-risk patients and preoperative discharge planning so as to help prevent unscheduled readmissions, which are predictive of a poorer prognosis.
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Affiliation(s)
- P Bagan
- Service de chirurgie thoracique et vasculaire, hôpital Victor-Dupouy, Argenteuil, France.
| | - R Zaimi
- Service de chirurgie thoracique et vasculaire, hôpital Victor-Dupouy, Argenteuil, France
| | - B Dakhil
- Service de chirurgie thoracique et vasculaire, hôpital Victor-Dupouy, Argenteuil, France
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7
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Impact of enhanced pathway of care in uniportal video-assisted thoracoscopic surgery. Updates Surg 2022; 74:1097-1103. [PMID: 35013903 DOI: 10.1007/s13304-021-01217-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 12/05/2021] [Indexed: 10/19/2022]
Abstract
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.
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Abrão FC, Araujo de França S, de Abreu IRLB, das Neves Pereira JC, Del Massa EC, Oliver A, Cavalcante MGC. Enhanced recovery after surgery (ERAS ®) protocol adapted to the Brazilian reality: a prospective cohort study for thoracic patients. J Thorac Dis 2021; 13:5439-5447. [PMID: 34659810 PMCID: PMC8482344 DOI: 10.21037/jtd-21-920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 08/06/2021] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Fernando C Abrão
- Thoracic Surgery Department, Hospital Santa Marcelina, São Paulo, Brazil.,Thoracic Department, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Sabrina Araujo de França
- IPSPAC Research Department - Instituto Paulista de Saúde para Alta Complexidade, Santo Andre, Brazil
| | - Igor R L B de Abreu
- Thoracic Surgery Department, Hospital Santa Marcelina, São Paulo, Brazil.,Thoracic Surgery Department, Hospital São Camilo, São Paulo, Brazil
| | | | | | - Andréa Oliver
- Physiotherapy Department, Hospital Santa Marcelina, São Paulo, Brazil
| | - Maria Gabriela C Cavalcante
- Thoracic Surgery Department, Hospital Santa Marcelina, São Paulo, Brazil.,Thoracic Surgery Department, Hospital São Camilo, São Paulo, Brazil
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Khoury AL, McGinigle KL, Freeman NL, El-Zaatari H, Feltner C, Long JM. Enhanced recovery after thoracic surgery: Systematic review and meta-analysis. JTCVS OPEN 2021; 7:370-391. [PMID: 36003715 PMCID: PMC9390629 DOI: 10.1016/j.xjon.2021.07.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 07/08/2021] [Indexed: 12/29/2022]
Abstract
ERATS decreased length of stay, postoperative complications, and readmission.
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Affiliation(s)
- Audrey L. Khoury
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | | | - Nikki L. Freeman
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Helal El-Zaatari
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Cynthia Feltner
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jason M. Long
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
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Liu T, Feng J, Ge L, Jin F, Zhou C, Liu X. Feasibility, safety and outcomes of ambulation within 2 h postoperatively in patients with lung cancer undergoing thoracoscopic surgery. Int J Nurs Pract 2021; 28:e12994. [PMID: 34318965 DOI: 10.1111/ijn.12994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 07/08/2021] [Accepted: 07/10/2021] [Indexed: 12/09/2022]
Abstract
AIMS The aims of this study were to evaluate the safety, feasibility and outcomes of ambulation within 2 h after thoracoscopic surgery in patients with lung cancer. BACKGROUND There are no consensus guidelines on the ideal time for early ambulation following thoracic surgery, although enhanced recovery programmes have been proposed since years. METHODS This non-randomized, concurrent-control study was conducted on patients who underwent thoracoscopic surgery between October 2020 and February 2021. Participants were assigned to either the observation group (ambulation within 2 h of extubation) or the control group (ambulation on the first postoperative day). RESULTS Of the 325 patients who were eligible, 227 were included in the study. Eighty-three per cent of patients were able to walk any distance within 2 h of extubation, and no adverse events occurred in patients. The length of hospital stay and time to first postoperative flatus were significantly shorter in the observation group than in the control group. There were no differences in the occurrence of postoperative complications and orthostatic hypotension, readmission rate and 6-min walk distance at discharge. CONCLUSION Ambulation within 2 h of extubation was safe and feasible and could lead to better recovery in patients with lung cancer undergoing thoracoscopic surgery.
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Affiliation(s)
- Tingting Liu
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jing Feng
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Ling Ge
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Fengxia Jin
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Chao Zhou
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaoxin Liu
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
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Moret A, Madelaine L, Cottenet J, Sophie Mariet A, Quantin C, Bernard A, Pagès PB. [Readmissions after lung resection in France: The PMSI database]. Rev Mal Respir 2021; 38:673-680. [PMID: 34175166 DOI: 10.1016/j.rmr.2021.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 03/29/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Readmission within 30 days is an indicator of the quality of care, because it often reflects post-discharge care that is not optimal. The objective of this work is to measure over time on the one hand the readmission rate and on the other hand the number of hospitals with a standardized readmission rate beyond the national average. METHOD All patients with major pulmonary resection for lung cancer in France were extracted from the PMSI national database. Readmission within 30 days was defined as any new hospitalization either in the same hospital or in another establishment. RESULTS From January 1, 2005 to December 31, 2018, 110,603 patients were included. The 30-day all-cause readmissions rate was 24.9% (n=27,540). Patients after pneumonectomy had a readmission rate of 37% (n=4918) and 23% after lobectomy (n=2684) (P<0.0001). For the first period, we counted 10 hospitals with a standardized readmissions rate above the 99.8 limit and 10 hospitals above the 95% limit. For the second period, 8 hospitals had a standardized readmission rate above the 99.8% limit and 11 hospitals above the 95% limit. For the third period, 7 hospitals had a standardized readmission rate above the 99.8% limit and 6 hospitals above the 95% limit. CONCLUSION Readmissions to hospital 30 days after major lung resection for cancer in France declined little during these three periods. Measures to prevent readmissions should be introduced.
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Affiliation(s)
- A Moret
- Service de chirurgie thoracique et cardio-vasculaire, CHU Dijon, Dijon, France
| | - L Madelaine
- Service de chirurgie thoracique et cardio-vasculaire, CHU Dijon, Dijon, France; Inserm UMR 1231, université de Bourgogne, Dijon, France
| | - J Cottenet
- Departement de biostatistique, CHU Bocage, Université de Bourgogne, Dijon, France
| | - A Sophie Mariet
- Departement de biostatistique, CHU Bocage, Université de Bourgogne, Dijon, France
| | - C Quantin
- Departement de biostatistique, CHU Bocage, Université de Bourgogne, Dijon, France; Inserm, CIC 1432, Centre d'investigation clinique, hôpital de Dijon, université de Bourgogne, Dijon, France; Inserm, UVSQ, Institut Pasteur, université Paris-Saclay, Paris, France
| | - A Bernard
- Service de chirurgie thoracique et cardio-vasculaire, CHU Dijon, Dijon, France.
| | - P B Pagès
- Service de chirurgie thoracique et cardio-vasculaire, CHU Dijon, Dijon, France; Inserm UMR 1231, université de Bourgogne, Dijon, France
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12
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Li R, Wang K, Qu C, Qi W, Fang T, Yue W, Tian H. The effect of the enhanced recovery after surgery program on lung cancer surgery: a systematic review and meta-analysis. J Thorac Dis 2021; 13:3566-3586. [PMID: 34277051 PMCID: PMC8264698 DOI: 10.21037/jtd-21-433] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 05/14/2021] [Indexed: 12/25/2022]
Abstract
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.
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Affiliation(s)
- Rongyang Li
- Department of Thoracic Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Kun Wang
- Department of Thoracic Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Chenghao Qu
- Department of Thoracic Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Weifeng Qi
- Department of Thoracic Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Tao Fang
- Department of Thoracic Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Weiming Yue
- Department of Thoracic Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Hui Tian
- Department of Thoracic Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Cheeloo College of Medicine, Shandong University, Jinan, China
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Wang C, Lai Y, Li P, Su J, Che G. Influence of enhanced recovery after surgery (ERAS) on patients receiving lung resection: a retrospective study of 1749 cases. BMC Surg 2021; 21:115. [PMID: 33676488 PMCID: PMC7936477 DOI: 10.1186/s12893-020-00960-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 11/12/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The study aimed to evaluate the outcomes following the implementation of enhanced recovery after surgery (ERAS) for patients undergoing lung cancer surgery. METHOD A retrospective cohort study involving 1749 patients with lung cancer undergoing pulmonary resection was conducted. The patients were divided into two time period groups for analysis (routine pathway and ERAS pathway). Logistic regression analysis was performed to assess the risks of developing postoperative pulmonary complications. RESULTS Among the 1749 patients, 691 were stratified into the ERAS group, and 1058 in to the routine group. The ERAS group presented with shorter postoperative in-hospital length of stay (LOS) (4.0 vs 6.0, P < 0.001), total LOS (10.0 vs. 13.0 days, P < 0.001), and lower total in-hospital costs (P < 0.001), including material (P < 0.001) and drug expenses (P < 0.001). Furthermore, the ERAS group also presented with a lower occurrence of postoperative pulmonary complications (PPCs) than the routine group (15.2% vs. 19.5%, P = 0.022). Likewise, a significantly lower occurrence of pneumonia (8.4% vs. 14.2%, P < 0.001) and atelectasis (5.9% vs. 9.8%, P = 0.004) was found in the ERAS group. Regarding the binary logistic regression, the ERAS intervention was the sole independent factor for the occurrence of PPCs (OR: 0.601, 95% CI 0.434-0.824, P = 0.002). In addition, age (OR: 1.032, 95% CI 1.018-1.046), COPD (OR: 1.792, 95% CI 1.196-2.686), and FEV1 (OR: 0.205, 95% CI 0.125-0.339) were also independent predictors of PPCs. CONCLUSION Implementation of an ERAS pathway shows improved postoperative outcomes, including shortened LOS, lower in-hospital costs, and reduced occurrence of PPCs, providing benefits to the postoperative recovery of patients with lung cancer undergoing surgical treatment.
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Affiliation(s)
- Chunmei Wang
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Yutian Lai
- Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Pengfei Li
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Jianhuan Su
- Rehabilitation Department, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Guowei Che
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China.
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Berna P, Quesnel C, Assouad J, Bagan P, Etienne H, Fourdrain A, Le Guen M, Leone M, Lorne E, Nguyen YNL, Pages PB, Roz H, Garnier M. Guidelines on enhanced recovery after pulmonary lobectomy. Anaesth Crit Care Pain Med 2021; 40:100791. [PMID: 33451912 DOI: 10.1016/j.accpm.2020.100791] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To establish recommendations for optimisation of the management of patients undergoing pulmonary lobectomy, particularly Enhanced Recovery After Surgery (ERAS). DESIGN A consensus committee of 13 experts from the French Society of Anaesthesia and Intensive Care Medicine (Soci,t, franOaise d'anesth,sie et de r,animation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Soci,t, franOaise de chirurgie thoracique et cardiovasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence. METHODS Five domains were defined: 1) patient pathway and patient information; 2) preoperative management and rehabilitation; 3) anaesthesia and analgesia for lobectomy; 4) surgical strategy for lobectomy; and 5) enhanced recovery after surgery. For each domain, the objective of the recommendations was to address a number of questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). An extensive literature search on these questions was carried out and analysed using the GRADE® methodology. Recommendations were formulated according to the GRADE® methodology, and were then voted by all experts according to the GRADE grid method. RESULTS The SFAR/SFCTCV guideline panel provided 32 recommendations on the management of patients undergoing pulmonary lobectomy. After two voting rounds and several amendments, a strong consensus was reached for 31 of the 32 recommendations and a moderate consensus was reached for the last recommendation. Seven of these recommendations present a high level of evidence (GRADE 1+), 23 have a moderate level of evidence (18 GRADE 2+ and 5 GRADE 2-), and 2 correspond to expert opinions. Finally, no recommendation was provided for 2 of the questions. CONCLUSIONS A strong consensus was expressed by the experts to provide recommendations to optimise the whole perioperative management of patients undergoing pulmonary lobectomy.
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Affiliation(s)
- Pascal Berna
- Department of Thoracic Surgery, Amiens University Hospital, 80000 Amiens, France
| | - Christophe Quesnel
- Sorbonne Universit,, APHP, DMU DREAM, Service d'Anesth,sie-R,animation et M,decine P,riop,ratoire, H"pital Tenon, 75020 Paris, France
| | - Jalal Assouad
- Department of Thoracic Surgery, Tenon University Hospital, Sorbonne Universit,, 75020 Paris, France
| | - Patrick Bagan
- Department of Thoracic and Vascular Surgery, Victor Dupouy Hospital, 95100 Argenteuil, France
| | - Harry Etienne
- Department of Thoracic Surgery, Tenon University Hospital, Sorbonne Universit,, 75020 Paris, France
| | - Alex Fourdrain
- Department of Thoracic Surgery, Amiens University Hospital, 80000 Amiens, France
| | - Morgan Le Guen
- D,partement d'Anesth,sie, H"pital Foch, Universit, Versailles Saint Quentin, 92150 Suresnes, France; INRA UMR 892 VIM, 78350 Jouy-en-Josas, France
| | - Marc Leone
- Aix Marseille Universit, - Assistance Publique H"pitaux de Marseille - Service d'Anesth,sie et de R,animation - H"pital Nord - 13005 Marseille, France
| | - Emmanuel Lorne
- Departement d'Anesth,sie-R,animation, Clinique du Mill,naire, 34000 Montpellier, France
| | - Y N-Lan Nguyen
- Anaesthesiology and Critical Care Department, APHP Centre, Paris University, 75000 Paris, France
| | - Pierre-Benoit Pages
- Department of Thoracic Surgery, Dijon Burgundy University Hospital, 21000 Dijon, France; INSERM UMR 1231, Dijon Burgundy University Hospital, University of Burgundy, 21000 Dijon, France
| | - Hadrien Roz
- Unit, d'Anesth,sie R,animation Thoracique, H"pital Haut Leveque, CHU de Bordeaux, 33000 Bordeaux, France
| | - Marc Garnier
- Sorbonne Universit,, APHP, DMU DREAM, Service d'Anesth,sie-R,animation et M,decine P,riop,ratoire, H"pital Tenon, 75020 Paris, France.
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15
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Piccioni F, Droghetti A, Bertani A, Coccia C, Corcione A, Corsico AG, Crisci R, Curcio C, Del Naja C, Feltracco P, Fontana D, Gonfiotti A, Lopez C, Massullo D, Nosotti M, Ragazzi R, Rispoli M, Romagnoli S, Scala R, Scudeller L, Taurchini M, Tognella S, Umari M, Valenza F, Petrini F. Recommendations from the Italian intersociety consensus on Perioperative Anesthesia Care in Thoracic surgery (PACTS) part 1: preadmission and preoperative care. Perioper Med (Lond) 2020; 9:37. [PMID: 33292657 PMCID: PMC7704118 DOI: 10.1186/s13741-020-00168-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 11/03/2020] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Anesthetic care in patients undergoing thoracic surgery presents specific challenges that necessitate standardized, multidisciplionary, and continuously updated guidelines for perioperative care. METHODS A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, comprising 24 members from 19 Italian centers, was established to develop recommendations for anesthesia practice in patients undergoing thoracic surgery (specifically lung resection for cancer). The project focused on preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and PubMed and Embase literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventative Services Task Force criteria. RESULTS Recommendations for preoperative care focus on risk assessment, patient preparation (prehabilitation), and the choice of procedure (open thoracotomy vs. video-assisted thoracic surgery). CONCLUSIONS These recommendations should help pulmonologists to improve preoperative management in thoracic surgery patients. Further refinement of the recommendations can be anticipated as the literature continues to evolve.
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Affiliation(s)
- Federico Piccioni
- Department of Critical and Supportive Care, Fondazione IRCCS Istituto Nazionale dei Tumori, via Venezian 1, 20133, Milan, Italy.
| | | | - Alessandro Bertani
- Division of Thoracic Surgery and Lung Transplantation, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS ISMETT - UPMC, Palermo, Italy
| | - Cecilia Coccia
- Department of Anesthesia and Critical Care Medicine, National Cancer Institute "Regina Elena"-IRCCS, Rome, Italy
| | - Antonio Corcione
- Department of Critical Care Area Monaldi Hospital, Ospedali dei Colli, Naples, Italy
| | - Angelo Guido Corsico
- Division of Respiratory Diseases, IRCCS Policlinico San Matteo Foundation and Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Roberto Crisci
- Department of Thoracic Surgery, University of L'Aquila, L'Aquila, Italy
| | - Carlo Curcio
- Thoracic Surgery, AORN dei Colli Vincenzo Monaldi Hospital, Naples, Italy
| | - Carlo Del Naja
- Department of Thoracic Surgery, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, FG, Italy
| | - Paolo Feltracco
- Department of Medicine, Anaesthesia and Intensive Care, University Hospital of Padova, Padua, Italy
| | - Diego Fontana
- Thoracic Surgery Unit - San Giovanni Bosco Hospital - Torino, Turin, Italy
| | | | - Camillo Lopez
- Thoracic Surgery Unit, V Fazzi Hospital, Lecce, Italy
| | - Domenico Massullo
- Anesthesiology and Intensive Care Unit, Azienda Ospedaliero Universitaria S. Andrea, Rome, Italy
| | - Mario Nosotti
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Riccardo Ragazzi
- Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliero-Universitaria Sant'Anna, Ferrara, Italy
| | - Marco Rispoli
- Anesthesia and Intensive Care, AORN dei Colli Vincenzo Monaldi Hospital, Naples, Italy
| | - Stefano Romagnoli
- Department of Health Science, Section of Anesthesia and Critical Care, University of Florence, Florence, Italy
- Department of Anesthesia and Critical Care, Careggi University Hospital, Florence, Italy
| | - Raffaele Scala
- Pneumology and Respiratory Intensive Care Unit, San Donato Hospital, Arezzo, Italy
| | - Luigia Scudeller
- Clinical Epidemiology Unit, Scientific Direction, Fondazione IRCCS San Matteo, Pavia, Italy
| | - Marco Taurchini
- Department of Thoracic Surgery, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, FG, Italy
| | - Silvia Tognella
- Respiratory Unit, Orlandi General Hospital, Bussolengo, Verona, Italy
| | - Marzia Umari
- Combined Department of Emergency, Urgency and Admission, Cattinara University Hospital, Trieste, Italy
| | - Franco Valenza
- Department of Critical and Supportive Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
- Department of Oncology and Onco-Hematology, University of Milan, Milan, Italy
| | - Flavia Petrini
- Department of Anaesthesia, Perioperative Medicine, Pain Therapy, RRS and Critical Care Area - DEA ASL2 Abruzzo, Chieti University Hospital, Chieti, Italy
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Piccioni F, Droghetti A, Bertani A, Coccia C, Corcione A, Corsico AG, Crisci R, Curcio C, Del Naja C, Feltracco P, Fontana D, Gonfiotti A, Lopez C, Massullo D, Nosotti M, Ragazzi R, Rispoli M, Romagnoli S, Scala R, Scudeller L, Taurchini M, Tognella S, Umari M, Valenza F, Petrini F. Recommendations from the Italian intersociety consensus on Perioperative Anesthesa Care in Thoracic surgery (PACTS) part 2: intraoperative and postoperative care. Perioper Med (Lond) 2020; 9:31. [PMID: 33106758 PMCID: PMC7582032 DOI: 10.1186/s13741-020-00159-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 09/22/2020] [Indexed: 02/08/2023] Open
Abstract
Introduction Anesthetic care in patients undergoing thoracic surgery presents specific challenges that require a multidisciplinary approach to management. There remains a need for standardized, evidence-based, continuously updated guidelines for perioperative care in these patients. Methods A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, was established to develop recommendations for anesthesia practice in patients undergoing elective lung resection for lung cancer. The project addressed three key areas: preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventive Services Task Force criteria. Results Recommendations for intraoperative care focus on airway management, and monitoring of vital signs, hemodynamics, blood gases, neuromuscular blockade, and depth of anesthesia. Recommendations for postoperative care focus on the provision of multimodal analgesia, intensive care unit (ICU) care, and specific measures such as chest drainage, mobilization, noninvasive ventilation, and atrial fibrillation prophylaxis. Conclusions These recommendations should help clinicians to improve intraoperative and postoperative management, and thereby achieve better postoperative outcomes in thoracic surgery patients. Further refinement of the recommendations can be anticipated as the literature continues to evolve.
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Affiliation(s)
- Federico Piccioni
- Department of Critical and Supportive Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Alessandro Bertani
- Division of Thoracic Surgery and Lung Transplantation, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS ISMETT - UPMC, Palermo, Italy
| | - Cecilia Coccia
- Department of Anesthesia and Critical Care Medicine, National Cancer Institute "Regina Elena"-IRCCS, Rome, Italy
| | - Antonio Corcione
- Department of Critical Care Area Monaldi Hospital, Ospedali dei Colli, Naples, Italy
| | - Angelo Guido Corsico
- Division of Respiratory Diseases, IRCCS Policlinico San Matteo Foundation and Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Roberto Crisci
- Department of Thoracic Surgery, University of L'Aquila, L'Aquila, Italy
| | - Carlo Curcio
- Thoracic Surgery, AORN dei Colli Vincenzo Monaldi Hospital, Naples, Italy
| | - Carlo Del Naja
- Department of Thoracic Surgery, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, FG Italy
| | - Paolo Feltracco
- Department of Medicine, Anaesthesia and Intensive Care, University Hospital of Padova, Padova, Italy
| | - Diego Fontana
- Thoracic Surgery Unit - San Giovanni Bosco Hospital, Turin, Italy
| | | | - Camillo Lopez
- Thoracic Surgery Unit, 'V Fazzi' Hospital, Lecce, Italy
| | - Domenico Massullo
- Anesthesiology and Intensive Care Unit, Azienda Ospedaliero Universitaria S. Andrea, Rome, Italy
| | - Mario Nosotti
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Riccardo Ragazzi
- Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliero-Universitaria Sant'Anna, Ferrara, Italy
| | - Marco Rispoli
- Anesthesia and Intensive Care, AORN dei Colli Vincenzo Monaldi Hospital, Naples, Italy
| | - Stefano Romagnoli
- Department of Health Science, Section of Anesthesia and Critical Care, University of Florence, Florence, Italy.,Department of Anesthesia and Critical Care, Careggi University Hospital, Florence, Italy
| | - Raffaele Scala
- Pneumology and Respiratory Intensive Care Unit, San Donato Hospital, Arezzo, Italy
| | - Luigia Scudeller
- Clinical Epidemiology Unit, Scientific Direction, Fondazione IRCCS San Matteo, Pavia, Italy
| | - Marco Taurchini
- Department of Thoracic Surgery, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, FG Italy
| | - Silvia Tognella
- Respiratory Unit, Orlandi General Hospital, Bussolengo, Verona, Italy
| | - Marzia Umari
- Combined Department of Emergency, Urgency and Admission, Cattinara University Hospital, Trieste, Italy
| | - Franco Valenza
- Department of Critical and Supportive Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.,Department of Oncology and Onco-Hematology, University of Milan, Milan, Italy
| | - Flavia Petrini
- Department of Anaesthesia, Perioperative Medicine, Pain Therapy, RRS and Critical Care Area - DEA ASL2 Abruzzo, Chieti University Hospital, Chieti, Italy
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Tahiri M, Goudie E, Jouquan A, Martin J, Ferraro P, Liberman M. Enhanced recovery after video-assisted thoracoscopic surgery lobectomy: a prospective, historically controlled, propensity-matched clinical study. Can J Surg 2020; 63:E233-E240. [PMID: 32386474 DOI: 10.1503/cjs.001919] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background Enhanced recovery pathways or fast-tracking following surgery can decrease the rate of postoperative complications and hospital length of stay. The objectives of this study were to implement an enhanced recovery after surgery (ERAS) pathway for patients undergoing a video-assisted thoracoscopic surgery (VATS) lobectomy, to assess the safety and efficiency of this protocol by measuring associated postoperative outcomes, and to compare the outcomes for patients in the ERAS group with the outcomes for patients in a propensity-matched control group. Methods The study was a prospective clinical trial. Patients who were scheduled to undergo VATS lobectomy at the Centre hospitalier de l'Université de Montréal in Montréal, Quebec, Canada, were enrolled between November 2015 and October 2016. The ERAS pathway was used for all enrolled patients. The primary outcome was the number and severity of complications measured by the Comprehensive Complication Index. Secondary outcomes included length of stay, readmission and recovery. Recovery of patients was measured using EQ-5D-5L preoperatively and at 1 week, 1 month and 4 months after surgery. Prospectively enrolled patients were propensity matched to historical controls. Results Ninety-eight patients (36 men and 62 women) in the ERAS group and 98 patients in the control group (29 men and 69 women) were included in the analysis. The mean age was 65.2 ± 9.3 years, the mean body mass index (BMI) was 26.9 ± 5.9 kg/m2 and the median Charlson Comorbidity Index score was 2 (interquartile range [IQR] 2-3) in the ERAS group. In the control group, the mean age was 66.2 ± 9.4 years, the mean BMI was 27.4 ± 5.6 kg/m2 and the median Charlson Comorbidity Index score was 3 (IQR 2-3). A total of 23 patients (23.4%) in the ERAS group and 28 (28.6%) in the control group experienced 1 or more postoperative complications. The mean Comprehensive Complication Index score was 7.4 ± 16.8 in the ERAS group compared with 8.0 ± 14.3 in the control group (p = 0.79). The median postoperative length of stay was 3 days in the ERAS group and 5 days in the control group (p < 0.001). Five patients in the ERAS group and 4 patients in the control group were readmitted. The protocol adherence rate was 64.3%. Conclusion It is feasible to implement an enhanced recovery protocol after VATS lobectomy. Although the pathway is still early in its development in Canada, implementation of an ERAS pathway after VATS lobectomy was associated with decreased length of stay, with no observable increase in complication or readmission rates.
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Affiliation(s)
- Mehdi Tahiri
- From the Division of Thoracic Surgery, Université de Montréal, Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman); and the CHUM Endoscopic Tracheobronchial and Oesophageal Centre (CETOC), Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman)
| | - Eric Goudie
- From the Division of Thoracic Surgery, Université de Montréal, Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman); and the CHUM Endoscopic Tracheobronchial and Oesophageal Centre (CETOC), Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman)
| | - Adeline Jouquan
- From the Division of Thoracic Surgery, Université de Montréal, Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman); and the CHUM Endoscopic Tracheobronchial and Oesophageal Centre (CETOC), Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman)
| | - Jocelyne Martin
- From the Division of Thoracic Surgery, Université de Montréal, Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman); and the CHUM Endoscopic Tracheobronchial and Oesophageal Centre (CETOC), Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman)
| | - Pasquale Ferraro
- From the Division of Thoracic Surgery, Université de Montréal, Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman); and the CHUM Endoscopic Tracheobronchial and Oesophageal Centre (CETOC), Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman)
| | - Moishe Liberman
- From the Division of Thoracic Surgery, Université de Montréal, Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman); and the CHUM Endoscopic Tracheobronchial and Oesophageal Centre (CETOC), Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman)
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Nunns M, Shaw L, Briscoe S, Thompson Coon J, Hemsley A, McGrath JS, Lovegrove CJ, Thomas D, Anderson R. Multicomponent hospital-led interventions to reduce hospital stay for older adults following elective surgery: a systematic review. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07400] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BackgroundElective older adult inpatient admissions are increasingly common. Older adults are at an elevated risk of adverse events in hospital, potentially increasing with lengthier hospital stay. Hospital-led organisational strategies may optimise hospital stay for elective older adult inpatients.ObjectivesTo evaluate the effectiveness and cost-effectiveness of hospital-led multicomponent interventions to reduce hospital stay for older adults undergoing elective hospital admissions.Data sourcesSeven bibliographic databases (MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Health Management Information Consortium, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature and Allied and Complementary Medicine Database) were searched from inception to date of search (August 2017), alongside carrying out of web searches, citation searching, inspecting relevant reviews, consulting stakeholders and contacting authors. This search was duplicated, with an additional cost-filter, to identify cost-effectiveness evidence.Review methodsComparative studies were sought that evaluated the effectiveness or cost-effectiveness of relevant interventions in elective inpatients with a mean or median age of ≥ 60 years. Study selection, data extraction and quality assessment were completed independently by two reviewers. The main outcome was length of stay, but all outcomes were considered. Studies were sorted by procedure, intervention and outcome categories. Where possible, standardised mean differences or odds ratios were calculated. Meta-analysis was performed when multiple randomised controlled trials had the same intervention, treatment procedure, comparator and outcome. Findings were explored using narrative synthesis.FindingsA total of 218 articles were included, with 80 articles from 73 effectiveness studies (n = 26,365 patients) prioritised for synthesis, including 34 randomised controlled trials conducted outside the UK and 39 studies from the UK, of which 12 were randomised controlled trials. Fifteen studies included cost-effectiveness data. The evidence was dominated by enhanced recovery protocols and prehabilitation, implemented to improve recovery from either colorectal surgery or lower limb arthroplasty. Six other surgical categories and four other intervention types were identified. Meta-analysis found that enhanced recovery protocols were associated with 1.5 days’ reduction in hospital stay among patients undergoing colorectal surgery (Cohen’sd = –0.51, 95% confidence interval –0.78 to –0.24;p < 0.001) and with 5 days’ reduction among those undergoing upper abdominal surgery (Cohen’sd = –1.04, 95% confidence interval –1.55 to –0.53;p < 0.001). Evidence from the UK was not pooled (owing to mixed study designs), but it echoed findings from the international literature. Length of stay usually was reduced with intervention or was no different. Other clinical outcomes also improved or were no worse with intervention. Patient-reported outcomes were not frequently reported. Cost and cost-effectiveness evidence came from 15 highly heterogeneous studies and was less conclusive.LimitationsStudies were usually of moderate or weak quality. Some intervention or treatment types were under-reported or absent. The reporting of variance data often precluded secondary analysis.ConclusionsEnhanced recovery and prehabilitation interventions were associated with reduced hospital stay without detriment to other clinical outcomes, particularly for patients undergoing colorectal surgery, lower limb arthroplasty or upper abdominal surgery. The impacts on patient-reported outcomes, health-care costs or additional service use are not well known.Future workFurther studies evaluating of the effectiveness of new enhanced recovery pathways are not required in colorectal surgery or lower limb arthroplasty. However, the applicability of these pathways to other procedures is uncertain. Future studies should evaluate the implementation of interventions to reduce service variation, in-hospital patient-reported outcomes, impacts on health and social care service use, and longer-term patient-reported outcomes.Study registrationThis study is registered as PROSPERO CRD42017080637.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Michael Nunns
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Liz Shaw
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Simon Briscoe
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Jo Thompson Coon
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Anthony Hemsley
- Department of Healthcare for Older People, Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - John S McGrath
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
- Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - Christopher J Lovegrove
- Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
- School of Health Professions, Faculty of Health & Human Sciences, University of Plymouth, Plymouth, UK
| | - David Thomas
- Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - Rob Anderson
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
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von Meyenfeldt EM, Hoeijmakers F, Marres GMH, van Thiel ERE, Marra E, Marang-van de Mheen PJ, Schreurs H(WH. Variation in length of stay after minimally invasive lung resection: a reflection of perioperative care routines? Eur J Cardiothorac Surg 2019; 57:747-753. [DOI: 10.1093/ejcts/ezz303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 09/20/2019] [Accepted: 10/02/2019] [Indexed: 12/11/2022] Open
Abstract
Abstract
OBJECTIVES
Good perioperative care is aimed at rapid recovery, without complications or readmissions. Length of stay (LOS) is influenced not only by perioperative care routines but also by patient factors, tumour factors, treatment characteristics and complications. The present study examines variation in LOS between hospitals after minimally invasive lung resections for both complicated and uncomplicated patients to assess whether LOS is a hospital characteristic influenced by local perioperative routines or other factors.
METHODS
Dutch Lung Cancer Audit (surgery) data were used. Median LOS was calculated on hospital level, stratified by the severity of complications. Lowest quartile (short) LOS per hospital, corrected for case-mix factors by multivariable logistic regression, was presented in funnel plots. We correlated short LOS in complicated versus uncomplicated patients to assess whether short LOS clustered in the same hospitals regardless of complications.
RESULTS
Data from 6055 patients in 42 hospitals were included. Median LOS in uncomplicated patients varied from 3 to 8 days between hospitals and increased most markedly for patients with major complications. Considerable between-hospital variation persisted after case-mix correction, but more in uncomplicated than complicated patients. Short LOS in uncomplicated and complicated patients were significantly correlated (r = 0.53, P < 0.001).
CONCLUSIONS
LOS after minimally invasive anatomical lung resections varied between hospitals particularly in uncomplicated patients. The significant correlation between short LOS in uncomplicated and complicated patients suggests that LOS is a hospital characteristic potentially influenced by local processes. Standardizing and optimizing perioperative care could help limit practice variation with improved LOS and complication rates.
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Affiliation(s)
- Erik M von Meyenfeldt
- Department of Thoracic Surgery, Lung Cancer Centre, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Fieke Hoeijmakers
- Department of Surgery, Leiden University Medical Centre, Leiden, Netherlands
- Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, Netherlands
| | - Geertruid M H Marres
- Department of Thoracic Surgery, Lung Cancer Centre, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Eric R E van Thiel
- Department of Thoracic Oncology, Lung Cancer Centre, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Elske Marra
- Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, Netherlands
| | - Perla J Marang-van de Mheen
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Centre, Leiden, Netherlands
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King M, Kerr A, Dixon S, Taylor S, Smith A, Merriman C, Mitchell J, Canavan J, Hunter V. Multicentre review of readmission rates within 30 days of discharge following lung cancer surgery. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2019; 28:S16-S22. [PMID: 31556737 DOI: 10.12968/bjon.2019.28.17.s16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Postoperative complications following curative lung cancer surgery are well recognised, but there is limited data on 30-day readmission rates. The UK Thoracic Surgery Group conducted a multicentre review over a 3-month period to assess readmission rates. Overall readmission among the 268 patients who had undergone primary lung cancer surgery was 30 (11%); 14/30 of readmissions occurred within 7 days of discharge, with 13/30 patients readmitted to a hospital that had not performed the surgery. The causes of readmission were mainly pulmonary related (16/30). Readmission was associated with being discharged with a pleural drain 11/30 (P<0.01), having two or more postoperative complications 11/30 (P<0.01) and a patient's readiness for discharge 9/30 (P=0.001). There was a trend toward an association with smoking 13/30 (P=0.18). The authors suggest that a greater focus on patients presenting with characteristics associated with readmission, and incorporating a patient's readiness for discharge, may reduce readmission, although more studies are needed.
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Affiliation(s)
- Maureen King
- Thoracic Oncology Clinical Nurse Specialist, Royal Papworth Hospital, Cambridge
| | - Amy Kerr
- Senior Thoracic Surgery Research Nurse, Heart of England NHS Foundation Trust, Birmingham
| | - Sandra Dixon
- Macmillan Thoracic Surgical Nurse Specialist, Leeds General Infirmary, Leeds
| | - Sarah Taylor
- Thoracic Nurse Specialist, Glenfield Hospital, Leicester
| | - Alison Smith
- Advanced Practitioner in Cardiothoracic Surgery, Harefield Hospital, Uxbridge
| | - Charlotte Merriman
- Macmillan Advanced Nurse Practitioner, Oxford University Hospitals NHS Trust, Oxford
| | - Jenny Mitchell
- Advanced Nurse Practitioner, Thoracic Surgery, Oxford University Hospitals NHS Trust, Oxford
| | - Jane Canavan
- Macmillan Advanced Therapist Practitioner, Oxford University Hospital, Oxford
| | - Verity Hunter
- Clinical Audit and Effectiveness Supervisor, Royal Papworth Hospital, Cambridge
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21
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Nelson DB, Mehran RJ, Mitchell KG, Correa AM, Sepesi B, Antonoff MB, Rice DC. Enhanced recovery after thoracic surgery is associated with improved adjuvant chemotherapy completion for non–small cell lung cancer. J Thorac Cardiovasc Surg 2019; 158:279-286.e1. [DOI: 10.1016/j.jtcvs.2019.03.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 02/05/2019] [Accepted: 03/02/2019] [Indexed: 02/03/2023]
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22
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Zhang C, Zhang H, Wu W, Liu D, Yang D, Zhang M, Lu C. Prophylactic octreotide does not reduce the incidence of postoperative chylothorax following lobectomy: Results from a retrospective study. Medicine (Baltimore) 2019; 98:e16599. [PMID: 31335742 PMCID: PMC6708833 DOI: 10.1097/md.0000000000016599] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Chylothorax after lobectomy is common, lacking reliable preventive measures. Octreotide is widely used for treatment of chyle leakage, but its role in preventing chylothorax has not been estimated. The aim of this study was to evaluate whether prophylactic octreotide could reduce the incidence of postoperative chylothorax.Patients who underwent lobectomy for lung cancer from January 2016 to September 2018 were retrospectively reviewed. The cases in prophylactic group received octreotide 1 day before the surgery until removal of chest tubes, while those in the control group did not use it unless the diagnosis of chylothorax.A total of 379 patients were enrolled, with 190 patients in control and 189 cases in prophylactic group. Octreotide was well tolerated in patients who received this agent. No 30-day mortality was indicated. Seven cases in control (3.7%, 7/190) and 3 cases in prophylactic group (1.6%, 3/189) with chylothorax were observed (P = .337). The patients in prophylactic group showed shorter duration of chest drainage ([3.6 ± 1.6] days vs [4.1 ± 2.0] days, P = .006) and reduced drainage volume ([441.8 ± 271.1] mL vs [638.7 ± 463.3] mL, P < .001). In addition, they showed similar stations and numbers of dissected lymph nodes, surgery-related complications, and postoperative hospital stay. Besides, 11 (5.8%, 11/190) patients in control and 6 (3.2%, 6/189) cases in the prophylactic group were readmitted for pleural effusion needing reinsertion of chest tubes (P = .321). Moreover, multivariable logistic analysis showed that induction therapy (odds ratio [OR] =12.03; 95% confidence interval [CI] 3.15-46.03, P < .001) was a risk factor, while high-volume experience of the surgeon (OR = 0.23; 95% CI 0.06-0.97, P = .045) was a preventive factor of surgery-related chylothorax. Additionally, prophylactic octreotide (OR = 0.18; 95% CI 0.11-0.28, P < .001) and perioperative low-fat diet (OR = 0.46; 95% CI 0.29-0.73, P = .001) were negatively associated with the drainage volume of pleural effusion. Furthermore, high-volume experience of the surgeon (OR = 6.03; 95% CI 1.30-27.85, P = .021) and induction therapy (OR = 8.87; 95% CI 2.97-26.48, P < .001) were risk factors of unplanned readmission.Prophylactic octreotide does not reduce the incidence of postoperative chylothorax or unplanned readmission following anatomic lobectomy. The routine application of octreotide should not be recommended. High-quality trials are required to validate these findings.
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Affiliation(s)
- Chu Zhang
- Department of Thoracic Surgery, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing
| | - Hui Zhang
- Department of Thoracic Surgery, Xuzhou Central Hospital Affiliated to Southeast University, Xuzhou, China
| | - Wenbin Wu
- Department of Thoracic Surgery, Xuzhou Central Hospital Affiliated to Southeast University, Xuzhou, China
| | - Dong Liu
- Department of Thoracic Surgery, Xuzhou Central Hospital Affiliated to Southeast University, Xuzhou, China
| | - Dunpeng Yang
- Department of Thoracic Surgery, Xuzhou Central Hospital Affiliated to Southeast University, Xuzhou, China
| | - Miao Zhang
- Department of Thoracic Surgery, Xuzhou Central Hospital Affiliated to Southeast University, Xuzhou, China
| | - Cuntao Lu
- Department of Thoracic Surgery, Xuzhou Central Hospital Affiliated to Southeast University, Xuzhou, China
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Kuroda H, Sugita Y, Watanabe K, Nakanishi K, Sakakura N, Naito Y, Sakao Y. Successful postoperative recovery management after thoracoscopic lobectomy and segmentectomy using an ERAS-based protocol of immediate ice cream intake and early ambulation: a 3-year study. Cancer Manag Res 2019; 11:4201-4207. [PMID: 31190989 PMCID: PMC6511617 DOI: 10.2147/cmar.s195219] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 03/12/2019] [Indexed: 12/16/2022] Open
Abstract
Background: Enhanced recovery after surgery (ERAS) protocols are well known for reducing post-operative complications, facilitating early recovery and reducing hospitalization. In this study, we developed ERAS protocols involving immediate ice cream intake for checking postoperative chylothorax and subsequent early ambulation in order to investigate whether these methods have postoperative benefits. Methods: We retrospectively evaluated 500 patients who underwent thoracoscopic segmentectomy and/or lobectomy (TSL) between January 2014 and September 2017. The patients were divided into two groups: 271 patients for Phase I and 229 for Phase II. Ice cream intake commenced during Phase I. Phase I patients were made to walk on the following day, whereas Phase II ambulate within 4 hrs after immediate ice-cream intake. Results: The mean ice cream intake was significantly higher in Phase II than in Phase I (81.6% vs 56.1%). In Phase II, 91.2% and 94.0% were able to ambulate within 4 and 6 hrs, respectively. Minor postoperative complications (Clavien–Dindo I–II classification) were lower in Phase II (3.1%) than in Phase I (10.4%); however, we found no statistical significance (p=0.08). Multivariate analysis showed that ice cream intake and removal of chest drainage tube within 4–6 hrs significantly contributed to the reduction of hospitalization to ≤3 postoperative days (p=0.03 and p<0.01). Conclusions: The results of this study suggested that our ERAS protocol represented by immediate ice cream intake, and early ambulation is feasible and can help in reducing postoperative complications, chest drainage duration, and hospitalization after TSL.
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Affiliation(s)
| | | | - Kiyoe Watanabe
- Department of Nursing, Aichi Cancer Center Hospital, Nagoya, Japan
| | | | | | - Yumiko Naito
- Department of Nursing, Aichi Cancer Center Hospital, Nagoya, Japan
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Zhang C, Zhang RM, Pan Y, Wu WB, Zhang M. Late-onset chylothorax during chemotherapy after lobectomy for lung cancer: A case report and review of the literature. Medicine (Baltimore) 2019; 98:e15909. [PMID: 31145354 PMCID: PMC6708882 DOI: 10.1097/md.0000000000015909] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Chylothorax is usually diagnosed within a few days after lobectomy. Late-onset chylothorax following trauma or thoracic surgery is rare but potentially lethal, lacking reliable preventive methods. PATIENT CONCERNS A 54-year-old male patient complained of dyspnea during adjuvant chemotherapy on the 35th postoperative day after right middle lobectomy and systemic lymph node dissection (SLND) for lung cancer. His computed tomography indicated massive pleural effusion filling in the right chest cavity. DIAGNOSES The patient was primarily diagnosed as late-onset chylothorax, without definite evidence to exclude spontaneous chylous leakage. INTERVENTIONS Uniportal video-assisted thoracoscopic thoracic duct ligation (TDL) was performed for him, as conservative treatment using octreotide with fat-free diet turned out to be ineffective. OUTCOMES His pleural effusion was gradually diminished after reoperation, and the patient was discharged 9 days after TDL. LESSONS Postoperative late-onset or spontaneous chylothorax should be kept in mind after pulmonary resection and SLND, and the exclusion of chylous leakage could be considered as a precondition of chest tube removal.
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Affiliation(s)
- Chu Zhang
- Department of Thoracic Surgery, Shaoxing People's Hospital (Shaoxing Hospital of Zhejiang University), Shaoxing
| | - Rui-Mei Zhang
- Department of General Surgery, Xuzhou Infectious Disease Hospital
| | - Yong Pan
- Department of General Surgery, Xuzhou Infectious Disease Hospital
| | - Wen-Bin Wu
- Department of Thoracic Surgery, Xuzhou Central Hospital Affiliated to Southeast University, Xuzhou, China
| | - Miao Zhang
- Department of Thoracic Surgery, Xuzhou Central Hospital Affiliated to Southeast University, Xuzhou, China
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25
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Abstract
PURPOSE OF REVIEW Guidelines for enhanced recovery after surgery (ERAS) have recently been published for lung surgery. Although some of the recommendations are generic or focused on anesthetic and nursing care, other recommendations are more specific to a thoracic surgeon's practice. The present review concentrates on the surgical approach, optimal chest drain management, and the importance of early mobilization. RECENT FINDINGS Most lung cancer resections are still performed via an open thoracotomy approach. If a thoracotomy is to be used, a muscle-sparing approach may result in reduced pain and better postoperative function. Sparing of the intercostal bundle also reduces pain. There is now evidence that minimally invasive surgery for early lung cancer results in superior patient outcomes. Postoperatively, single chest tubes should be used without the routine application of external suction. Digital drainage systems are more reliable and may produce superior outcomes. Conservative chest drain removal policies are unnecessary and impair patient recovery. Early mobilization protocols should be instigated to reduce postoperative complications. SUMMARY The use of ERAS after lung surgery has the potential to improve patient outcomes. Although specific surgical elements are in the minority, thoracic surgeons should be involved in all aspects of perioperative care as part of the wider multidisciplinary team.
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Chevrollier GS, Nemecz AK, Devin C, Go KV, Yi M, Keith SW, Cowan SW, Evans NR. Early Discharge Does Not Increase Readmission Rates After Minimally Invasive Anatomic Lung Resection. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2019; 14:218-226. [DOI: 10.1177/1556984519836821] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Objective Enhanced recovery pathways reduce length of stay and costs following lung resection. However, many fear that early discharge may lead to increased hospital readmissions. In this study, we aimed to determine whether early discharge was associated with increased readmission following anatomic lung resection. Methods Using the lung resection database approved by our institutional review board, we identified all patients undergoing minimally invasive lobectomy and segmentectomy between January 2010 and March 2017 at our institution, where an enhanced recovery pathway is well established. Thirty-day readmissions were compared between patients with short- and average length of stay, defined as 1 to 2 days and 3 to 5 days, respectively. Multivariable logistic regression analysis of patients matched by propensity scores was performed to determine odds of 30-day readmission for each group. Significance was set at P < 0.05. Results A total of 296 patients met inclusion criteria. Unadjusted analysis revealed a 3-fold increased rate of readmission in the group with average length of stay (9%, n = 12) versus the group with short length of stay (3%, n = 5; P < 0.01). At baseline, patients with average length of stay had increased rates of preoperative chemotherapy (13%, n = 18 vs. 4%, n = 6; P < 0.01) and radiation (12%, n = 16 vs. 3%, n = 5). Patients with average length of stay also had higher rates of lobectomy (95%, n = 127 vs. 86%, n = 140; P = 0.02) and postoperative complications (31%, n = 41 vs. 4%, n = 7; P < 0.01). On multivariable analysis, patients with average length of stay had a 2.3-fold greater odds of readmission, which was not statistically significant (OR = 2.33; 95% CI, 0.60 to 9.02; P = 0.22). Conclusions Early discharge following minimally invasive anatomic lung resection does not increase the risk of hospital readmission in patients treated within an enhanced recovery pathway.
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Affiliation(s)
- Guillaume S. Chevrollier
- Department of Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Amanda K. Nemecz
- Department of Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Courtney Devin
- Department of Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Kendrick V. Go
- Department of Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Misung Yi
- Department of Pharmacology and Experimental Therapeutics, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Scott W. Keith
- Department of Pharmacology and Experimental Therapeutics, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Scott W. Cowan
- Department of Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Nathaniel R. Evans
- Department of Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
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Comacchio GM, Monaci N, Verderi E, Schiavon M, Rea F. Enhanced recovery after elective surgery for lung cancer patients: analysis of current pathways and perspectives. J Thorac Dis 2019; 11:S515-S522. [PMID: 31032070 DOI: 10.21037/jtd.2019.01.99] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The concept of enhanced recovery after surgery (ERAS), initially introduced in the field of colorectal surgery, has been developed in order to optimize the postoperative course. In recent years the number of authors analyzing the role of ERAS in lung cancer surgery is increasing, highlighting several interventions with positive effects on the postoperative course. Yet it is still difficult to draw definite conclusions and specific guidelines, as most of these studies largely differ for their methodological aspects and study populations. Herein we focus on the key elements of each single intervention, trying to identify what we can apply in a common pathway, and which aspects are still to be evaluated for the validation of an ERAS program.
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Affiliation(s)
- Giovanni Maria Comacchio
- Thoracic Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Nicola Monaci
- Thoracic Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Enrico Verderi
- Thoracic Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Marco Schiavon
- Thoracic Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Federico Rea
- Thoracic Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
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Batchelor TJP, Rasburn NJ, Abdelnour-Berchtold E, Brunelli A, Cerfolio RJ, Gonzalez M, Ljungqvist O, Petersen RH, Popescu WM, Slinger PD, Naidu B. Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced Recovery After Surgery (ERAS®) Society and the European Society of Thoracic Surgeons (ESTS). Eur J Cardiothorac Surg 2018; 55:91-115. [DOI: 10.1093/ejcts/ezy301] [Citation(s) in RCA: 461] [Impact Index Per Article: 76.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 07/31/2018] [Indexed: 02/06/2023] Open
Affiliation(s)
- Timothy J P Batchelor
- Department of Thoracic Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Neil J Rasburn
- Department of Anaesthesia, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | | | - Robert J Cerfolio
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, NY, USA
| | - Michel Gonzalez
- Division of Thoracic Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - René H Petersen
- Department of Thoracic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Wanda M Popescu
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
| | - Peter D Slinger
- Department of Anesthesia, University Health Network – Toronto General Hospital, Toronto, ON, Canada
| | - Babu Naidu
- Department of Thoracic Surgery, Heart of England NHS Foundation Trust, Birmingham, UK
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Gonzalez M, Abdelnour-Berchtold E, Perentes JY, Doucet V, Zellweger M, Marcucci C, Ris HB, Krueger T, Gronchi F. An enhanced recovery after surgery program for video-assisted thoracoscopic surgery anatomical lung resections is cost-effective. J Thorac Dis 2018; 10:5879-5888. [PMID: 30505496 DOI: 10.21037/jtd.2018.09.100] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Background Enhanced recovery after surgery (ERAS) programs have been reported to decrease complications and shorten hospital stays after lung resections, but their implementation requires time and financial investment with dedicated staff. The aim of this study was to evaluate the clinical and economic outcomes of video-assisted thoracoscopic surgery (VATS) anatomical pulmonary resections before and after implementation of an ERAS program. Methods The first 50 consecutive patients undergoing VATS lobectomy or segmentectomy for malignancy after implementation of an ERAS program were compared with 50 consecutive patients treated before its introduction. The ERAS protocol included preoperative counseling, reduced preoperative fasting with concomitant carbohydrate loading, avoidance of premedication, standardized surgery, anesthesia and postoperative analgesia, early removal of chest tube, nutrition and mobilization. Length of stay, readmissions and cardio-pulmonary complications within 30 days were compared. Total costs were collected for each patient and a cost-minimization analysis integrating ERAS-specific costs was performed. Results Both groups were similar in terms of demographics and surgical characteristics. The ERAS group had significantly shorter postoperative length of stay (median: 4 vs. 7 days, P<0.0001), decreased pulmonary complications (16% vs. 38%; P=0.01) and decreased overall post-operative complications (24% vs. 48%, P=0.03). One patient in each group was readmitted and there was no 30-day mortality. ERAS-specific costs were calculated at €729 per patient including the clinical nurse and database costs. Average total hospitalization costs were significantly lower in ERAS group (€15,945 vs. €20,360, P<0.0001), mainly due to lower costs during the post-operative period (€7,449 vs. €11,454, P<0.0001) in comparison with the intra-operative period (€8,496 vs. €8,906, P=0.303). Cost-minimization analysis showed a mean saving in the ERAS group of €3,686 per patient. Conclusions An ERAS program for VATS anatomical lung resection is cost-effective and is associated with a lower complication rate and a shorter postoperative hospitalization.
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Affiliation(s)
- Michel Gonzalez
- Service of Thoracic Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | | | - Jean Yannis Perentes
- Service of Thoracic Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Valérie Doucet
- Service of Thoracic Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Mathieu Zellweger
- Service of Thoracic Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Carlos Marcucci
- Service of Anesthesiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Hans-Beat Ris
- Service of Thoracic Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Thorsten Krueger
- Service of Thoracic Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Fabrizio Gronchi
- Service of Anesthesiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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30
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Safety of Next Day Discharge After Lobectomy: Have We Broken the Speed Limit? Ann Thorac Surg 2018; 106:998-1001. [DOI: 10.1016/j.athoracsur.2018.05.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 05/01/2018] [Accepted: 05/14/2018] [Indexed: 11/18/2022]
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Abstract
PURPOSE OF REVIEW Both surgical workload and the age of those patients being considered for radial pulmonary resection are increasing. Enhanced recovery programmes are now well established in most surgical disciplines and are increasingly reported in thoracic procedures. This review will discuss the relevant principles of these programmes as applied to an increasing elderly population. RECENT FINDINGS Elderly patients undergoing less radial surgical resections without lymphadenectomy have comparable outcomes to those undergoing classical curative treatment. Patients require careful assessment and self-reported quality of life metrics or function may be a better marker of outcome than static measures such as lung function. Hypotension, low values for bispectral index and low anaesthetic gas mean alveolar concentration values are common and independent predictors of mortality in the elderly. Paravertebral blockade is preferred to epidural anaesthesia because of a more favourable side-effect profile and comparable efficacy. As yet no robust work has examined the efficacy of an integrated enhanced recovery programme in thoracic surgery. SUMMARY Elderly patients are suitable for enhanced recovery programmes but these must be tailored to individual circumstance. Further work is required to comprehensively assess their value in a modern healthcare setting.
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Martin LW, Sarosiek BM, Harrison MA, Hedrick T, Isbell JM, Krupnick AS, Lau CL, Mehaffey JH, Thiele RH, Walters DM, Blank RS. Implementing a Thoracic Enhanced Recovery Program: Lessons Learned in the First Year. Ann Thorac Surg 2018; 105:1597-1604. [DOI: 10.1016/j.athoracsur.2018.01.080] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 01/24/2018] [Accepted: 01/26/2018] [Indexed: 01/23/2023]
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34
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Brunelli A, Imperatori A, Droghetti A. Enhanced recovery pathways version 2.0 in thoracic surgery. J Thorac Dis 2018; 10:S497-S498. [PMID: 29629195 DOI: 10.21037/jtd.2017.12.81] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Andrea Imperatori
- Department of Thoracic Surgery, St. James's University Hospital, Leeds, UK
| | - Andrea Droghetti
- Department of Thoracic Surgery, Carlo Poma Hospital, Mantova, Italy
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35
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The impact of enhanced recovery after surgery (ERAS) protocol compliance on morbidity from resection for primary lung cancer. J Thorac Cardiovasc Surg 2018; 155:1843-1852. [DOI: 10.1016/j.jtcvs.2017.10.151] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 10/12/2017] [Accepted: 10/24/2017] [Indexed: 02/07/2023]
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Bertani A, Ferrari P, Terzo D, Russo E, Burgio G, De Monte L, Raffaele F, Droghetti A, Crisci R. A comprehensive protocol for physiokinesis therapy and enhanced recovery after surgery in patients undergoing video-assisted thoracoscopic surgery lobectomy. J Thorac Dis 2018; 10:S499-S511. [PMID: 29629196 DOI: 10.21037/jtd.2018.02.55] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Video-assisted thoracoscopic surgery (VATS) lobectomy has recently been adopted as the gold standard surgical option for the treatment of early stage non-small cell lung cancer. Enhanced recovery after surgery (ERAS) is being progressively adopted in thoracic surgery to improve the postoperative outcomes. Even if the benefits of ERAS are universally accepted, to date a standardized and uniform approach has not been described in the medical literature. The Italian VATS group has recently proposed to include in the VATS lobectomy database a structured protocol for ERAS. Methods The ERAS section of the Italian VATS group is proposing a comprehensive ERAS protocol within the VATS lobectomy database, allowing the prospective collection of a dedicated set of data. Separate sections of the protocol are dedicated to different topics of ERAS. This study is specifically dedicated to the section of physiokinesis therapy. The medical literature will be extensively reviewed and a physiotherapy (PT) protocol of ERAS will be presented and discussed. A seta of structured clinical pathways will also be suggested for adoption in the VATS Group database. Discussion Pre- and post-operative adoption of an ERAS protocol in patients undergoing VATS lobectomy may promote an improved post-operative course, a shorter hospital stay and an overall more comfortable patients' experience. The mainstays of a physiokinesis therapy ERAS protocol are patients' education, constant physical and respiratory therapy sessions, and adoption of adequate devices. Although many studies have investigated the usefulness of physical and respiratory physiokinesis therapy, a comprehensive ERAS protocol for VATS lobectomy patients has not yet been described. The proposed ERAS platform, adopted by the VATS Group database, will contribute to a prospective data collection and allow a scientific analysis of the results.
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Affiliation(s)
- Alessandro Bertani
- Division of Thoracic Surgery and Lung Transplantation, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS ISMETT - UPMC, Palermo, Italy
| | - Paolo Ferrari
- Division of Thoracic Surgery, A. Businco Cancer Center, Ospedale Brotzu, Cagliari, Italy
| | - Danilo Terzo
- Rehabilitation Services, IRCCS ISMETT - UPMC, Palermo, Italy
| | - Emanuele Russo
- Division of Thoracic Surgery and Lung Transplantation, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS ISMETT - UPMC, Palermo, Italy
| | - Gaetano Burgio
- Department of Anesthesia and CCM, IRCCS ISMETT - UPMC, Palermo, Italy
| | - Lavinia De Monte
- Division of Thoracic Surgery and Lung Transplantation, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS ISMETT - UPMC, Palermo, Italy
| | - Francesco Raffaele
- Division of Thoracic Surgery and Lung Transplantation, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS ISMETT - UPMC, Palermo, Italy
| | | | - Roberto Crisci
- Division of Thoracic Surgery, University of L'Aquila, L'Aquila, Italy
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Kumar R, Donahue JM. Editorial for economic impact of an enhanced recovery pathway for lung resection. J Thorac Dis 2018; 10:7-9. [PMID: 29600009 DOI: 10.21037/jtd.2017.12.73] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Rajat Kumar
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - James M Donahue
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
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Paci P, Madani A, Lee L, Mata J, Mulder DS, Spicer J, Ferri LE, Feldman LS. Economic Impact of an Enhanced Recovery Pathway for Lung Resection. Ann Thorac Surg 2017; 104:950-957. [PMID: 28778343 DOI: 10.1016/j.athoracsur.2017.05.085] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 05/24/2017] [Accepted: 05/30/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Multimodal enhanced recovery pathways (ERP) improve clinical outcomes and hospital length of stay for patients undergoing lung resection. However, data supporting their economic impact is lacking. This study evaluated the effect of an ERP on costs of lung resection. METHODS Adult patients undergoing elective lung resection from August 2011 to August 2013 at a single university-affiliated institution were prospectively recruited. Pneumonectomies and extended resections were excluded. Beginning in September 2012, patients were enrolled in a multimodal ERP. Outcomes were recorded until 90 days after discharge. Total costs from institutional, health care system, and societal perspectives are reported in 2016 Canadian dollars, with uncertainty expressed as 95% confidence intervals derived using bootstrapped estimates (10,000 repetitions). RESULTS The study included 133 patients (conventional care: n = 58; ERP: n = 75). Patient and operative characteristics were similar between the groups. The ERP group had shorter median (interquartile range) length of stay (4 [3 to 6] days vs 6 [4 to 9] days, p < 0.01), decreased total complications (32% vs 52%, p = 0.02), and decreased pulmonary complications (16% vs 34%, p = 0.01), with no difference in readmissions. After discharge, there was a trend towards less caregiver burden for the ERP group (53 ± 90 hours vs 101 ± 252 hours, p = 0.17). Overall societal costs were lower in the ERP group (mean difference per patient: -$4,396 Canadian; 95% confidence interval -$8,674 to $618 Canadian). CONCLUSIONS A multidisciplinary ERP is associated with improved clinical outcomes and societal cost savings compared with conventional perioperative management for elective lung resection.
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Affiliation(s)
- Philippe Paci
- Department of Surgery, McGill University, Montreal, Quebec, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University, Montreal, Quebec, Canada
| | - Amin Madani
- Department of Surgery, McGill University, Montreal, Quebec, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University, Montreal, Quebec, Canada
| | - Lawrence Lee
- Department of Surgery, McGill University, Montreal, Quebec, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University, Montreal, Quebec, Canada
| | - Juan Mata
- Department of Surgery, McGill University, Montreal, Quebec, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University, Montreal, Quebec, Canada
| | - David S Mulder
- Department of Surgery, McGill University, Montreal, Quebec, Canada; Division of Thoracic Surgery, McGill University, Montreal, Quebec, Canada
| | - Jonathan Spicer
- Department of Surgery, McGill University, Montreal, Quebec, Canada; Division of Thoracic Surgery, McGill University, Montreal, Quebec, Canada
| | - Lorenzo E Ferri
- Department of Surgery, McGill University, Montreal, Quebec, Canada; Division of Thoracic Surgery, McGill University, Montreal, Quebec, Canada
| | - Liane S Feldman
- Department of Surgery, McGill University, Montreal, Quebec, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University, Montreal, Quebec, Canada.
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Enhanced recovery pathway versus standard care in patients undergoing video-assisted thoracoscopic lobectomy. J Thorac Cardiovasc Surg 2017; 154:2084-2090. [PMID: 28728783 DOI: 10.1016/j.jtcvs.2017.06.037] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 06/09/2017] [Accepted: 06/16/2017] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The objective of this study was to compare outcomes after video-assisted thoracoscopic lobectomy or segmentectomy before and after introduction of an enhanced recovery program. METHODS Data from 600 patients undergoing video-assisted lobectomy or segmentectomy between April 2014 and January 2017 were analyzed. A comparative analysis was performed between patients undergoing operation before (365 patients) and after (235 patients) the start of the enhanced recovery program. The incidence of cardiopulmonary complications and 30-day and 90-day mortality, postoperative length of stay, and 30-day and 90-day hospital readmission rates were evaluated. Risk-adjusted cardiopulmonary morbidity and 30-day mortality were calculated for each group and compared. RESULTS The 2 groups had a similar postoperative length of stay (enhanced recovery pathway median 5 days vs pre-enhanced recovery pathway 4, P = .44), cardiopulmonary complication rates (enhanced recovery pathway 22.6% vs pre-enhanced recovery pathway 22.4%, P = .98), 30-day mortality rates (enhanced recovery pathway 3.8% vs pre-enhanced recovery pathway 2.2%, P = .31), and 90-day mortality rates (enhanced recovery pathway 4.7% vs pre-enhanced recovery pathway 3.0%, P = .37). No differences were noted in terms of 30-day (enhanced recovery pathway 7.2% vs pre-enhanced recovery pathway 7.4%, P = .94) or 90-day readmission rates (enhanced recovery pathway 9.8% vs pre-enhanced recovery pathway 12.3%, P = .34). The risk-adjusted cardiopulmonary morbidity rates were similar in the 2 periods (P = .76), whereas the risk-adjusted 30-day mortality was higher in the enhanced recovery pathway period compared with the pre-enhanced recovery pathway mortality (P = .0004). CONCLUSIONS We found no benefit conferred by the enhanced recovery program on outcomes such as cardiopulmonary complications, 30- and 90-day mortality, length of stay, and readmissions. Enhanced recovery program elements may be insufficiently different than previous standards of perioperative care to confer detectable benefits in our settings.
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Salati M, Brunelli A, Xiumè F, Monteverde M, Sabbatini A, Tiberi M, Pompili C, Palloni R, Refai M. Video-assisted thoracic surgery lobectomy does not offer any functional recovery advantage in comparison to the open approach 3 months after the operation: a case matched analysis†. Eur J Cardiothorac Surg 2017; 51:1177-1182. [DOI: 10.1093/ejcts/ezx013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 01/03/2017] [Indexed: 11/13/2022] Open
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Rocco G, Morabito A, Leone A, Muto P, Fiore F, Budillon A. Management of non-small cell lung cancer in the era of personalized medicine. Int J Biochem Cell Biol 2016; 78:173-179. [DOI: 10.1016/j.biocel.2016.07.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 07/11/2016] [Accepted: 07/13/2016] [Indexed: 01/20/2023]
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New Fast-Track Concepts in Thoracic Surgery: Anesthetic Implications. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0152-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Refai M, Salati M, Tiberi M, Sabbatini A, Gentili P. Clinical pathway for thoracic surgery in an Italian centre. J Thorac Dis 2016; 8:S23-8. [PMID: 26941966 DOI: 10.3978/j.issn.2072-1439.2015.12.34] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Clinical care pathways are developed to standardize postoperative patient care and the main impetus is to improve quality of care, decrease variation in care and reduce costs. We report the clinical pathway of care adopted at our centre since the introduction of Uniportal VATS program for major lung resections.
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Affiliation(s)
- Majed Refai
- 1 Division of Thoracic Surgery, Ospedali Riuniti Ancona, Ancona, Italy ; 2 Section of Minimally Invasive Thoracic Surgery, Division of Thoracic Surgery, Ospedali Riuniti Ancona, Ancona, Italy ; 3 Anesthesia and Intensive Care Unit, Ospedali Riuniti Ancona, Ancona, Italy
| | - Michele Salati
- 1 Division of Thoracic Surgery, Ospedali Riuniti Ancona, Ancona, Italy ; 2 Section of Minimally Invasive Thoracic Surgery, Division of Thoracic Surgery, Ospedali Riuniti Ancona, Ancona, Italy ; 3 Anesthesia and Intensive Care Unit, Ospedali Riuniti Ancona, Ancona, Italy
| | - Michela Tiberi
- 1 Division of Thoracic Surgery, Ospedali Riuniti Ancona, Ancona, Italy ; 2 Section of Minimally Invasive Thoracic Surgery, Division of Thoracic Surgery, Ospedali Riuniti Ancona, Ancona, Italy ; 3 Anesthesia and Intensive Care Unit, Ospedali Riuniti Ancona, Ancona, Italy
| | - Armando Sabbatini
- 1 Division of Thoracic Surgery, Ospedali Riuniti Ancona, Ancona, Italy ; 2 Section of Minimally Invasive Thoracic Surgery, Division of Thoracic Surgery, Ospedali Riuniti Ancona, Ancona, Italy ; 3 Anesthesia and Intensive Care Unit, Ospedali Riuniti Ancona, Ancona, Italy
| | - Paolo Gentili
- 1 Division of Thoracic Surgery, Ospedali Riuniti Ancona, Ancona, Italy ; 2 Section of Minimally Invasive Thoracic Surgery, Division of Thoracic Surgery, Ospedali Riuniti Ancona, Ancona, Italy ; 3 Anesthesia and Intensive Care Unit, Ospedali Riuniti Ancona, Ancona, Italy
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Pompili C, Miserocchi G. Air leak after lung resection: pathophysiology and patients' implications. J Thorac Dis 2016; 8:S46-54. [PMID: 26941970 DOI: 10.3978/j.issn.2072-1439.2015.11.08] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Protocols for the management of air leaks are critical aspects in the postoperative course of patients following lung resections. Many investigations in the last decade are focusing on the chest tube modalities or preventative measures, however, little is known about the pathophysiology of air leak and the patient perception of this common complication. This review concentrates on understanding the reasons why a pulmonary parenchyma may start to leak or an air leak may be longer than others. Experimental works support the notion that lung overdistension may favor air leak. These studies may represent the basis of future investigations. Furthermore, the standardization of nomenclature in the field of pleural space management and the creation of novel air leak scoring systems have contributed to improve the knowledge among thoracic surgeons and facilitate the organization of trials on this matter. We tried to summarize available evidences about the patient perception of a prolonged air leak and about what would be useful for them in order to prevent worsening of their quality of life. Future investigations are warranted to better understand the pathophysiologic mechanisms responsible of prolonged air leak in order to define tailored treatments and protocols. Improving the care at home with web-based telemonitoring or real time connected chest drainage may in a future improve the quality of life of the patients experience this complication and also enhance hospital finances.
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Affiliation(s)
- Cecilia Pompili
- 1 Division of Thoracic Surgery, St James' University Hospital, Leeds, UK ; 2 Department of Health Sciences, University of Milano-Bicocca, Milano, Italy
| | - Giuseppe Miserocchi
- 1 Division of Thoracic Surgery, St James' University Hospital, Leeds, UK ; 2 Department of Health Sciences, University of Milano-Bicocca, Milano, Italy
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Fiore JF, Bejjani J, Conrad K, Niculiseanu P, Landry T, Lee L, Ferri LE, Feldman LS. Systematic review of the influence of enhanced recovery pathways in elective lung resection. J Thorac Cardiovasc Surg 2016; 151:708-715.e6. [DOI: 10.1016/j.jtcvs.2015.09.112] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 09/01/2015] [Accepted: 09/28/2015] [Indexed: 11/29/2022]
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Puri V, Patel AP, Crabtree TD, Bell JM, Broderick SR, Kreisel D, Krupnick AS, Patterson GA, Meyers BF. Unexpected readmission after lung cancer surgery: A benign event? J Thorac Cardiovasc Surg 2015; 150:1496-1504, 1505.e1-5; discussion 1504-5. [PMID: 26410004 DOI: 10.1016/j.jtcvs.2015.08.067] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 08/06/2015] [Accepted: 08/11/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The study objective was to study the incidence, predictors, and implications of unanticipated early postoperative readmission after lung resection for non-small cell lung cancer. METHODS Patients undergoing surgery for clinical stage I to III non-small cell lung cancer were abstracted from the National Cancer Database. Regression models were fitted to identify predictors of 30-day readmission and to study the association of unplanned readmission with 30-day and long-term survival. RESULTS Between 1998 and 2010, 129,893 patients underwent resection for stage I to III non-small cell lung cancer. Of these, 5624 (4.3%) were unexpectedly readmitted within 30 days. In a multivariate regression model, increasing age, male gender, preoperative radiation, and pneumonectomy (odds ratio, 1.77; 95% confidence interval, 1.56-2.00) were associated with unexpected readmissions. Longer index hospitalization and higher Charlson comorbidity score were also predictive of readmission. The 30-day mortality for readmitted patients was higher (3.9% vs 2.8%), as was the 90-day mortality (7.0% vs 3.3%, both P < .001). In a multivariate Cox proportional hazards model of long-term survival, increasing age, higher Charlson comorbidity score, and higher pathologic stage (hazard ratio, for stage III 1.81; 95% confidence interval, 1.42-2.29) were associated with greater risk of mortality. Unplanned readmission was independently associated with a higher risk of long-term mortality (hazard ratio, 1.40; 95% confidence interval, 1.34-1.47). The median survival for readmitted patients was significantly shorter (38.7 vs 58.5 months, P < .001). CONCLUSIONS Unplanned readmissions are not rare after resection for non-small cell lung cancer. Such events are associated with a greater risk of short- and long-term mortality. With the renewed national focus on readmissions and potential financial disincentives, greater resource allocation is needed to identify patients at risk and develop measures to avoid the associated adverse outcomes.
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Affiliation(s)
- Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo.
| | - Aalok P Patel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Traves D Crabtree
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Jennifer M Bell
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Stephen R Broderick
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - A Sasha Krupnick
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
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Madani A, Fiore JF, Wang Y, Bejjani J, Sivakumaran L, Mata J, Watson D, Carli F, Mulder DS, Sirois C, Ferri LE, Feldman LS. An enhanced recovery pathway reduces duration of stay and complications after open pulmonary lobectomy. Surgery 2015; 158:899-908; discussion 908-10. [PMID: 26189953 DOI: 10.1016/j.surg.2015.04.046] [Citation(s) in RCA: 118] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 03/31/2015] [Accepted: 04/05/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Few studies have investigated the effectiveness of enhanced recovery pathways (ERP) for lung resection. This study estimates the impact of an ERP for lobectomy on duration of stay, complications, and readmissions. METHODS Patients undergoing open lobectomy were identified from an OR database between 2011 and 2013. Beginning September 2012, all patients were managed according to a 4-day multidisciplinary ERP with written daily patient education treatment plans, multimodal analgesia, early diet, structured mobilization and standardized drain management. Pre-pathway (PRE) and post-pathway (POST) patients were compared in terms of duration of stay, complications, and readmissions. RESULTS We identified 234 patients (PRE, 127; POST, 107). Groups were similar with respect to age, gender, American Society of Anesthesiologists score, and baseline pulmonary function. Compared with the PRE group, the POST group had decreased duration of stay (median, 6 [interquartile range (IQR), 5-7] vs 7 [6-10] days; P < .05), total complications (40 [37%] vs 64 [50%]; P < .05), urinary tract infections (3 [3%] vs 15 [12%]; P < .05), and chest tube duration (median, 4 [IQR, 3-6] vs 5 [4-7] days; P < .05), with no difference in readmissions (7 [7%] vs 6 [5%]; P < .05) or chest tube reinsertion (4 [4%] vs 6 [5%]; P < .05). Decreased duration of stay was driven by patients without complications (median, 5 [IQR, 4-6] vs 6 [5-7] days; P < .05). CONCLUSION Implementation of a multimodal ERP for lobectomy was associated with decreased duration of stay and complications with no difference in readmissions.
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Affiliation(s)
- Amin Madani
- Department of Surgery, McGill University, Montreal, Quebec, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University, Montreal, Quebec, Canada
| | - Julio F Fiore
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University, Montreal, Quebec, Canada
| | - Yifan Wang
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University, Montreal, Quebec, Canada
| | - Jimmy Bejjani
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University, Montreal, Quebec, Canada
| | - Lojan Sivakumaran
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University, Montreal, Quebec, Canada
| | - Juan Mata
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University, Montreal, Quebec, Canada
| | - Debbie Watson
- Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Franco Carli
- Department of Anaesthesia, McGill University, Montreal, Quebec, Canada
| | - David S Mulder
- Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Christian Sirois
- Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Lorenzo E Ferri
- Department of Surgery, McGill University, Montreal, Quebec, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University, Montreal, Quebec, Canada
| | - Liane S Feldman
- Department of Surgery, McGill University, Montreal, Quebec, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University, Montreal, Quebec, Canada.
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Bjerregaard LS, Jensen K, Petersen RH, Hansen HJ. Routinely obtained chest X-rays after elective video-assisted thoracoscopic surgery can be omitted in most patients; a retrospective, observational study. Gen Thorac Cardiovasc Surg 2015; 63:465-71. [PMID: 26007694 DOI: 10.1007/s11748-015-0560-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 05/13/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To investigate whether the use of routinely obtained chest X-rays is necessary after elective VATS. METHODS We retrospectively reviewed 1097 chest X-rays obtained routinely after elective VATS, performed in patients aged over 15 years during an 18-month period. VATS procedures were divided into three groups according to the degree of pulmonary resection. The chest X-rays (obtained anterior-posterior in one plane with the patient in the supine position) were categorized as abnormal if showing pneumothorax >5 cm, possible intra-thoracic bleeding and/or a displaced chest tube. Medical charts were reviewed for all patients with abnormal chest X-rays to see if an intervention was made based on the X-ray. In case of an intervention, detailed clinical data were collected. RESULTS 44 of 1097 chest X-rays (4.0 %) were abnormal and 10 of these X-rays (0.9 %) led to a clinical intervention. Proportions of abnormal chest X-rays were unequally distributed between groups (p < 0.001), whereas the number of interventions was not (p = 0.43). Of the ten chests X-rays that led to an intervention, three showed possible intra-thoracic bleeding, six showed pneumothorax >5 cm and one showed a kinked chest tube. All the patients with possible intra-thoracic bleeding were re-explored in the operating theatre the same day. CONCLUSIONS Only 10 of 1097 chest X-rays (0.9 %) obtained routinely after elective VATS procedures led to a clinical intervention, supporting the abandon of routine chest X rays in favour of a more individualised approach, based on clinical observations.
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Affiliation(s)
- Lars S Bjerregaard
- Department of Cardiothoracic Anaesthesia and Section for Surgical Pathophysiology, Rigshospitalet Dept. 7621, Copenhagen University Hospital, Copenhagen, Denmark,
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Assi R, Wong DJ, Boffa DJ, Detterbeck FC, Wang Z, Chupp GL, Kim AW. Hospital readmission after pulmonary lobectomy is not affected by surgical approach. Ann Thorac Surg 2014; 99:393-8. [PMID: 25497070 DOI: 10.1016/j.athoracsur.2014.10.014] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 09/28/2014] [Accepted: 10/07/2014] [Indexed: 01/01/2023]
Abstract
BACKGROUND The aim of this study is to identify the predictors of hospital readmission or early unplanned return to clinic within 30 days of discharge after pulmonary lobectomy. METHODS The medical records of patients undergoing lobectomy by the thoracic surgery service between January 2009 and July 2012 were reviewed. All lobectomies were included irrespective of the etiology of disease. Multivariate logistic regression methods were used to identify predictors of readmission and or early unplanned return to clinic. RESULTS Two hundred thirteen patients underwent a pulmonary lobectomy during the study period (median age, 67 years). Pathologic diagnosis was malignant in 94% of the patients and benign in 6%. Minimally invasive approaches were used in 69% of the patients, whereas open thoracotomy was used in 31%. Median hospital length of stay was 4 days, and postoperative mortality occurred in 1 patient (0.5%). The Charlson comorbidity index was 1 ± 1. Predicted postoperative forced expiratory volume in 1 second and diffusing capacity of the lung for carbon monoxide were 68% ± 18% and 64% ± 17%, respectively. Postoperative complications occurred in 31% of patients; 13% required readmission to the hospital within 30 days of discharge or early unplanned return to clinic. Predictors of readmission or early unplanned return to clinic were unplanned transfer to the intensive care unit (odds ratio, 10.4; 95% confidence interval, 1.1 to 103.5; p = 0.04) and Charlson comorbidity index greater than 0 (odds ratio, 1.5; 95% confidence interval, 1.04 to 2.03; p = 0.03). Readmission or early unplanned return to clinic was independent of surgical approach (p = 0.32). CONCLUSIONS Patients who require a postoperative transfer to the intensive care unit or with higher Charlson comorbidity index are at higher risk for hospital readmission after pulmonary lobectomy. Readmission was not affected by the surgical approach. Whether a different strategy to follow-up for these high-risk patients can prevent readmission remains to be determined.
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Affiliation(s)
- Roland Assi
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Daniel J Wong
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Daniel J Boffa
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Frank C Detterbeck
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Zuoheng Wang
- Section of Pulmonary and Critical Care Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Geoffrey L Chupp
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Anthony W Kim
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut.
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