Matched Pairs Comparison of an Enhanced Recovery Pathway Versus Conventional Management on Opioid Exposure and Pain Control in Patients Undergoing Lung Surgery

Improving care in lung cancer surgery: a review of quality measures and evolving standards

PURPOSE OF REVIEW

Lung cancer is the leading cause of cancer-related death in the United States. Pulmonary resection, in addition to perioperative systemic therapies, is a cornerstone of treatment for operable patients with early-stage and locoregional disease. In recent years, increased emphasis has been placed on surgical quality metrics: specific and evidence-based structural, process, and outcome measures that aim to decrease variation in lung cancer care and improve long term outcomes. These metrics can be divided into potential areas of intervention or improvement in the preoperative, intraoperative, and postoperative phases of care and form the basis of guidelines issued by organizations including the National Cancer Center Network (NCCN) and Society of Thoracic Surgeons (STS). This review focuses on established quality metrics associated with lung cancer surgery with an emphasis on the most recent research and guidelines.

RECENT FINDINGS

Over the past 18 months, quality metrics across the peri-operative care period were explored, including optimal invasive mediastinal staging preoperatively, the extent of intraoperative lymphadenectomy, surgical approaches related to minimally invasive resection, and enhanced recovery pathways that facilitate early discharge following pulmonary resection.

SUMMARY

Quality metrics in lung cancer surgery is an exciting and important area of research. Adherence to quality metrics has been shown to improve overall survival and guidelines supporting their use allows targeted quality improvement efforts at a local level to facilitate more consistent, less variable oncologic outcomes across centers.

Operation room nursing based on humanized nursing mode combined with nitric oxide on rehabilitation effect after lung surgery

BACKGROUND

With advancements in the diagnosis and treatment of lung diseases, lung segment surgery has become increasingly common. Postoperative rehabilitation is critical for patient recovery, yet challenges such as complications and adverse outcomes persist. Incorporating humanized nursing modes and novel treatments like nitric oxide inhalation may enhance recovery and reduce postoperative complications.

AIM

To evaluate the effects of a humanized nursing mode combined with nitric oxide inhalation on the rehabilitation outcomes of patients undergoing lung surgery, focusing on pulmonary function, recovery speed, and overall treatment costs.

METHODS

A total of 79 patients who underwent lung surgery at a tertiary hospital from March 2021 to December 2021 were divided into a control group (n = 39) receiving a routine nursing program and an experimental group (n = 40) receiving additional humanized nursing interventions and atomized inhalation of nitric oxide. Key indicators were compared between the two groups alongside an analysis of treatment costs.

RESULTS

The experimental group demonstrated significant improvements in pulmonary function, reduced average recovery time, and lower total treatment costs compared to the control group. Moreover, the quality of life in the experimental group was significantly better in the 3 months post-surgery, indicating a more effective rehabilitation process.

CONCLUSION

The combination of humanized nursing mode and nitric oxide inhalation in postoperative care for lung surgery patients significantly enhances pulmonary rehabilitation outcomes, accelerates recovery, and reduces economic burden. This approach offers a promising reference for improving patient care and rehabilitation efficiency following lung surgery.

Influence of higher body mass index on postoperative nausea and vomiting in patients following thoracic surgery for lung cancer: a propensity score-matched cohort study

This study aimed to quantify the association between body mass index (BMI) and postoperative nausea and vomiting (PONV) within the initial 48 h following thoracic surgery for lung cancer. We then explored whether changes in serum inflammatory factor concentrations were related to BMI during the early postoperative period. We conducted a propensity score-matched (PSM), retrospective cohort study at a specialized tertiary medical center. A total of 194 patients aged 18-80 years who underwent thoracic surgery for lung cancer at Shanghai Pulmonary Hospital between January and June 2021 were enrolled. The primary outcome was the incidence of PONV during the first 48 h after surgery. Nausea, vomiting or retching at different time periods, severe pain, and concentrations of perioperative serum inflammatory factors including CRP, IL-6, IL-12, and IFN-γ were also assessed. Patients in the high BMI group (BMI ≥ 25 kg/m2) had a lower incidence of PONV than those in the normal BMI group (18.5-25 kg/m2) within the first 48 h after surgery (22 vs. 50%, p = 0.004). The incidence of nausea was lower at 0-12 h (14.5 vs. 37.1%, p = 0.004) and 12-24 h (8.1 vs. 22.6%, p = 0.025) in the high BMI group after surgery, and the incidence of vomiting was lower at 0-12 h (12.9 vs. 30.6%, p = 0.017) in higher BMI after surgery. We found no significant difference in the incidence of severe pain [severe static pain (p = 0.697) and severe dynamic pain (p = 0.158)]. Moreover, higher concentrations of IL-12 (2.24 ± 2.67 pg/ml vs. 1.48 ± 1.14 pg/ml, p = 0.048) and IFN-γ [1.55 (1.00) pg/ml vs. 1.30 (0.89) pg/ml, p = 0.041] were observed in patients with normal BMI on the first day after surgery. Given this finding, patients with a normal BMI should receive more attention for the prevention of PONV than those with a high BMI following thoracic surgery for lung cancer.Trial registration: http://www.chictr.org.cn and ChiCTR2100052380 (24/10/2021).

Five-Year Sustained Impact of a Thoracic Enhanced Recovery After Surgery Program

BACKGROUND

Our thoracic enhanced recovery program (ERP) decreased the use of postoperative morphine equivalents and hospital costs 1 year after implementation at our tertiary center. The sustainability and potential increasing benefit of this program were evaluated.

METHODS

From 2015 to 2021, we prospectively analyzed the outcomes of patients who underwent elective pleural, pulmonary, or mediastinal operations at our institution. Patients were separated on the basis of the incision (video-assisted thoracoscopic surgery [VATS] or thoracotomy). The ERP protocol was initiated on May 1, 2016, and includes preoperative education, carbohydrate loading, opioid-sparing analgesia, conservative fluid management, protective ventilation, and early ambulation. Outcomes of patients before (2015, pre-VATS and pre-thoracotomy) and after (May 1, 2016, to December 31, 2021, ERP-VATS and ERP-thoracotomy) ERP implementation were compared.

RESULTS

The cohort included 1079 patients (pre-ERP era, n = 224 [21%]; ERP era, n = 855 [79%]). There was a median reduction of 1.5 hospital days per patient for ERP-thoracotomy and 1 hospital day per patient for ERP-VATS. Median postoperative morphine equivalents decreased in both groups (125 vs 45 mg, in ERP-thoracotomy; 84 vs 23 mg, ERP-VATS; P < .001), as did total admission cost ($32,118 vs $23,775, ERP-thoracotomy; $17,367 vs $11,560, ERP-VATS; P < .001). Median total fluid balance during the hospital stay decreased significantly. Rates of postoperative atrial fibrillation and urinary retention decreased across both subgroups.

CONCLUSIONS

ERP for thoracic surgery is sustainable and has been demonstrated to improve patient outcomes, to decrease opioid use, and to lower hospital costs. Therefore, it has the potential to become the standard of care.

Surgical Approach and Persistent Opioid Use in Medicare Patients Undergoing Lung Cancer Resection

BACKGROUND

Robotic and video-assisted thoracoscopic surgery (VATS) approaches for lung resection are associated with decreased inpatient opioid use compared with open surgery. Whether these approaches affect outpatient persistent opioid use remains unknown.

METHODS

Non-small cell lung cancer patients aged 66 years or more who underwent lung resection between 2008 and 2017 were identified from the Surveillance, Epidemiology, and End Results-Medicare database. Persistent opioid use was defined as filling an opioid prescription 3 to 6 months after lung resection. Adjusted analyses were performed to evaluate surgical approach and persistent opioid use.

RESULTS

We identified 19,673 patients: 7479 (38%) underwent open surgery, 10,388 (52.8%) VATS, and 1806 (9.2%) robotic surgery. Persistent opioid use was 38% in the entire cohort, including 27% of opioid naïve patients, and highest after open surgery (42.5%), followed by VATS (35.3%) and robotic (33.1%, P < .001). In multivariable analyses, robotic (odds ratio 0.84; 95% CI, 0.72-0.98; P = .028) and VATS (odds ratio 0.87; 95% CI, 0.79-0.95; P = .003) approaches were both associated with decreased persistent opioid use compared with open surgery in opioid naïve patients. At 12 months, patients resected using a robotic approach had the lowest oral morphine equivalent per month compared with VATS (133 vs 160, P < .001) and open surgery (133 vs 200, P < .001). Among chronic opioid patients, surgical approach was not associated with postoperative opioid use.

CONCLUSIONS

Persistent opioid use after lung resection is common. Both robotic and VATS approaches were associated with decreased persistent opioid use compared with open surgery among opioid naïve patients. Whether a robotic approach yields additional long-term advantages over VATS warrants further investigation.

A Novel Opioid-Sparing Analgesia Following Thoracoscopic Surgery: A Non-Inferiority Trial

Purpose

This randomized, non-inferiority study aimed to observe the feasibility of opioid-sparing analgesia based on modified intercostal nerve block (MINB) following thoracoscopic surgery.

Patients and Methods

60 patients scheduled for single-port thoracoscopic lobectomy were randomized to the intervention group or control group. After MINB was performed in both groups at the end of the surgery, the intervention group received patient controlled-intravenous analgesia (PCIA) of dexmedetomidine 0.05 µg/kg/h for 72 h after surgery, and the control group received conventional PCIA of sufentanil 3 µg/kg for 72 h. The primary outcome was a visual analog scale (VAS) on coughing 24 h after surgery. Secondary outcomes included the time to first analgesic request, pressing times of PCIA, time to first flatus, and hospital stay.

Results

There was no difference in the cough-VAS at 24 h (median [interquartile range]) between the intervention group [3 (2-4)] and control group [3 (2-4), P = 0.36]. The median difference (95% CI) in the cough-VAS at 24 h was [0 (0 to 1), P = 0.36]. There was no significant difference in the time to first analgesic request, pressing times of PCIA, and hospital stay between groups (P > 0.05). A significant decrease in time to first flatus was observed in the intervention group (P < 0.01).

Conclusion

Opioid-sparing analgesia provided safe and analogous postoperative analgesia with a shortened time to first flatus, compared with sufentanil-based analgesia in thoracoscopic surgery. This might be a novel method recommended for thoracoscopic surgery.

Outcomes Related to Cardiac Enhanced Recovery After Surgery Protocol

OBJECTIVES

The objective of this study was to assess the quality of pain control and outcomes in patients who underwent coronary artery bypass graft (CABG) over a period of 96 hours preimplementation of a cardiac enhanced recovery after surgery (C-ERAS) protocol compared with postimplementation.

DESIGN

Single-center, retrospective cohort study.

SETTING

Cleveland Clinic Akron General Hospital.

PARTICIPANTS

Patients ≥18 years of age who underwent CABG surgery and received perioperative pain management pre- and post-C-ERAS protocol implementation at admission to Cleveland Clinic Akron General Hospital.

INTERVENTIONS

A hospital C-ERAS protocol that included a multimodal analgesia approach to postoperative pain management.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the amount of opioid used measured in morphine milligram equivalents (MME) within 96 hours postoperatively. A total of 146 charts were reviewed, with 133 included (66 pre-C-ERAS and 67 post-C-ERAS). There was a significant reduction in median MMEs 96 hours postoperatively post-C-ERAS (98 [52-135] v 211 [130-290], p < 0.001). Additionally, a significant reduction in median MMEs was observed post-C-ERAS before (65 [43-100] v 129 [95-165], p < 0.001) and after (10 [0-40] v 68 [21-141], p < 0.001) chest tube removal and for the entire prescription at discharge (0 [0-109] v 90 [0-210], p = 0.005).

CONCLUSIONS

Implementing a C-ERAS protocol within a CABG surgery patient population reduced the amount of MME.

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Current Surgical Indications for Non-Small-Cell Lung Cancer

With recent strides made within the field of thoracic oncology, the management of NSCLC is evolving rapidly. Careful patient selection and timing of multi-modality therapy to permit the optimization of therapeutic benefit must be pursued. While chemotherapy and radiotherapy continue to have a role in the management of lung cancer, surgical therapy remains an essential component of lung cancer treatment in early, locally and regionally advanced, as well as in selected, cases of metastatic disease. Recent and most impactful advances in the treatment of lung cancer relate to the advent of immunotherapy and targeted therapy, molecular profiling, and predictive biomarker discovery. Many of these systemic therapies are a part of the standard of care in metastatic NSCLC, and their indications are expanding towards surgically operable lung cancer to improve survival outcomes. Numerous completed and ongoing clinical trials in the surgically operable NSCLC speak to the interest and importance of the multi-modality therapy even in earlier stages of NSCLC. In this review, we focus on the current standard of care indications for surgical therapy in stage I-IV NSCLC as well as on the anticipated future direction of multi-disciplinary lung cancer therapy.

Sustained reduction of discharge opioid prescriptions in an enhanced recovery after thoracic surgery program: A multilevel generalized linear model

BACKGROUND

Enhanced Recovery After Surgery programs have been shown to effectively reduce opioid prescriptions at discharge after their implementation in several institutions, but little is known regarding the sustainability of this effect. Understanding opioid prescribing patterns after long-term implementation of Enhanced Recovery After Surgery initiatives may help guide further opioid prescription reduction and improvements. Our group aimed to determine whether reductions in opioid prescriptions at discharge are sustained in an Enhanced Recovery After Surgery program for thoracic surgery.

METHODS

This retrospective cohort included 2,081 patients undergoing thoracic surgery within a 4-year Enhanced Recovery After Surgery program from March 2016 through April 2020. Our Enhanced Recovery After Surgery protocol included a standardized multimodal analgesic regimen (ie, preoperative gabapentin, tramadol, intercostal nerve block with liposomal bupivacaine, and intraoperative acetaminophen, and ketorolac) and the rest of the interventions recommended by the Enhanced Recovery After Surgery society guidelines. Our primary outcomes were the presence of opioid prescriptions at discharge (hydrocodone, hydromorphone, and oxycodone) and the total opioid amount prescribed (morphine equivalent daily dose). Multilevel generalized linear models were used to account for surgeon variabilities and types of thoracic resection.

RESULTS

Over the study period, the rate of opioid prescriptions at discharge reduced from 35% (Mar 2016) to 25% (Apr 2020), and the amount of opioid prescribed declined from 184 ± 321 morphine equivalent daily dose to 94 ± 251 morphine equivalent daily dose. In multilevel generalized linear models, there was a sustained downward trend in opioid prescriptions over the study period (β -11.8 morphine equivalent daily dose per year, P = .048), which was also directly correlated with the use of minimally invasive surgery (β -84.9 morphine equivalent daily dose for video-assisted thoracoscopic surgery, P < .001; β -139.2 morphine equivalent daily dose for robotic-assisted thoracic surgery, P < .001), intraoperative opioid administration (β -1.4 morphine equivalent daily dose per 1 morphine equivalent dose, P = .026), and the amount of postoperative acetaminophen (β -18.2 morphine equivalent daily dose per 1 g, P = .026). The sustained reduction of opioid prescriptions at discharge did not impact hospital readmission rates within 30 days (odds ratio 1.17, 95% confidence interval 0.86-1.59, P = .306). Subgroup analysis showed a significant, sustained decrease in hydromorphone (β -10.9 morphine equivalent daily dose per year, P = .004), but not for hydrocodone prescriptions (β -5.7 morphine equivalent daily dose per year, P = .168) or oxycodone (β +4.78 morphine equivalent daily dose per year, P = .183).

CONCLUSION

Our Enhanced Recovery After Surgery program for thoracic surgery contributed to a sustained reduction of opioid prescriptions at discharge, which positively correlated with the duration of its implementation and the use of minimally invasive surgical techniques but was negatively impacted by the amount of intraoperative opioid administration.

Anesthetic Management for Pulmonary Resection: Current Concepts and Improving Safety of Anesthesia

Increasingly complex procedures are routinely performed using minimally invasive approaches, allowing cancers to be resected with short hospital stays, minimal postsurgical discomfort, and improved odds of cancer-free survival. Along with these changes, the focus of anesthetic management for lung resection surgery has expanded from the provision of ideal surgical conditions and safe intraoperative patient care to include preoperative patient training and optimization and postoperative pain management techniques that can impact pulmonary outcomes as well as patient lengths of stay.

Effect of Ultrasound-Guided Quadratus Lumborum Block Preemptive Analgesia on Postoperative Recovery of Patients with Open Radical Colon Cancer Surgery: A Retrospective Study

Purpose

To evaluate the effect of ultrasound-guided quadratus lumborum block (QLB) preemptive analgesia on recovery in colon cancer patients undergoing open radical surgery and provide reference for its clinical application.

Methods

From July 2019 to June 2020, according to the anesthesia method, 56 patients who received open radical colon surgery were divided into two groups: Group Q (n=27), which received QLB combined general anesthesia, and Group C (n=29), which received general anesthesia only. Both groups were given self-controlled intravenous analgesia pump after surgery. The primary outcome is a series of parameters representing postoperative recovery. The secondary outcome was VAS scores and opioid consumption.

Results

The first time of getting up, flatus, taking semi-liquid diet and the postoperative hospital stay in Group Q were significantly reduced (P<0.01). The rest and active VAS scores were significantly lower in Group Q (P<0.01). The opioids consumption was significantly decreased in Group Q (P<0.05).

Conclusion

The application of ultrasound-guided QLB preemptive analgesia in open radical colon cancer surgery can significantly enhance the postoperative analgesia effect, reduce opioid consumption, and accelerate the postoperative recovery of the patients.

Clinical Trial Registration Number

The Chinese Clinical Trial Registry (ChiCTR-2000034824).

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

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

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

Background

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

Methods

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

Results

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

Conclusions

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

Targeting Myeloid-Derived Suppressor Cells for Premetastatic Niche Disruption After Tumor Resection

Surgical resection is a common therapeutic option for primary solid tumors. However, high cancer recurrence and metastatic rates after resection are the main cause of cancer related mortalities. This implies the existence of a "fertile soil" following surgery that facilitates colonization by circulating cancer cells. Myeloid-derived suppressor cells (MDSCs) are essential for premetastatic niche formation, and may persist in distant organs for up to 2 weeks after surgery. These postsurgical persistent lung MDSCs exhibit stronger immunosuppression compared with presurgical MDSCs, suggesting that surgery enhances MDSC function. Surgical stress and trauma trigger the secretion of systemic inflammatory cytokines, which enhance MDSC mobilization and proliferation. Additionally, damage associated molecular patterns (DAMPs) directly activate MDSCs through pattern recognition receptor-mediated signals. Surgery also increases vascular permeability, induces an increase in lysyl oxidase and extracellular matrix remodeling in lungs, that enhances MDSC mobilization. Postsurgical therapies that inhibit the induction of premetastatic niches by MDSCs promote the long-term survival of patients. Cyclooxygenase-2 inhibitors and β-blockade, or their combination, may minimize the impact of surgical stress on MDSCs. Anti-DAMPs and associated inflammatory signaling inhibitors also are potential therapies. Existing therapies under tumor-bearing conditions, such as MDSCs depletion with low-dose chemotherapy or tyrosine kinase inhibitors, MDSCs differentiation using all-trans retinoic acid, and STAT3 inhibition merit clinical evaluation during the perioperative period. In addition, combining low-dose epigenetic drugs with chemokine receptors, reversing immunosuppression through the Enhanced Recovery After Surgery protocol, repairing vascular leakage, or inhibiting extracellular matrix remodeling also may enhance the long-term survival of curative resection patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Enhanced Recovery After Surgery (ERAS) in Head and Neck Oncologic Surgery: A Case-Matched Analysis of Perioperative and Pain Outcomes

BACKGROUND

Enhanced recovery after surgery (ERAS) pathways are well established in certain surgical specialties because findings have shown significant improvements in outcomes. Convincing literature in head and neck cancer (HNC) surgery is lacking. This study aimed to assess the effect of an ERAS pathway on National Surgical Quality Improvement Program (NSQIP)-based occurrences and pain-related outcomes in HNC surgery.

METHODS

The study matched 200 patients undergoing head and neck oncologic surgery on an ERAS pathway between 1 March 2016 and 31 March 2019 with control subjects (1:1 ratio) during the same period. Demographic and perioperative data collected from the NSQIP database were extracted. Pain scores and medication usage were electronically extracted from our electronic medical record system and compared. Risk factors for high opioid usage also were assessed.

RESULTS

Both groups were statistically similar in baseline characteristics. The ERAS group had fewer planned intensive care unit (ICU) admissions (4% vs. 14%; p < 0.001), a shorter mean hospital stay (7.2 ± 2.3 vs. 8.7 ± 4.2 days; p < 0.001), and fewer overall complications (18.6% vs. 27.0%; p = 0.045). Morphine milligram equivalent requirements over 72 h were significantly reduced during 72 h in the ERAS group (138.8 ± 181.5 vs. 207.9 ± 205.5; p < 0.001). In the multivariate analysis, the risk factors for high opioid analgesic usage included preoperative opioid usage, age younger than 65 years, race, patient-controlled analgesia use, and ICU admission.

CONCLUSION

The study findings showed that ERAS in HNC surgery can result in improved outcomes and resource use, and that these results are sustainable. The outcomes described in this report can be further used to optimize ERAS pathways.