Feasibility analysis for the development of a video-assisted thoracoscopic (VATS) lobectomy 23-hour recovery pathway

Beyond the Frontline: A Triple-Line Approach of Thoracic Surgeons in Lung Cancer Management-State of the Art

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.

OUP accepted manuscript

Background

Despite implementation of enhanced recovery after surgery (ERAS) in lung surgery, potential barriers for improvements should be identified. The aim of this single-centre, prospective ERAS cohort study was to explore reasons for delayed patient discharge after video-assisted thoracoscopic surgery (VATS) lobectomy with a median length of hospital stay (LOS) of 2 days.

Methods

Consecutive patients referred for VATS lobectomy were consulted twice daily by an investigator for the primary reasons for continued hospitalization. The secondary outcomes were risk factors for delayed recovery using univariate and multivariate regression analyses.

Results

A total of 147 patients were included (69 with LOS more than 2 days and 78 with LOS of 2 days or less) from April 2020 to December 2020. Air leak (27.7 per cent), pneumonia (20.2 per cent), pain (15.3 per cent), urinary/renal factors (11.0 per cent), atrial fibrillation (7.0 per cent), respiratory failure (4.5 per cent), cognitive factors/delirium (4.3 per cent), gastrointestinal factors (3.8 per cent), oxygen dependency (2.7 per cent), social factors (2.0 per cent), and pleural effusion (1.4 per cent) were important factors for discharge more than 2 days after surgery. The 30-day readmission rate after discharge was 21 per cent for LOS of 2 days or less and 22 per cent for LOS more than 2 days (P = 0.856). On a multivariate regression model, age (per 5-year increase, odds ratio (OR) 1.29, 95 per cent c.i. 1.01 to 1.66, P = 0.043) and forced expiratory volume in 1 s (FEV₁) per cent (per 5 per cent increase, OR 0.89, 95 per cent c.i. 0.81 to 0.98, P = 0.021) were significantly related to discharge after more than 2 days.

Conclusion

Despite a short median LOS of 2 days, air leak, pneumonia, and pain remain the most important challenges for further improvement of the ERAS programme. Age and FEV₁ per cent were statistically significant risk factors for LOS longer than 2 days.

The Role of Surgery in Lung Cancer Treatment: Present Indications and Future Perspectives-State of the Art

Non-small cell lung cancers (NSCLC) are different today, due to the increased use of screening programs and of innovative systemic therapies, leading to the diagnosis of earlier and pre-invasive tumors, and of more advanced and controlled metastatic tumors. Surgery for NSCLC remains the cornerstone treatment when it can be performed. The role of surgery and surgeons has also evolved because surgeons not only perform the initial curative lung cancer resection but they also accompany and follow-up patients from pre-operative rehabilitation, to treatment for recurrences. Surgery is personalized, according to cancer characteristics, including cancer extensions, from pre-invasive and local tumors to locally advanced, metastatic disease, or residual disease after medical treatment, anticipating recurrences, and patients' characteristics. Surgical management is constantly evolving to offer the best oncologic resection adapted to each NSCLC stage. Today, NSCLC can be considered as a chronic disease and surgery is a valuable tool for the diagnosis and treatment of recurrences, and in palliative conditions to relieve dyspnea and improve patients' comfort.

Prehabilitation in Thoracic Cancer Surgery: From Research to Standard of Care

OBJECTIVE

To determine whether personalized, stepped prehabilitation care is a feasible, safe, and effective implementation strategy.

DESIGN

Quality improvement project. Data collected prospectively from August 2018 to December 2019 were analyzed retrospectively to describe the clinical implementation of a prehabilitation care program for elective lung cancer surgery.

SETTING

Single center, tertiary university hospital.

PARTICIPANTS

Eighty-one consecutive adult patients living in the metropolitan area of Montreal were included if an elective resection of suspected or confirmed lung cancer was planned.

INTERVENTIONS

At the earliest contemplation of surgery, the whole cohort was screened for impaired physical, nutritional, and/or psychological status. Patients screened at higher risk received dedicated assessment and personalized prehabilitation care upon specific needs.

MEASUREMENTS AND MAIN RESULTS

Patients' specific needs and their access and flow through the different services were described. Prehabilitation effectiveness was evaluated using walking and exercise tests, and adverse events were monitored. Eighty-one patients were screened for functional impairments. Forty patients showed reduction of physical function, seven of them refused the specific assessment, one refused in-hospital exercise; 48 patients showed nutritional risk, eight of them refused or did not comply with nutritional therapy. Overall, 45 high-risk patients received a one-month personalized prehabilitation program: 16 partook in a trimodal program (exercise, nutrition, and psychological), and 22 received a program with both nutrition and exercise. No adverse events occurred during the study period. After prehabilitation, six-minute waking distance improved by 29.9 meters (standard deviation 47.3 m) (n = 35; p = 0.001) and the oxygen uptake at the anaerobic threshold improved by 1.6 (1.7) mL/kg/min (n = 13; p = 0.004). Length of hospital stay was two (interquartile range one-four) days in prehabilitated patients versus three (two-seven) days in the usual care group (p = 0.101).

CONCLUSIONS

A personalized, stepped prehabilitation program targeting high-risk patients undergoing elective lung cancer surgery was feasible, safe, and effective.

Safety and Feasibility of Thoracic Malignancy Surgery During the COVID-19 Pandemic

Background

The coronavirus disease 2019 (COVID-19) pandemic has decreased surgical activity, particularly in the field of oncology, because of the suspicion of a higher risk of COVID-19–related severe events. This study aimed to investigate the feasibility and safety of thoracic cancer surgery in the most severely affected European and Canadian regions during the COVID-19 pandemic.

Methods

The study investigators prospectively collected data on surgical procedures for malignant thoracic diseases from January 1 to April 30, 2020. The study included patients from 6 high-volume thoracic surgery departments: Nancy and Strasbourg (France), Freiburg (Germany), Milan and Turin (Italy), and Montreal (Canada). The centers involved in this research are all located in the most severely affected regions of those countries. An assessment of COVID-19–related symptoms, polymerase chain reaction (PCR)–confirmed COVID-19 infection, rates of hospital and intensive care unit admissions, and death was performed for each patient. Every deceased patient was tested for COVID-19 by PCR.

Results

In the study period, 731 patients who underwent 734 surgical procedures were included. In the whole cohort, 9 cases (1.2%) of COVID-19 were confirmed by PCR, including 5 in-hospital contaminants. Four patients (0.5%) needed readmission for oxygen requirements. In this subgroup, 2 patients (0.3%) needed intensive care unit and mechanical ventilatory support. The total number of deaths in the whole cohort was 22 (3%). A single death was related to COVID-19 (0.14%).

Conclusions

Maintaining surgical oncologic activity in the era of the COVID-19 pandemic seems safe and feasible, with very low postoperative morbidity or mortality. To continue to offer the best care to patients who do not have COVID-19, reports on other diseases are urgently needed.