Enhanced recovery programs in lung cancer surgery: systematic review and meta-analysis of randomized controlled trials

Comparative clinical experience of subcostal VATS versus conventional uniportal lateral VATS approach

INTRODUCTION

The present study reports the first clinical experience with subcostal uniportal VATS (suVATS) compared with the conventional lateral uniportal VATS (luVATS) approach.

PATIENTS AND METHODS

All patients who underwent suVATS between January 2019 and April 2020 were included. Patients who had undergone luVATS for similar indications were included as the control group. The data were prospectively and retrospectively analysed.

RESULTS

The suVATS group included 38 patients with a mean age of 61 (30-83) years. The luVATS group included 33 patients (mean age, 69 years; range: 46-89 years). An intercostal block was performed intraoperatively in the luVATS group. Local infiltration under anaesthesia was performed around the incision in the suVATS group. The duration of the surgery was significantly longer in the suVATS group. However, the chest tube treatment and hospital stay duration were significantly shorter in the suVATS group. The routinely recorded Visual Analogue Scale scores on the first post-operative day and the day of discharge were significantly lower in the suVATS group.

CONCLUSION

Subcostal uniportal VATS enables a shorter drainage treatment duration and hospital stay and significantly reduces post-operative pain. Thus, a faster patient recovery can be achieved.

Clinical outcomes and staff satisfaction after adoption of digital chest drainage system for minimally invasive lung resections

Background

Digital chest drainage systems (DCDS) provide reliable pleural drainage while quantifying fluid output and air leak. However, the benefits of DCDS in the contemporary era of minimally invasive thoracic surgery and enhanced recovery after surgery (ERAS) protocols have not been fully investigated. Additionally, hospital and resident staff experiences after implementation of a DCDS have not been fully explored. The objective of this study was to evaluate the clinical outcomes and hospital staff experience after adoption of a DCDS for minimally invasive lung resections.

Methods

A single-center retrospective review of patients who underwent minimally invasive lung resection (lobectomy, segmentectomy, and wedge resection) and received a DCDS from 11/1/2021 to 11/1/2022. DCDS patients were compared to sequential historical controls (3/1/2019-6/30/2021) who received a analog chest drainage system. For the analog system, chest tubes were removed when no bubbles were observed in the water seal compartment with Valsalva, cough, and in variable positions. With a DCDS, chest tubes were removed when the air leak was less than 30 cc/min for 8 hours, with no spikes. All patients followed an institutional ERAS protocol. Primary outcomes were length of stay (LOS) and chest tube duration. Hospital staff and residents were surveyed regarding their experience.

Results

One hundred and twenty-four patients received DCDS, and 248 received an analog chest drainage system. There was a reduction in mean LOS (3.6 vs. 4.4 days, P=0.01) and chest tube duration (2.7 vs. 3.6 days, P=0.03) in the DCDS group. Hospital staff (n=77, 46% response rate) reported the DCDS easier to use (60%, P<0.001) and easier to care for patients with (65%, P<0.001) compared to the analog system. Surgical residents (n=28, 56% response rate) reported increased confidence in interpretation of air leak (75%, P<0.001) and decision-making surrounding chest tube removal (79%, P<0.001).

Conclusions

Using a DCDS can reduce LOS and chest tube duration in the contemporary setting of minimally invasive lung resections and ERAS protocols. Increased confidence of resident decision-making for chest tube removal may contribute to improved outcomes.

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

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

A meta-analysis of the implementation of enhanced recovery after surgery pathways in anterior cervical spine surgery for degenerative cervical spine diseases

OBJECTIVE

To systematically evaluate the perioperative effects of enhanced recovery after surgery (ERAS) protocol on anterior cervical spine surgery by means of meta-analysis.

METHODS

According to the PRISMA guidelines, the article's search on the China National Knowledge Infrastructure (CNKI), Wanfang data resource system, VIP, PubMed database and Cochrane library was conducted to identify clinical studies investigating the effects of ERAS protocols on anterior cervical spine surgery. A quantitative meta-analysis was performed for the clinical outcomes extracted from the studies that met inclusion criteria.

RESULTS

Of the 21 studies identified from the article search, 10 studies met inclusion criteria. The meta-analysis showed shorter length of stay (LOS) (MD = -2.16, 95% CI (-2.57, -1.75), P < 0.00001) and higher patient satisfaction for the ERAS protocols (OR = 3.13, 95% CI (1.97, 4.98), P < 0.00001). Furthermore, ERAS programs led to significant decreases in cost (MD = -0.81, 95% CI (-1.08, -0.53), P < 0.00001) and complication rates (OR = 0.15, 95% CI (0.08, 0.27), P < 0.00001), but no difference in 90-day readmission (OR = 0.63, 95% CI (0.30, 1.35), P = 0.24).

CONCLUSIONS

The data of this study suggest that the implementation of ERAS protocol decreases LOS, cost and complications rates and improve satisfaction for the patients undergoing anterior cervical spine surgery. To support the practice use of ERAS in anterior cervical spine surgery further, controlled trials will be indispensable.

Enhanced recovery after surgery pathway leads to decreased length of stay for patients undergoing minimally invasive lung resection

Background

Enhanced recovery after surgery (ERAS) protocols in thoracic surgery have been demonstrated to impact length of stay (LOS), complication rates, and postoperative opioid use. However, ERAS protocols for minimally invasive lung resections have not been well described. Given most lung resections are now performed minimally invasively, there is a gap in the literature regarding the efficacy of ERAS protocols in this setting. In this study, we analyzed patient outcomes following implementation of an ERAS protocol for minimally invasive lung resections.

Methods

Outcome data was retrospectively collected for 442 patients undergoing minimally invasive lung resections between January 1st, 2015 and October 26th, 2021. Patients were divided into either a pre-ERAS (n=193) or ERAS (n=249) group. Primary outcomes included LOS, postoperative complications, intensive care unit (ICU) admission status, 30-day hospital readmissions, and 30-day mortality. Secondary outcomes included common postoperative complications required for the Society for Thoracic Surgeons (STS) database.

Results

We observed an overall decrease in median LOS (4.0 vs. 3.0 days, P=0.030) and ICU admission status (15% vs. 7.6%, P=0.020) after implementation of our ERAS protocol. The difference in LOS was significantly lower for anatomic lung resections, but not non-anatomic resections. There was no difference in 30-day readmissions and a 0% mortality rate in both groups. Overall, there was a low complication rate that was similar between groups.

Conclusions

The implementation of an ERAS protocol led to decreased LOS and decreased ICU admission in patients undergoing minimally invasive lung resection. Process standardization optimizes performance by providers by decreasing decision fatigue and improving decision making, which may contribute to the improved outcomes observed in this study.

Transforming Outcomes of Spine Surgery-Exploring the Power of Enhanced Recovery After Surgery Protocol: A Systematic Review and Meta-Analyses of 15 198 Patients

BACKGROUND AND OBJECTIVES

Enhanced recovery after surgery (ERAS) protocols aim to optimize patient outcomes by reducing the surgical stress response, expediting recovery, and reducing care costs. We aimed to evaluate the impact of implementing ERAS protocols on the perioperative surgical outcomes and financial implications associated with spine surgeries.

METHODS

A systematic review and meta-analysis of peer-reviewed studies directly comparing outcome differences between spine surgeries performed with and without utilization of ERAS pathways was conducted along Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Of 676 unique articles identified, 59 with 15 198 aggregate patients (7748 ERAS; 7450 non-ERAS) were included. ERAS-treated patients had shorter operative times (mean difference [MD]: 10.2 mins; P < .01), shorter hospitalizations (MD: 1.41 days, P < .01), fewer perioperative complications (relative risk [RR] = 0.64, P < .01), lower postoperative opioid use (MD of morphine equivalent dose: 164.36 mg; P < .01), and more rapid mobilization/time to first out-of-bed ambulation (MD: 0.92 days; P < .01). Spine surgeries employing ERAS were also associated with lower total costs (MD: $1140.26/patient; P < .01), especially in the United States (MD: $2869.11/patient, P < .01) and lower postoperative visual analog pain scores (MD = 0.56, P < .01), without any change in odds of 30-day readmission (RR: 0.80, P = .13) or reoperation (RR: 0.88, P = .60). Subanalyses based on the region of spine showed significantly lower length of stay in both cervical and lumbar surgeries implementing ERAS. Type of procedure showed a significantly lesser time-to-initiate mobilization in fusion surgeries using ERAS protocols compared with decompression.

CONCLUSION

The present meta-analysis indicates that current literature supports ERAS implementation as a means of reducing care costs and safely accelerating hospital discharge for patients undergoing spine surgery.

Length of Postoperative Hospital Stay and Related Factors After Lobectomy for Lung Cancer: A Pre-enhanced Recovery After Surgery (ERAS) Single Center Assessment

BACKGROUND

Lobectomy for lung cancer often presents a lot of potentially severe complications after surgery for patients. Enhanced Recovery After Surgery (ERAS) is a program to improve unexpected events. When implementing ERAS, there needs to be evidence of relevant factors that prolong hospital stays to encourage the participation of medical staff and leaders. This study is to determine the length of hospital stay (LOS) and its related factors after surgery in patients undergoing lobectomy for non-small cell lung cancer.

METHODS

 A descriptive retrospective study was conducted on 99 patients undergoing lobectomy for non-small cell lung cancer at University Medical Center Ho Chi Minh City. Data were extracted from a computerized database of patients who were hospitalized for lobectomy in the treatment of non-small cell lung cancer from January 2018 to December 2021. The primary outcome was the postoperative LOS.

RESULTS

Median postoperative LOS was 5.2 days (interquartile range 4.8 to 6.8 days). The complication rate was 19.2%, of which Clavien-Dindo II accounted for the highest at 9.1%. The 30-day readmission rate was 13.1%. The median of LOS in the current cigarette smoker's group was 1.9 days higher than the never-cigarette smoker's group and 1.5 days higher than the former cigarette smokers (p<0.001). Tumor-nodes-metastasis (TNM) stage III showed the highest LOS compared to other stages (p=0.029). Open surgery and thoracoscopic conversion to open showed postoperative LOS about two days longer than thoracoscopic surgery (p<0.001). ​Performing muscle relaxation and early extubation, multimodal analgesia reduced postoperative LOS by 1.6 days (p<0.001), and preoperative physical therapy and early physical therapy at recovery reduced postoperative LOS by 1.3 days (p<0.001). There was a strong positive correlation between the duration of endotracheal retention, duration of thoracic drainage, amount of blood loss, and postoperative LOS (R>0.5, p<0.001). The duration of the Post-Anesthesia Care Unit and fasting time after surgery showed an average positive correlation with postoperative LOS (0.3

CONCLUSIONS

The median postoperative LOS was 5.2 days, and more than half of patients stayed in the hospital for over five days. Some factors affect the LOS, including current cigarette smokers, TNM stage, surgical approaches, some care processes such as early extubation, multimodal pain relief, physical therapy, vomiting, duration of thoracic drainage, amount of blood loss, duration of Post-Anesthesia Care Unit (hours), duration of thoracic drainage (days), preoperative and postoperative fasting time (hours). The study results help propose many changes in perioperative care for patients undergoing lung cancer surgery.

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Key Words

• complications
• eras
• length of hospital stay
• lobectomy
• lung cancer
• vietnam

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Affiliation(s)

Ho Tat Bang Thoracic and Vascular Department, University Medical Center Ho Chi Minh City, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh, VNM Health Organization and Management Department, Faculty of Public Health, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh, VNM
Tran Thanh Vy Thoracic and Vascular Department, University Medical Center Ho Chi Minh City, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh, VNM Cardiovascular and Thoracic Surgery Department, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh, VNM
Nguyen Van Tap Faculty of Medical Management, Nguyen Tat Thanh University, Ho Chi Minh City, VNM

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Efficacy of the Enhanced Recovery After Surgery program for thoracic surgery in a developing country

Purpose

Enhanced Recovery After Surgery (ERAS) is a strategy used to improve perioperative outcomes and reduce complications. However, data on the efficacy of ERAS in thoracic surgery in developing countries are limited. The current study aimed to validate the benefits of ERAS among patients at a single institution.

Methods

This was a retrospective study of patients who underwent pulmonary resection at Vajira Hospital, Bangkok, Thailand, between 2016 and 2020. To compare outcomes, patients were divided into the pre-ERAS group (2016-2018) and the post-ERAS group (2019-2020) using propensity score matching (1:2) with the year 2019 as the cutoff for introducing ERAS protocols at our institution.

Results

In total, 321 patients were included in the analysis (pre-ERAS group, n = 74; post-ERAS group, n = 247). After propensity score matching, 56 and 112 patients were classified under the pre- and post-ERAS groups, respectively. The post-ERAS group had significantly lower pain scores than the pre-ERAS group on postoperative days 1, 2, and 3, and a lower volume of intraoperative blood loss. In the multivariable analysis, the post-ERAS group had a shorter chest tube duration (mean difference = -1.62 days, 95% confidence interval = -2.65 to -0.31) and length of hospital stay (mean difference = -2.40 days, 95% confidence interval = -4.45 to -0.65) than the pre-ERAS group.

Conclusion

The use of ERAS guidelines in pulmonary resection is beneficial. Although no significant differences were observed in postoperative complication rate, intensive care unit stay, and additional cost burden between the two groups, patients in the post-ERAS group had a shorter postoperative chest tube duration, shorter hospital stays, shorter operative time, lower postoperative pain score, and lower volume of intraoperative blood loss.

Expanded central role of the respiratory physiotherapists in the community setting

The development of community hubs through the Slaintecare initiative will rely on respiratory physiotherapists and clinical nurse specialists for the management of chronic respiratory diseases. The role of the respiratory physiotherapist has evolved dramatically over the last decade. We review the increasing scope of practice of the physiotherapist and the evidence base for same. We pay particular attention to the role of the physiotherapist in areas such as pulmonary rehabilitation, sputum clearance, neuromuscular disease, chronic respiratory failure, ambulatory oxygen assessments and dysfunctional breathing. We give an in depth review of sputum clearance techniques. We also address areas of potential future expansion for the role of the physiotherapist such as prescription and initiation of non-invasive ventilation.

Multi-level analysis and evaluation of organizational improvements in thoracic surgery according to a Value-Based HealthCare approach

Background

Value-Based HealthCare (VBHC), designed by Harvard University, is an evolving model of healthcare delivery that achieves better patient outcomes and greater financial sustainability for the healthcare professionals. According to this innovative approach, the value is determined by a panel of indicators and the ratio between results and costs. Our goal was to develop a panel of thoracic-fashioned key-performance indicators (KPIs) creating a model that could be applied in thoracic surgery for the first time, reporting our early experience.

Methods

Fifty-five indicators were developed based on literature review: 37 for outcomes and 18 for costs. Outcomes were measured by a 7 level Likert scale, while overall costs were defined through the sum of the individual economic performance on each resource indicator. An observational retrospective cross-sectional study was designed to make a cost-effective evaluation of the indicators. Therefore, the Patient Value in Thoracic Surgery (PVTS) score calculated value gained for every lung cancer patient undergoing lung resection at our surgical department.

Results

A total of 552 patients were enrolled. From 2017 to 2019 mean outcome indicators per patient were 109, 113 and 110 while mean costs per patient were 7.370, 7.536 and 7.313 euros respectively. Hospital stay and waiting time from consultation to surgery for lung cancer patients decreased from 7.3 to 5 and from 25.2 to 21.9 days, respectively. On the contrary, number of patients increased but overall costs decreased, despite cost of consumables has gone from 2.314 to 3.438 euros, since cost of hospitalization and occupancy of the operating room (OR) improved (from 4.288 to 3.158 euros). Variables analyzed showed that overall value delivered grew from 14.8 to 15.

Conclusions

Introducing a new concept of value, the VBHC theory applied to thoracic surgery may revolutionize traditional organizational management in lung cancer patients, showing how value delivered can increase in accordance with outcomes, despite the growth of part of the costs. Our panel of indicators has been created to provide an innovative score to successfully identify improvements needed and quantify their effectiveness in Thoracic Surgery and our early experience reports encouraging results.

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

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

Enhanced recovery after surgery (ERAS) in Latin America: The story so far

Despite modern perioperative care, postoperative complications continue to play a significant role in patient's recovery. Implementation of enhanced recovery pathways has consistently demonstrated better outcomes, reduced complications, and improved length of stay across the globe. However, the literature is scarce with regard to the peaks and valleys encountered during the implementation of these programs in Latin America. The purpose of this review is to shed light on the development and establishment of enhanced recovery pathways in the region. Moreover, it discusses current challenges and future perspectives on perioperative optimization.

Malignant neoplasm of the bronchi and lung: Russian clinical guidelines

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Video-assisted thoracoscopic treatment as two-day surgery for lung neoplasms: a propensity-matched analysis

Background

Enhanced recovery after surgery programs have reduced complications and shortened hospital stays after lung resection. This study aimed to determine whether video-assisted thoracoscopic surgery performed as a two-day surgery for lung neoplasms was safe and cost-effective.

Methods

This retrospective, propensity-matched, cohort analysis was conducted from January 2020 to August 2020. Among 959 patients who underwent video-assisted thoracoscopic surgery, 739 underwent inpatient surgery and 220 underwent two-day surgery. Propensity-matched analysis, incorporating preoperative variables, was used to compare postoperative complications, post-discharge follow-up results, and hospitalization costs between the groups.

Results

Propensity matching estimated 218 patients in each group. The mean length of hospital stay was shorter in the two-day surgery group (2.17 ± 0.89 days) than in the inpatient surgery group (6.31 ± 2.13 days) (P < 0.001). Delayed removal of chest tubes accounted for over half of the delayed discharges in the inpatient (17 [54.8%]) and two-day surgery (13 [65.0%]) groups. The postoperative pneumonia/atelectasis incidence was lower in the two-day surgery group than in the inpatient surgery group (P = 0.032). The two-day surgery group patients were readmitted to the hospital due to massive pleural effusion, pneumothorax, fever, severe chest pain, and physical weakness. The mean total hospitalization cost in the two-day surgery group was lower than that in the inpatient surgery group (¥ 33,926.1 versus ¥ 38,422.7, P < 0.001). Basic medical, nursing, drug, laboratory-related, and nonsurgical consumable costs in the two-day surgery group were significantly reduced.

Conclusions

Two-day surgery is a safe, feasible, and cost-effective procedure for selected patients with lung neoplasms when combined with accurate preoperative evaluations, successful intraoperative assessments, and effective postoperative health care guidance.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09938-x.

Effects of enhanced recovery after surgery plus pulmonary rehabilitation on complications after video-assisted lung cancer surgery: a multicentre randomised controlled trial

BACKGROUND

Lung cancer surgery is associated with a high incidence of postoperative pulmonary complications (PPCs). We evaluated whether enhanced recovery after surgery plus pulmonary rehabilitation was superior over enhanced recovery after surgery alone in reducing the incidence of postoperative PPCs and length of hospital stay.

METHODS

In this pragmatic multicentre, randomised controlled, parallel-group clinical trial, eligible patients scheduled for video-assisted lung cancer surgery were randomly assigned (1:1) to either a newly developed programme that integrated preoperative and postoperative pulmonary rehabilitation components into a generic thoracic enhanced recovery after surgery pathway, or routine thoracic enhanced recovery after surgery. Primary outcome was the overall occurrence of PPCs within 2 weeks after surgery. Secondary outcomes were the occurrence of specific complications, time to removal of chest drain, and length of hospital stay (LOS).

RESULTS

Of 428 patients scheduled for lung cancer surgery, 374 were randomised with 187 allocated to the experimental programme and 187 to control. Incidence of PPCs at 14 Days was 18.7% (35/187) in the experimental group and 33.2% (62/187) in the control group (intention-to-treat, unadjusted HR 0.524, 95% CI 0.347 to 0.792, p=0.002). Particularly, significant risk reduction was observed regarding pleural effusion, pneumonia and atelectasis. Time to removal of chest drain and LOS were not significantly reduced in the experimental group.

CONCLUSIONS

Adding pulmonary rehabilitation to enhanced recovery after surgery appears to be effective in reducing the incidence of PPCs, but not LOS. Standard integration of pulmonary rehabilitation into thoracic enhanced recovery after surgery is a promising approach to PPC prophylaxis.

TRIAL REGISTRATION NUMBER

ChiCTR1900024646.

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

Objective

Methods

Results

Conclusions

Tumor organoids: applications in cancer modeling and potentials in precision medicine

Cancer is a top-ranked life-threatening disease with intratumor heterogeneity. Tumor heterogeneity is associated with metastasis, relapse, and therapy resistance. These factors contribute to treatment failure and an unfavorable prognosis. Personalized tumor models faithfully capturing the tumor heterogeneity of individual patients are urgently needed for precision medicine. Advances in stem cell culture have given rise to powerful organoid technology for the generation of in vitro three-dimensional tissues that have been shown to more accurately recapitulate the structures, specific functions, molecular characteristics, genomic alterations, expression profiles, and tumor microenvironment of primary tumors. Tumoroids in vitro serve as an important component of the pipeline for the discovery of potential therapeutic targets and the identification of novel compounds. In this review, we will summarize recent advances in tumoroid cultures as an excellent tool for accurate cancer modeling. Additionally, vascularization and immune microenvironment modeling based on organoid technology will also be described. Furthermore, we will summarize the great potential of tumor organoids in predicting the therapeutic response, investigating resistance-related mechanisms, optimizing treatment strategies, and exploring potential therapies. In addition, the bottlenecks and challenges of current tumoroids will also be discussed in this review.

Perioperative enhanced recovery programmes for women with gynaecological cancers

BACKGROUND

Gynaecological cancers account for 15% of newly diagnosed cancer cases in women worldwide. In recent years, increasing evidence demonstrates that traditional approaches in perioperative care practice may be unnecessary or even harmful. The enhanced recovery after surgery (ERAS) programme has therefore been gradually introduced to replace traditional approaches in perioperative care. There is an emerging body of evidence outside of gynaecological cancer which has identified that perioperative ERAS programmes decrease length of postoperative hospital stay and reduce medical expenditure without increasing complication rates, mortality, and readmission rates. However, evidence-based decisions on perioperative care practice for major surgery in gynaecological cancer are limited. This is an updated version of the original Cochrane Review published in Issue 3, 2015.

OBJECTIVES

To evaluate the beneficial and harmful effects of perioperative enhanced recovery after surgery (ERAS) programmes in gynaecological cancer care on length of postoperative hospital stay, postoperative complications, mortality, readmission, bowel functions, quality of life, participant satisfaction, and economic outcomes.

SEARCH METHODS

We searched the following electronic databases for the literature published from inception until October 2020: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PubMed, AMED (Allied and Complementary Medicine), CINAHL (Cumulative Index to Nursing and Allied Health Literature), Scopus, and four Chinese databases including the China Biomedical Literature Database (CBM), WanFang Data, China National Knowledge Infrastructure (CNKI), and Weipu Database. We also searched four trial registration platforms and grey literature databases for ongoing and unpublished trials, and handsearched the reference lists of included trials and accessible reviews for relevant references.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared ERAS programmes for perioperative care in women with gynaecological cancer to traditional care strategies.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies for inclusion, extracted the data and assessed methodological quality for each included study using the Cochrane risk of bias tool 2 (RoB 2) for RCTs. Using Review Manager 5.4, we pooled the data and calculated the measures of treatment effect with the mean difference (MD), standardised mean difference (SMD), and risk ratio (RR) with a 95% confidence interval (CI) to reflect the summary estimates and uncertainty.

MAIN RESULTS

We included seven RCTs with 747 participants. All studies compared ERAS programmes with traditional care strategies for women with gynaecological cancer. We had substantial concerns regarding the methodological quality of the included studies since the included RCTs had moderate to high risk of bias in domains including randomisation process, deviations from intended interventions, and measurement of outcomes. ERAS programmes may reduce length of postoperative hospital stay (MD -1.71 days, 95% CI -2.59 to -0.84; I2 = 86%; 6 studies, 638 participants; low-certainty evidence). ERAS programmes may result in no difference in overall complication rates (RR 0.71, 95% CI 0.48 to 1.05; I2 = 42%; 5 studies, 537 participants; low-certainty evidence). The certainty of evidence was very low regarding the effect of ERAS programmes on all-cause mortality within 30 days of discharge (RR 0.98, 95% CI 0.14 to 6.68; 1 study, 99 participants). ERAS programmes may reduce readmission rates within 30 days of operation (RR 0.45, 95% CI 0.22 to 0.90; I2 = 0%; 3 studies, 385 participants; low-certainty evidence). ERAS programmes may reduce the time to first flatus (MD -0.82 days, 95% CI -1.00 to -0.63; I2 = 35%; 4 studies, 432 participants; low-certainty evidence) and the time to first defaecation (MD -0.96 days, 95% CI -1.47 to -0.44; I2 = 0%; 2 studies, 228 participants; low-certainty evidence). The studies did not report the effects of ERAS programmes on quality of life. The evidence on the effects of ERAS programmes on participant satisfaction was very uncertain due to the limited number of studies. The adoption of ERAS strategies may not increase medical expenditure, though the evidence was of very low certainty (SMD -0.22, 95% CI -0.68 to 0.25; I2 = 54%; 2 studies, 167 participants).

AUTHORS' CONCLUSIONS

Low-certainty evidence suggests that ERAS programmes may shorten length of postoperative hospital stay, reduce readmissions, and facilitate postoperative bowel function recovery without compromising participant safety. Further well-conducted studies are required in order to validate the certainty of these findings.

Evaluation of enhanced recovery after spine surgery: Specificities in an academic public hospital

INTRODUCTION

Enhanced recovery after surgery (ERAS) has been well described in many surgical specialties, including orthopedics. Application in spine surgery, on the other hand, is more recent and not yet precisely assessed. The present study aimed to assess the implementation of an ERAS program in a European spine surgery department and its impact on length of hospital stay and complications rate.

MATERIALS AND METHODS

A comparative observational study was conducted on patient progression with and without ERAS. As of the launch date of the program, all eligible patients were included over a 6-month period. A retrospective control group comprised patients managed over the same 6-month period of the previous year, matched for pathology, comorbidity and individual surgeon. Endpoints comprised mean length of stay and major complications (i.e., requiring readmission or revision surgery within 90days).

RESULTS

Eighty-eight patients were included: 44 per group. Demographic characteristics did not significantly differ between groups. Mean length of stay, taking all pathologies together, was 3.3days in ERAS versus 6days in the control group (p<0.001). Complications rates did not significantly differ between groups (p=1).

DISCUSSION

The introduction of the ERAS program gave care teams the opportunity to think over good practices and set up a number of concomitant measures generally agreed to be effective in isolation. The present study showed ERAS to be perfectly feasible in a public-sector structure, reducing length of stay without increasing the rate of complications.

LEVEL OF EVIDENCE

IV CEBM.

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

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

Feasibility, safety and outcomes of ambulation within 2 h postoperatively in patients with lung cancer undergoing thoracoscopic surgery

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.

Early discharge after thoracoscopic anatomical pulmonary resection for non-small-cell lung cancer

OBJECTIVES

Although video-assisted thoracic surgery (VATS) has shortened hospitalization duration for non-small-cell lung cancer (NSCLC) patients, the factors associated with early discharge remain unclear. This study aimed to identify patients eligible for a 72-h stay after VATS anatomical resection.

METHODS

Monocentric retrospective study including all consecutive patients undergoing VATS anatomical resection for NSCLC between February 2010 and December 2019. Two groups were defined according to the discharge: 'early discharge' (within 72 postoperative hours) and 'routine discharge' (at >72 postoperative hours).

RESULTS

A total of 660 patients with a median age of 66.5 years (interquartile range 60-73 years) (female/male: 321/339) underwent VATS anatomical pulmonary resection for NSCLC [segmentectomy in 169 (25.6%), lobectomy in 481 (72.9%), bilobectomy in 8 (1.2%) and pneumonectomy in 2 (0.3%) patients]. The cardiopulmonary and Clavien-Dindo III-IV postoperative complication rates were 32.6% and 7.7%, respectively. The median postoperative length of stay was 6 days (interquartile range 4-10 days). In total, 119 patients (18%) could be discharged within 72 h of surgery. On multivariable analysis, the factors significantly associated with an increased likelihood of early discharge were: body mass index >20 kg/m2 [odds ratio (OR) 2.37], absence of prior cardiopathy (OR 2), diffusing capacity of the lung for carbon monoxide >60% (OR 1.82), inclusion in an enhanced recovery after surgery protocol (OR 2.23), use of a single chest tube (OR 5.73) and postoperative transfer to the ward (OR 4.84). Factors significantly associated with a decreased likelihood of early discharge were: age >60 years (OR 0.53), American Society of Anaesthesiologists score >2 (OR 0.46) and use of an epidural catheter (OR 0.41). Readmission rates were not statistically different between both groups (5.9% vs 3.1%; P = 0.17).

CONCLUSIONS

Age, pulmonary functions and comorbidities may influence discharge after VATS anatomical resection. The early discharge does not increase readmission rates.

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.

Influence of enhanced recovery after surgery (ERAS) on patients receiving lung resection: a retrospective study of 1749 cases

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.

Incidence and Risk Factors of Postoperative Severe Discomfort After Elective Surgery Under General Anesthesia: A Prospective Observational Study

PURPOSE

Patient comfort is an important concern in patients receiving surgery, but the seriousness of discomfort during recovery is unknown. We investigated the incidence of postoperative discomfort based on the Standardized Endpoints in Perioperative Medicine initiative for patient comfort, and identified the risk factors.

DESIGN

This was a single-center prospective observational study.

METHODS

We enrolled adult patients who underwent elective surgery under general anesthesia between July and December 2018 at West China Hospital of Sichuan University (ChiCTR1800017324). The primary outcome was the incidence of postoperative severe discomfort (PoSD), defined as occurring when a patient experienced a severe rating in two or more domains in the six domains in the Standardized Endpoints in Perioperative Medicine initiative on the same day, including rest pain, postoperative nausea, and vomiting, dissatisfaction of gastrointestinal recovery, dissatisfaction of mobilization, sleep disturbance, and recovery. A generalized estimated equation was constructed to find risk factors of PoSD.

FINDINGS

In total, 440 patients completed the study. The incidence of PoSD was 28% on postoperative day (POD) 1, 13% on POD 2, 9% on POD 3, and 3.6% on both POD 5 and 7. The most common discomfort was serious sleep disturbance, ranging from 43% to 10% in the first week after surgery. Longer operative time (odds ratio [95% confidence interval]: 1.56 [1.19 to 2.05], P = .001), gastrointestinal surgery (5.03[2.08,12.17], P < .001), orthopaedic surgery (3.03 [1.35,6.79], P = .007), ear, nose, and throat (ENT) surgery (3.50 [1.22,10.02], P = .020) and postoperative complications (1.77 [1.03-3.04], P = .038) were significant risk factors of PoSD.

CONCLUSIONS

The incidence of PoSD after elective surgery under general anesthesia is high. Sleep disturbance was the most common problem identified. Anesthesia providers and perianesthesia nurses may need to optimize anesthetic application, combine different anesthesia methods, improve perioperative management, and provide interventions to reduce and to treat discomfort after surgeries.

Neuromuscular blockade management and postoperative outcomes in enhanced recovery colorectal surgery: secondary analysis of POWER trial

BACKGROUND

We evaluated the impact of neuromuscular blockade (NMB) management, monitoring and reversal on postoperative outcomes in colorectal surgical patients included in an enhanced recovery program.

METHODS

We performed a predefined analysis in 2084 patients undergoing elective colorectal surgery who participated in POWER study. We analyzed them for complications, length of hospital stay and mortality. Two groups were defined: 1) monitoring + reversal of the neuromuscular blockade (M+R) group: all patients receiving neuromuscular blockade monitoring plus reversal of it with any drug (neostigmine or sugammadex) were included; and 2) no monitoring nor reversal (noM+noR) group. In this group all the patients who did not receive monitoring and reversal of the neuromuscular blockade were allocated.

RESULTS

Multivariate analysis found no statistically significant differences in moderate-severe complications (174 [25.7%] vs. 124 [27.1%]; P=0.607), length of hospital stay (10.8±11.1 vs. 11.0 ±12.6 days; P=0.683) and mortality (6 [0.9%] vs. 5 [1.1%]; P=0.840) between the group receiving optimal neuromuscular management (M+R) and the one did not receive it (noM+noR). Univariate analysis showed patients reversed with neostigmine died more than those reversed with sugammadex (3 [2.7%] vs. 3 [0.5%]; P=0.048).

CONCLUSIONS

Our data suggest optimal neuromuscular blockade management in colorectal surgery is not associated with less moderate-severe complications, length of hospital stay or death during postoperative period in an enhanced recovery program. Neostigmine reversal seems to be linked to higher rate of mortality than sugammadex.

Multidisciplinary care in surgery: Are team-based interventions cost-effective?

BACKGROUND

Multidisciplinary care has been shown to improve outcomes for patients, and interprofessional collaboration has been demonstrated to be beneficial for providers. In the field of surgery, although a large number of multidisciplinary care teams have been described, no study to date has examined whether or not these team-based interventions are generally cost-effective. This is the first systematic review to examine cost savings attributable to multidisciplinary care across all surgical fields.

METHODS

A comprehensive literature review of articles published on cost outcomes associated with multidisciplinary surgical teams was performed. Selected articles reported on cost outcomes directly attributable to a collaborative intervention. Cost savings were totaled on a per-patient basis. Each article was also reviewed to determine whether the authors ultimately recommended the team-based intervention described.

RESULTS

A total of 1421 articles were identified in the initial query, of which 43 met inclusion criteria. Thirty-nine studies (91%) reported multidisciplinary care to be cost effective, with an average cost savings among all studies of $5815 per patient. No significant differences in the amount of savings achieved were found between different intervention subtypes. All studies ultimately recommended (40) or gave mixed reviews (3) of multidisciplinary care, regardless of whether cost savings were achieved.

CONCLUSION

Multidisciplinary surgical care is beneficial not only in terms of patient and provider outcomes, but also in reference to its cost-effectiveness. Well-designed multidisciplinary teams tend to optimize perioperative care for all involved parties. Efforts to improve surgical care should employ multidisciplinary teams to promote both quality and cost-effective care.

Transesophageal echocardiography for perioperative management in thoracic surgery

PURPOSE OF REVIEW

Perioperative transesophageal echocardiography (TEE) is most often employed during cardiac surgery. This review will summarize some of the recent findings relevant to TEE utilization during thoracic surgical procedures.

RECENT FINDINGS

Hemodynamic monitoring is a key component of goal-directed fluid therapy, which is also becoming more common for management of thoracic surgical procedures. Although usually not required for the anesthetic management of common thoracic surgeries, TEE is frequently used during lung transplantation and pulmonary thromboendarterectomy. Few clinical studies support current practice patterns, and most recommendations are based on expert opinion.

SUMMARY

Currently, routine use of TEE in thoracic surgery is often limited to specific high-risk patients and/or procedures. As in other perioperative settings, TEE may be utilized to elucidate the reasons for acute hemodynamic instability without apparent cause. Contraindications to TEE apply and have to be taken into consideration before performing a TEE on a thoracic surgical patient.

Clinical utility of enhanced recovery after surgery pathways in pediatric spinal deformity surgery: systematic review of the literature

OBJECTIVES

More than 7500 children undergo surgery for scoliosis each year, at an estimated annual cost to the health system of $1.1 billion. There is significant interest among patients, parents, providers, and payors in identifying methods for delivering quality outcomes at lower costs. Enhanced recovery after surgery (ERAS) protocols have been suggested as one possible solution. Here the authors conducted a systematic review of the literature describing the clinical and economic benefits of ERAS protocols in pediatric spinal deformity surgery.

METHODS

The authors identified all English-language articles on ERAS protocol use in pediatric spinal deformity surgery by using the following databases: PubMed/MEDLINE, Web of Science, Cochrane Reviews, EMBASE, CINAHL, and OVID MEDLINE. Quantitative analyses of comparative articles using random effects were performed for the following clinical outcomes: 1) length of stay (LOS); 2) complication rate; 3) wound infection rate; 4) 30-day readmission rate; 5) reoperation rate; and 6) postoperative pain scores.

RESULTS

Of 950 articles reviewed, 7 were included in the qualitative analysis and 6 were included in the quantitative analysis. The most frequently cited benefits of ERAS protocols were shorter LOS, earlier urinary catheter removal, and earlier discontinuation of patient-controlled analgesia pumps. Quantitative analyses showed ERAS protocols to be associated with shorter LOS (mean difference -1.12 days; 95% CI -1.51, -0.74; p < 0.001), fewer postoperative complications (OR 0.37; 95% CI 0.20, 0.68; p = 0.001), and lower pain scores on postoperative day (POD) 0 (mean -0.92; 95% CI -1.29, -0.56; p < 0.001) and POD 2 (-0.61; 95% CI -0.75, -0.47; p < 0.001). There were no differences in reoperation rate or POD 1 pain scores. ERAS-treated patients had a trend toward higher 30-day readmission rates and earlier discontinuation of patient-controlled analgesia (both p = 0.06). Insufficient data existed to reach a conclusion about cost differences.

CONCLUSIONS

The results of this systematic review suggest that ERAS protocols may shorten hospitalizations, reduce postoperative complication rates, and reduce postoperative pain scores in children undergoing scoliosis surgery. Publication biases exist, and therefore larger, prospective, multicenter data are needed to validate these results.

Systematic review and meta-analysis of the clinical utility of Enhanced Recovery After Surgery pathways in adult spine surgery

OBJECTIVE

Spine surgery has been identified as a significant source of healthcare expenditures in the United States. Prolonged hospitalization has been cited as one source of increased spending, and there has been drive from providers and payors alike to decrease inpatient stays. One strategy currently being explored is the use of Enhanced Recovery After Surgery (ERAS) protocols. Here, the authors review the literature on adult spine ERAS protocols, focusing on clinical benefits and cost reductions. They also conducted a quantitative meta-analysis examining the following: 1) length of stay (LOS), 2) complication rate, 3) wound infection rate, 4) 30-day readmission rate, and 5) 30-day reoperation rate.

METHODS

Using the PRISMA guidelines, a search of the PubMed/Medline, Web of Science, Cochrane Reviews, Embase, CINAHL, and OVID Medline databases was conducted to identify all full-text articles in the English-language literature describing ERAS protocol implementation for adult spine surgery. A quantitative meta-analysis using random-effects modeling was performed for the identified clinical outcomes using studies that directly compared ERAS protocols with conventional care.

RESULTS

Of 950 articles reviewed, 34 were included in the qualitative analysis and 20 were included in the quantitative analysis. The most common protocol types were general spine surgery protocols and protocols for lumbar spine surgery patients. The most frequently cited benefits of ERAS protocols were shorter LOS (n = 12), lower postoperative pain scores (n = 6), and decreased complication rates (n = 4). The meta-analysis demonstrated shorter LOS for the general spine surgery (mean difference -1.22 days [95% CI -1.98 to -0.47]) and lumbar spine ERAS protocols (-1.53 days [95% CI -2.89 to -0.16]). Neither general nor lumbar spine protocols led to a significant difference in complication rates. Insufficient data existed to perform a meta-analysis of the differences in costs or postoperative narcotic use.

CONCLUSIONS

Present data suggest that ERAS protocol implementation may reduce hospitalization time among adult spine surgery patients and may lead to reductions in complication rates when applied to specific populations. To generate high-quality evidence capable of supporting practice guidelines, though, additional controlled trials are necessary to validate these early findings in larger populations.

[Enhanced recovery after surgery-Does the ERAS concept keep its promises]

INTRODUCTION

Perioperative enhanced recovery after surgery (ERAS) concepts or fast-track are supposed to accelerate recovery after surgery, reduce postoperative complications and shorten the hospital stay when compared to traditional perioperative treatment.

METHODS

Electronic search of the PubMed database to identify systematic reviews with meta-analysis (SR) comparing ERAS and traditional treatment.

RESULTS

The presented SR investigated 70 randomized controlled studies (RCT) with 12,986 patients and 93 non-RCT (24,335 patients) concerning abdominal, thoracic and vascular as well as orthopedic surgery. The complication rates were decreased under ERAS following colorectal esophageal, liver and pulmonary resections as well as after implantation of hip endoprostheses. Pulmonary complications were reduced after ERAS esophageal, gastric and pulmonary resections. The first bowel movements occurred earlier after ERAS colorectal resections and delayed gastric emptying was less often observed after ERAS pancreatic resection. Following ERAS fast-track esophageal resection, anastomotic leakage was diagnosed less often as well as surgical complications after ERAS pulmonary resection. The ERAS in all studies concerning orthopedic surgery and trials investigating implantation of a hip endoprosthesis or knee endoprosthesis reduced the risk for postoperative blood transfusions. Regardless of the type of surgery, ERAS shortened hospital stay without increasing readmissions.

CONCLUSION

Numerous clinical trials have confirmed that ERAS reduces postoperative morbidity, shortens hospital stay and accelerates recovery without increasing readmission rates following most surgical operations.

Physiologic and psychologic adaptation to exercise interventions in lung cancer patients undergoing chemotherapy: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

The purpose of this meta-analysis is to investigate the effectiveness of exercise interventions in patients with lung cancer (LC) during chemotherapy regarding physiological and psychological outcomes.

METHODS

Databases including MEDLINE and EMBASE were used to find relevant randomized controlled trails that explored outcomes of exercise interventions for patients with LC during chemotherapy up to June 2020. Effect sizes were calculated by standardized mean difference statistics.

RESULTS

Six studies were included that involved 244 participants with average age of 65 years. Patients with LC participating in exercise interventions during chemotherapy had significantly increased strength, forced expired volume, and quality of life as well as significantly decreased pain. Effective exercise intervention characteristics were combined aerobic and resistance exercise, performance more than 5 times a week, moderate to vigorous intensity, and 1-h sessions.

CONCLUSION

Supervised participation in exercise improves strength, forced expired volume, and quality of life and relieves pain and depression during chemotherapy.

Impact of an enhanced recovery after surgery pathway on thoracoscopic lobectomy outcomes in non-small cell lung cancer patients: a propensity score-matched study

Background

This study evaluates the effect of enhanced recovery after surgery (ERAS) pathways on postoperative outcomes of non-small cell lung cancer (NSCLC) patients undergoing video-assisted thoracic surgery (VATS) lobectomy.

Methods

We retrospectively reviewed all consecutive patients undergoing VATS lobectomy for NSCLC between January 2014 and October 2019 and assigned them to the relevant group (“pre-ERAS” or “ERAS”). Length of stay, readmissions and complications within 30 days were compared between both groups. A propensity score-matched analysis was performed based on sex, age, type of operation, comorbidities, American Society of Anesthesiologists (ASA) score and preoperative pulmonary functions.

Results

A total of 307 records (164 male/143 female; 140 ERAS/167 pre-ERAS; median age: 67) were reviewed. There was no statistical difference in patient’s characteristics. Overall ERAS compliance was 81%. The ERAS group presented significantly shorter length of stay (median 5 vs. 7 days; P=0.004) without significant difference in cardiopulmonary complication rate (27.1% vs. 35.9%; P=0.1). Readmission (3.6% vs. 5.4%; P=0.75) and duration of drainage (median 2 vs. 3 days; P=0.14) were similar between groups. The propensity score-matched analysis showed that the length of hospital stay was reduced by 1.4 days (P=0.034) and the postoperative cardiopulmonary complication rate by 13% (P=0.044) in the ERAS group.

Conclusions

Adoption of an ERAS pathway for VATS lobectomies in NSCLC patients has decreased the length of hospital stay and the cardiopulmonary complication rate without affecting the readmission rate.

Recommendations from the Italian intersociety consensus on Perioperative Anesthesia Care in Thoracic surgery (PACTS) part 1: preadmission and preoperative care

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.

Does an enhanced recovery after surgery protocol affect perioperative surgical outcomes in stage III tubercular empyema? A comparative analysis of 243 patients

BACKGROUND

Enhanced recovery after surgery protocols in tuberculous empyema surgery have the potential for improved outcomes, but have not been studied widely. This study aimed to analyze the outcomes after implementation of an enhanced recovery after surgery protocol in patients undergoing surgery for tubercular empyema.

METHODS

A retrospective analysis of patients who underwent surgery for tuberculous empyema in a dedicated thoracic surgery center from March 2012 to March 2019 was performed. The control group included patients operated on between March 2012 and March 2016. The enhanced recovery after surgery protocol was strictly introduced into our practice from April 2016. The study group included patients operated on between April 2016 and March 2019. All perioperative outcomes were measured, documented, analyzed, and compared between the two groups. There were 166 patients in the control group and 77 in the study group.

RESULTS

Intraoperative blood loss (p = 0.0001), prolonged air leak (p = 0.04), chest tube duration (p = 0.005), and length of stay (p = 0.003) were significantly reduced in the study group. Overall rates of postoperative complications (p = 0.04) including wound infection (p = 0.01) were also significantly lower in the study group.

CONCLUSIONS

Implementation of an enhanced recovery after surgery protocol in patients undergoing surgery for tuberculous empyema is feasible and effective. Application of such a protocol leads to less intraoperative blood loss, shorter hospital stay and duration of chest drainage, and fewer complications. Application of enhanced recovery after surgery protocols are strongly recommended in tubercular empyema surgery.

Recommendations from the Italian intersociety consensus on Perioperative Anesthesa Care in Thoracic surgery (PACTS) part 2: intraoperative and postoperative care

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.

Four Hours Postoperative Mobilization is Feasible After Thoracoscopic Anatomical Pulmonary Resection

BACKGROUND

We aimed to analyze the feasibility and risk factors associated with early mobilization (EM) within 4 h after thoracoscopic lobectomy and segmentectomy.

METHODS

This study retrospectively evaluated 214 consecutive patients who underwent thoracoscopic anatomical pulmonary resection using our EM protocol between October 2017 and February 2019. We compared the correlations of the patients' characteristics including the total number of drugs and perioperative parameters such as air leak, and orthostatic hypotension (OH) between the EM (E group) and failed EM (F group) groups. Second, we evaluated risk factors for OH, which often causes critical complications.

RESULTS

A total of 198 patients (92.5%: E group) completed the EM protocol, whereas 16 patients did not (7.5%: F group). The primary causes of failure were severe pain, air leak, postoperative nausea and vomiting, and OH (n = 1, 3, 8, and 4). Upon univariate analysis, air leakage, OH, and non-hypertension were identified as risk factors for failed EM (all p <0.05). EM was associated with a shortened chest tube drainage period (p <0.01). Thirty patients (14%) experienced OH, and 20% of them failed EM. A total number of drugs ≥5 (p = 0.015) was an independent risk factor for OH. Operative and anesthetic variables were not associated with EM or OH.

CONCLUSIONS

The EM protocol was safe and useful for tubeless management. Surgeons should be advised to actively prevent air leak. Our EM protocol achieved a low frequency of OH in mobilization. Due to its versatility, our mobilization protocol may be promising, especially in patients without severe comorbidities. Clinical registration number: The study protocol was approved by the Review Board of Aichi Cancer Center (approval number: 2020-1-067).

Nutritional Support in Lung Cancer Patients: The State of the Art

Lung cancer (LC) represents the most commonly diagnosed neoplasm worldwide for both sexes and is the leading cause of cancer mortality. Malnutrition is a comorbidity frequently found in neoplastic patients, but it remains often underestimated and thus undertreated. In this review, we aimed to investigate the incidence of malnutrition among LC patients according to different screening and assessment tools, to evaluate the impact of weight loss and body composition on survival, and to analyze the efficacy of different nutritional interventions in this setting. Although malnutrition, weight loss, and body composition changes can affect survival and other clinical outcomes in LC patients, the role of nutritional interventions is not yet strongly proven, and further studies are recommended. Nevertheless, screening, assessing, and eventually treating malnutrition in LC patients are strongly recommended, according to the most recent nutritional intervention guidelines for oncology patients.

Comprehensive Pulmonary Rehabilitation is an Effective Way for Better Postoperative Outcomes in Surgical Lung Cancer Patients with Risk Factors: A Propensity Score-Matched Retrospective Cohort Study

Background

To investigate the effectiveness and cost minimization of comprehensive pulmonary rehabilitation (CPR) in lung cancer patients who underwent surgery.

Patients and Methods

A retrospective observational study based on medical records was conducted, with 2410 lung cancer patients who underwent an operation with/without CPR during the peri-operative period. Variables including clinical characteristics, length of stay (LOS), postoperative pulmonary complications (PPCs), and hospitalization expenses were compared between the intervention group (IG) and control group (CG). The CPR regimen consists of inspiratory muscle training (IMT), aerobic endurance training, and pharmacotherapy.

Results

Propensity score matching analysis was performed between two groups, and the ratio of matched patients was 1:4. Finally, 205 cases of IG and 820 cases of CG in the matched cohort of our study were identified. The length of postoperative hospital stay [median: 5 interquartile (4–7) vs 7 (4–8) days, P < 0.001] and drug expenses [7146 (5411–8987) vs 8253 (6048–11,483) ¥, P < 0.001] in the IG were lower compared with the CG. Additionally, the overall incidence of PPCs in the IG was reduced compared with the CG (26.8% vs 36.7%, P = 0.008), including pneumonia (10.7% vs 16.8%, P = 0.035) and atelectasis (8.8% vs 14.0%, P = 0.046). Multivariable analysis showed that CPR intervention (OR = 0.655, 95% CI: 0.430–0.865, P = 0.006), age ≥70 yr (OR = 1.919, 95% CI: 1.342–2.744, P < 0.001), smoking (OR = 2.048, 95% CI: 1.552–2.704, P < 0.001) and COPD (OR = 1.158, 95% CI: 1.160–2.152, P = 0.004) were related to PPCs.

Conclusion

The retrospective cohort study revealed a lower PPC rate and the shorter postoperative length of stay in the patients receiving CPR, demonstrating the clinical value of CRP as an effective strategy for surgical lung cancer patients with risk factors.

Enhanced recovery after surgery on multiple clinical outcomes: Umbrella review of systematic reviews and meta-analyses

BACKGROUND

Previously, many meta-analyses have reported the impact of enhanced recovery after surgery (ERAS) programs on many surgical specialties.

OBJECTIVES

To systematically assess the effects of ERAS pathways on multiple clinical outcomes in surgery.

DESIGN

An umbrella review of meta-analyses.

DATE SOURCES

PubMed, Embase, Web of Science and the Cochrane Library.

RESULTS

The umbrella review identified 23 meta-analyses of interventional study and observational study. Consistent and robust evidence shown that the ERAS programs can significantly reduce the length of hospital stay (MD: -2.349 days; 95%CI: -2.740 to -1.958) and costs (MD: -$639.064; 95%CI:: -933.850 to -344.278) in all the surgery patients included in the review compared with traditional perioperative care. The ERAS programs would not increase mortality in all surgeries and can even reduce 30-days mortality rate (OR: 0.40; 95%CI: 0.23 to 0.67) in orthopedic surgery. Meanwhile, it also would not increase morbidity except laparoscopic gastric cancer surgery (RR: 1.49; 95%CI: 1.04 to 2.13). Moreover, readmission rate was increased in open gastric cancer surgery (RR: 1.92; 95%CI: 1.00 to 3.67).

CONCLUSION

The ERAS programs are considered to be safe and efficient in surgery patients. However, precaution is necessary for gastric cancer surgery.

[Clinical Evaluation of Absorbable Regenerated Oxidized Cellulose in Lung Cancer Surgery]

背景与目的

胸腔镜下安全有效的止血是开展胸外科快速康复的重要条件，术中放置止血材料是肺癌腔镜手术中常用的方法，其中可吸收再生氧化纤维素是常用的止血材料。本研究旨在观察可吸收再生氧化纤维素在肺癌手术中的止血效果。

方法

回顾性分析2018年7月1日-2018年12月1日于浙江大学医学院附属第一医院胸外科行胸腔镜肺癌根治手术且术中使用可吸收再生氧化纤维素止血的42例患者的临床病理资料，选取围手术期指标作为结局事件进行统计分析。

结果

平均手术时间为（120.5±57.3）min，术中平均出血量为（26.8±21.6）mL，术后平均引流量为（513.6±359.5）mL，术后胸管平均留置时间为（2.6±1.2）d。

结论

胸腔镜肺癌根治术术中使用可吸收再生氧化纤维素具有良好的止血效果，适用于淋巴结清扫后创面填塞止血。

[Proper Selection of Enhanced Recovery after Surgery Programs between the Medical Service and Medical Intervence - Is It Time to Do?]

加速康复外科（enhanced recovery after surgery, ERAS）理念诞生与微创外科技术进步密切相关。ERAS发展过程中利用技术，又融入人文因素，使其高于技术，而丰富ERAS的内涵和外延。结合近年ERAS在外科各领域的进展，总结ERAS临床应用的现状与策略：一是微创技术进步使ERAS理念的临床应用成为必然；二是外科学理论与技术的发展，深入与扩大了ERAS的内涵与外延；三是ERAS临床应用需要我们更新观念；四是ERAS的临床实践需要在医疗服务和医疗干预之间合理选择；五是ERAS临床应用加减之间应用的现实问题与策略。从而深入理解ERAS的真正临床意义，更好地指导临床实践。

[Clinical Effect of Day Surgery in Patients with Lung Caner by Optimize Operating Process]

BACKGROUND

The types and number of day surgery are increasing, what is the result of day surgery of selected patients with lung cancer? To explore the operation process and clinical effect of day surgery in patients with lung cancer by fusing the concept of enhanced recovery after surgery (ERAS) and minimally invasive surgical techniques.

METHODS

A prospective study was planned with the approval of our institutional review board. 153 lung cancer patients who underwent anatomic resection in a single medical group between June 2019 and Nov 2019 were randomized. 20 patients were applied day surgery and 28 patients by inpatient surgery and the average length of stay, average hospital cost , complications and adverse reactions were analysed.

RESULTS

The average hospital day in DSG group (1 d) was significantly shorter than in ISG group (7.7±2.8) d (P=0.000). The average hospital cost in DSG group (38,297.3±3,408.7)¥ was significantly lower than in ISG group (47,831.1±7,376.1)¥ (P=0.000). There was no significant difference in the incidence of postoperative complications between the daytime surgery group (5.0%) and the inpatient surgery group (3.6%) (P=0.812). The postoperation adverse reactions in DSG (10.0%) and ISG (17.9%) is no difference (P=0.72).

CONCLUSIONS

Our study showed that the same clinical effect achieved between DSG and ISG, and recover quickly lung cancer patients after day surgery.

[Current Situation and Strategy of Day Surgery in Patients with Lung Cancer by Enhanced Recovery after Surgery]

加速康复外科（enhanced recovery after surgery, ERAS）理论、手术器械和治疗病种的变化，均需要重新审视现在的临床治疗观念和操作流程。ERAS理念从兴起到完善，为复杂却风险低的手术日间化提供了理论和技术支持。结合最近的国内外临床实践，以肺癌为例，分析肺癌手术日间化面临的问题与应对策略。从以下几方面论述：一是肺癌患者由住院手术转为日间手术（ambulatory surgery day surgery）的必要性与可行性；二是肺癌手术日间化的团队及平台建设；三是肺癌日间手术操作流程及围手术期管理需要优化；四是利用“分级诊疗-日间手术”模式保障患者安全；五是肺癌日间手术临床应用前景。