Enhanced Recovery After Surgery (ERAS®) in thoracic surgical oncology

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Enhanced recovery after surgery program focusing on chest tube management improves surgical recovery after video-assisted thoracoscopic surgery

OBJECTIVE

Chest drainage is a standard procedure in thoracoscopic surgery for lung cancer. However, chest tube placement may deteriorate the ventilation capacity and increase difficulty of postoperative management of patients. The study investigated on the effects of enhanced recovery after surgery (ERAS) program focusing on chest tube management on surgical recovery of lung cancer patients.

METHODS

The study population consisted of 60 patients undergoing video-assisted thoracoscopic surgery (VATS) after implementation of ERAS program and another group of 60 patients undergoing VATS before implementation of ERAS program.

RESULTS

The mean time of first food intake was 12.9 h required for the ERAS group, which was significantly shorter than 18.4 h required for the control group (p < 0.0001). The mean time of out-of-bed activity was 14.2 h taken for the ERAS group, which was notably shorter than 22.8 h taken for the control group (p < 0.0001). The duration of chest tube placement was 68.6 h in the ERAS group, which was remarkably shorter than 92.8 h in the control group (p < 0.0001). The rate overall postoperative complications were notably lower in the ERAS group than in the control group (p = 0.018). The visual analogue score (VAS) scores on the second postoperative day exhibited significant differences between the ERAS group and the control group (p = 0.017). The patients in the ERAS group had a shorter hospitalization stay than those in the control group (p < 0.0001).

CONCLUSION

The study suggests the ERAS program focusing on chest tube management could improve surgical recovery, remove patient chest tube earlier, and relieve patient pain after VATS.

Can postoperative complications be reduced by the application of ERAS protocols in operated non-small cell lung cancer patients?

Background

In our study, we aimed to evaluate the length of hospital stay and complication rate of patients before and after application o f t he E nhanced R ecovery A fter S urgery ( ERAS) protocols.

Methods

Between January 2001 and January 2021, a total of 845 patients (687 males, 158 females; mean age: 55±11 years; range, 19 to 89 years) who were operated with the diagnosis of non-small cell lung carcinoma were retrospectively analyzed. The patients were divided into three groups as follows: patients between 2001 and 2010 were evaluated as pre-ERAS (Group 1, n=285), patients between 2011 and 2015 as preparation for ERAS period (Group 2, n=269), and patients who had resection between 2016 and 2021 as the ERAS period (Group 3, n=291).

Results

All three groups were similar in terms of clinical, surgical and demographic characteristics. Smoking history was statistically significantly less in Group 3 (p=0.005). The forced expiratory volume in 1 sec/forced vital capacity and albumin levels were statistically significantly higher in Group 3 (p<0.001 and p=0.019, respectively). The leukocyte count and tumor maximum standardized uptake value were statistically significantly higher in Group 1 (p=0.018 and p=0.014, respectively). Postoperative hospitalization day, complication rate, and intensive care hospitalization rates were statistically significantly lower in Group 3 (p<0.001). The rate of additional disease was statistically significantly higher in Group 1 (p=0.030). Albumin level (<2.8 g/dL), lymphocyte/monocyte ratio (<1.35), and hemoglobin level (<8.3 g/dL) were found to be significant predictors of complication development.

Conclusion

With the application of ERAS protocols, length of postoperative hospital stay, complication rate, and the need for intensive care hospitalization decrease. Preoperative hemoglobin level, albumin level, and lymphocyte/monocyte ratio are the predictors of complication development. Increasing hemoglobin and albumin levels before operation may reduce postoperative complications.

Delayed Discharge after Thoracic Surgery under the Guidance of ERAS Protocols

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Prophylactic octreotide does not reduce the incidence of postoperative chylothorax following lobectomy: Results from a retrospective study

Chylothorax after lobectomy is common, lacking reliable preventive measures. Octreotide is widely used for treatment of chyle leakage, but its role in preventing chylothorax has not been estimated. The aim of this study was to evaluate whether prophylactic octreotide could reduce the incidence of postoperative chylothorax.Patients who underwent lobectomy for lung cancer from January 2016 to September 2018 were retrospectively reviewed. The cases in prophylactic group received octreotide 1 day before the surgery until removal of chest tubes, while those in the control group did not use it unless the diagnosis of chylothorax.A total of 379 patients were enrolled, with 190 patients in control and 189 cases in prophylactic group. Octreotide was well tolerated in patients who received this agent. No 30-day mortality was indicated. Seven cases in control (3.7%, 7/190) and 3 cases in prophylactic group (1.6%, 3/189) with chylothorax were observed (P = .337). The patients in prophylactic group showed shorter duration of chest drainage ([3.6 ± 1.6] days vs [4.1 ± 2.0] days, P = .006) and reduced drainage volume ([441.8 ± 271.1] mL vs [638.7 ± 463.3] mL, P < .001). In addition, they showed similar stations and numbers of dissected lymph nodes, surgery-related complications, and postoperative hospital stay. Besides, 11 (5.8%, 11/190) patients in control and 6 (3.2%, 6/189) cases in the prophylactic group were readmitted for pleural effusion needing reinsertion of chest tubes (P = .321). Moreover, multivariable logistic analysis showed that induction therapy (odds ratio [OR] =12.03; 95% confidence interval [CI] 3.15-46.03, P < .001) was a risk factor, while high-volume experience of the surgeon (OR = 0.23; 95% CI 0.06-0.97, P = .045) was a preventive factor of surgery-related chylothorax. Additionally, prophylactic octreotide (OR = 0.18; 95% CI 0.11-0.28, P < .001) and perioperative low-fat diet (OR = 0.46; 95% CI 0.29-0.73, P = .001) were negatively associated with the drainage volume of pleural effusion. Furthermore, high-volume experience of the surgeon (OR = 6.03; 95% CI 1.30-27.85, P = .021) and induction therapy (OR = 8.87; 95% CI 2.97-26.48, P < .001) were risk factors of unplanned readmission.Prophylactic octreotide does not reduce the incidence of postoperative chylothorax or unplanned readmission following anatomic lobectomy. The routine application of octreotide should not be recommended. High-quality trials are required to validate these findings.

Late-onset chylothorax during chemotherapy after lobectomy for lung cancer: A case report and review of the literature

RATIONALE

Chylothorax is usually diagnosed within a few days after lobectomy. Late-onset chylothorax following trauma or thoracic surgery is rare but potentially lethal, lacking reliable preventive methods.

PATIENT CONCERNS

A 54-year-old male patient complained of dyspnea during adjuvant chemotherapy on the 35th postoperative day after right middle lobectomy and systemic lymph node dissection (SLND) for lung cancer. His computed tomography indicated massive pleural effusion filling in the right chest cavity.

DIAGNOSES

The patient was primarily diagnosed as late-onset chylothorax, without definite evidence to exclude spontaneous chylous leakage.

INTERVENTIONS

Uniportal video-assisted thoracoscopic thoracic duct ligation (TDL) was performed for him, as conservative treatment using octreotide with fat-free diet turned out to be ineffective.

OUTCOMES

His pleural effusion was gradually diminished after reoperation, and the patient was discharged 9 days after TDL.

LESSONS

Postoperative late-onset or spontaneous chylothorax should be kept in mind after pulmonary resection and SLND, and the exclusion of chylous leakage could be considered as a precondition of chest tube removal.