Implementation of enhanced recovery after surgery program for lung resection

Introduction

Background

Enhanced recovery after surgery (ERAS), an evidence-based multimodal protocol of perioperative care, was firstly introduced in the late 1990s, and has been increasingly implemented in most surgical specialties. Over the years, ERAS pathways were seen to be effective in reducing hospital length of stay (LOS) and postoperative complication rates (1).

Comprehensive ERAS pathways encompass all phases of perioperative care, from initial consultation with a surgical team to post-operative recovery. Multiple improvements and efficiencies at every step in the peri-operative treatment trajectory are adopted in an evidence-based manner by a multidisciplinary team. These care elements are believed to have synergistic effects on the attenuation of operative stress responses and the protection of baseline function status, leading to an accelerated recovery (2,3). Individual care elements may not necessarily have significant benefits when studied in isolation, but their combination with other elements of the pathway is thought to have a synergistic effect (3).

Rationale and knowledge gap

In recent years, specific ERAS pathways for thoracic surgery have been published, with most reporting benefits such as shorter LOS, lower hospital costs, and fewer pulmonary and cardiac complications (4-8). In 2019, the European Society of Thoracic Surgery (ESTS) published the Guidelines for enhanced recovery after lung surgery (9). These comprehensive guidelines introduced 45 evidence-based recommendations for the ERAS protocol covering 21 areas of peri-operative care. These recommendations have formed the foundation for many ERAS protocols developed in recent years. Several systematic reviews have suggested various degrees of favorable outcomes regarding LOS, hospitalization costs, and reduced complications with ERAS protocols in lung surgery (10-12). However, these reviews also highlighted significant heterogeneity, which weakens the overall findings. This variability presents challenges in implementing, evaluating, and comparing ERAS protocols. The process of implementing a protocol is complex (4,13). Across countries, healthcare systems, and institutions, the emphasis on specific ERAS elements may differ. Variations exist in how protocol compliance is measured, which outcomes are evaluated, and how those outcomes are assessed. Indeed, the literature reports considerable variability in the extent to which ERAS guidelines are applied in clinical practice (5-8,14).

Objective

In this clinical practice review, we have selected seven perioperative elements from the ESTS guidelines that in our view are specific or essential to lung surgery. Based on a PubMed search for recent publications (from the past five years) on each topic, as well as the ESTS guidelines, we provide a brief discussion and expand on our clinical practice at the McGill University Health Centre (MUHC).

Key elements of ERAS in lung resection

Preoperative assessment and counselling

Preoperative counselling helps to set expectations about surgical and anaesthetic procedures and may diminish fear, fatigue and pain and enhance recovery and early discharge (15). Ideally patients should receive information in written, electronic, and oral formats. As in most surgeries, the preoperative consultation is also an opportunity to detect laboratory abnormalities and treat them if reversable, stratify the surgical risk, and address potential behavioral changes such as smoking cessation (16,17).

Pulmonary functions, preoperative exercise and prehabilitation

Forced expiratory volume at first second (FEV1) is essential parameter when evaluating patients for lung resection, and predicted postoperative FEV1 (ppoFEV1) has been shown to correlate with the risk of morbidity and mortality for lung surgery since the 1980s (18-23), although the majority of the surgeries in these studies were thoracotomies. In a 2009 retrospective observational study, FEV1 was an independent predictor of respiratory morbidity for thoracotomy patients but not for those treated with a thoracoscopic approach. Furthermore, there is growing evidence that in chronic obstructive pulmonary disease (COPD) patients, the measured postoperative FEV1 is higher than the evaluated ppoFEV1 (24-30), rendering it less reliable for this population. Carbon monoxide lung diffusion capacity (DLCO) has consistently been shown to play a central role in risk stratification before lung resection. Many studies have found predicted postoperative DLCO (ppoDLCO) to be a significant predictor of pulmonary complications and mortality in both patients with and without COPD (31-38). Nevertheless, low DLCO and/or FEV1 currently do not exclude a patient from lung resection surgery but are an indicator of the need for further investigation in the form of a cardiopulmonary exercise test, with low maximum rate of oxygen consumption attainable during physical exertion (VO₂max) (threshold ranging from 10–15 mL/kg/min in different trials) as a predictor of postoperative complications, pulmonary complications, and morbidity (39-42). In conclusion, poorer preoperative exercise capacity, and poor pulmonary function in particular, is associated with worse long- and short-term clinical outcomes, including postoperative complications, LOS, and survival following curative lung cancer surgery (42-45).

Optimizing these physiological parameters prior to surgery make sense as an approach to improve recovery in patients undergoing lung resection. Indeed, the benefit of pulmonary rehabilitation for patients with severe COPD in the absence of planned surgery is well characterized (46). Preoperative physical conditioning, or prehabilitation, is the process of enhancing the functional and physiological capacity of an individual to enable them to withstand a stressful event and may aid in recovery after surgery. In colorectal surgery, prehabilitation has been shown to be effective in returning a patient to baseline function prior to a surgical insult (47,48). Although shown to be beneficial (49-52), study heterogeneity, the exact duration, intensity, structure, and patient selection to achieve maximum efficacy is uncertain. Studies report an improvement in peak oxygen consumption, lung function, and in functional capacity (measured with the 6-minute walk test) from baseline to post-intervention (52).

A Randomized Controlled Trial conducted at The Montreal General Hospital, demonstrated that home-based multimodal prehabilitation program 4 weeks prior to lung resection surgery was as effective in recovering functional capacity as the post-operative rehabilitation with the same multimodal intervention (53). The program consisted of moderate aerobic and resistance exercises in a home base setting, and included nutritional counseling with whey protein supplementation, and anxiety-reduction strategies. The prehabilitation program is an important tool in our arsenal when dealing with high-risk patients. Moreover, the time of treatment during neoadjuvant systemic therapy offers an ideal opportunity to improve the baseline functional status of the patient in preparation for an eventual surgery. At The Montreal General Hospital a significant portion of patients undergoing neoadjuvant therapy utilized this program (54).

Pain management

Proper pain management is vital after thoracic surgery, as pain can be debilitating and lead to poor outcomes, such as respiratory complications, longer hospital stays, poor quality of life, and chronic post-thoracotomy pain syndrome. A multimodal analgesic strategy is required to keep the patient comfortable, allow early mobilization, and reduce the risk of pulmonary complications. Avoidance of opioids allow better post-operative nausea and vomiting (PONV) control and quick return to oral diet. Inadequate analgesia following either VATS or thoracotomy can exacerbate a compromised respiratory status. It may lead to respiratory failure secondary to splinting or pneumonia as a result of an ineffective cough and poor clearance of secretions. Pain increases immediate risks to the patient of hypoxaemia, hypercarbia, increased myocardial work, arrhythmias, and ischemia. Therefore, an enhanced recovery pathway for thoracic surgery must combine multimodal approach with systemic, regional analgesia and local anaesthetic techniques while attempting to avoid opioids and their side effects (55). Patient education is also important as well-informed patients may experience less pain (56).

Intraoperative regional analgesia

Historically, thoracic epidural analgesia was considered gold standard in thoracic surgery, as it was helpful in reducing pulmonary complications, although in itself has adverse effects such as urinary retention, hypotension, and muscular weakness (57). As surgical and anaesthetic techniques continue to develop and offer efficient and safe alternatives, the role of epidural anesthesia in thoracic surgery is quickly diminishing. A variety of novel techniques are currently routinely used and investigated worldwide, such as paravertebral analgesia, intercostal catheters and blocks, serratus anterior plane block, and erector spinae plane block. These techniques have been shown to provide an effective analgesia, reduce post-operative opioid consumption, and have low complication profile (55,58-65). These techniques can be used in conjuncture, and the method of choice based on operator preference and experience with the specific techniques.

At The Montreal General Hospital, our regional anesthesia of choice is usually an ultrasound-guided erector spinae plane block, performed by the anesthetist prior to surgery, plus intercostal block performed by the surgeon during the operation.

Post-operative multimodal analgesia

Postoperatively, a multimodal analgesic regimen should be employed, aiming to minimize the use of opioids. The use of additive or synergistic effects of different types of analgesics, should ideally allow the side effects of individual drugs to be minimized while potentiating their positive effects and reducing the use of opioids.

Acetaminophen is a vital part of postoperative pain control and can be administered either intravenously or orally (66). It has been shown that adding acetaminophen after major can reduce morphine consumption by 20% but did not decrease the incidence of morphine-related adverse effects (67). Acetaminophen at clinical doses has few contraindications or side effects. It is considered safe for patients at risk of renal failure (68). Non-steroidal anti-inflammatory drugs (NSAIDs) in combination with acetaminophen are more effective than either drug alone (69). NSAIDs have been used to control post-thoracotomy pain (70) and significantly improve pain control in patients receiving systemic opioids (71,72). The risk of Renal failure is a common reason for avoidance of NSAIDs patients.

Opioids, while beneficial in providing analgesia and prevent splinting, can have detrimental effects (PONV, constipation, sedation and the suppression of ventilation and coughing). Therefore, their use, including patient-controlled analgesia, should be kept to a minimum or avoided when possible.

Surgical technique

Although minimally invasive techniques like VATS and robotic surgery are becoming increasingly popular, a significant number of pulmonary resections worldwide are still performed using thoracotomy. Adoption of the technique was slow, with debates over the lack of evidence regarding the safety and oncologic outcomes (mainly, accuracy and extension of lymph node dissection). Although over the years, studies showed that minimally invasive techniques are associated with favorable outcomes, such as less pain, better shoulder function, earlier mobilization, shorter LOS, better preservation of pulmonary function and better quality of life (73-75), until recently the scarcity of randomised control trials has hindered the adoption of the techniques. Recently, a large UK multicenter randomized controlled trial, the VIOLET trial, was published. In this study, participants were blinded to the surgical approach (VATS versus thoracotomy) until hospital discharge. The trial demonstrated that VATS lobectomy was associated with less pain, fewer complications, and improved quality of life, without compromising oncologic outcomes (74). The clinical benefits of a minimally invasive approach are particularly evident in high-risk patients with poor predicted postoperative lung function (76). At The Montreal General Hospital, we use VATS for most of our patients, including post neoadjuvant and complex resections (77) as well as for locally advanced disease.

Minimal invasive thoracic surgery is a constantly evolving field, with a variety of techniques. The biportal and single portal approaches are increasingly replacing the traditional triportal VATS, maintaining that by decreasing the number of accesses and consequently reducing the number of damaged intercostal nerves, an additional advantage would be obtained in term of postoperative pain. The subxiphoid and subcostal approaches avoid the intercostal nerves, decreasing post-operative pain. On the other hand, an increased risk of bleeding has been reported in subxiphoid VATS lobectomy, and it requires highly experienced thoracoscopic surgeons and adequate instrumentation (78).

Robotic-assisted thoracic surgery (RATS) is the other main approach in thoracic minimal invasive surgery, and it is increasingly used worldwide. The robotic advantages compared to VATS are binocular visualization allowing an excellent high-definition three-dimensional view of the operating field, and the degrees of freedom of robotics instruments compared to the straight rigid ones used by VATS. The main limits are high costs, the availability in peripherical structures and longer learning curve in surgeons without solid mini-invasive background (79).

Studies comparing the different methods have not consistently shown significant advantage of one over the other (80-82). The debate over these methods will probably continue to exist over the next years, with surgeons using the approaches in which they feel comfortable and safe while operating.

Chest drain management

Post-operative chest tubes are an important element of recovery after lung resection surgery, as they can cause pain, reduced pulmonary function and immobility, irrespective of the surgical approach (83). Minimising chest tube number and duration is an important part of an ERAS program.

Surgical technique

Prevention is the first step in order to minimize post-operative chest tube duration and avoid prolonged air leak. A 2017 systematic review and meta-analysis demonstrated that fissureless technique in pulmonary lobectomy could significantly reduce the incidence of prolonged air leak and the duration of chest tube (84,85). Fibrin glue, absorbable meshes, and various surgical sealants have been reported and commercially advocated as preventive measures for air leaks. However, they have yet to be routinely adopted, possibly due to concerns about cost or effectiveness. In The Montreal General Hospital, whenever possible, the lobectomies are performed in fissureless technique. We do not routinely use any sealers.

Suction versus water seal

The evidence regarding the use of external suction is conflicting (86-88). While no suction has been shown to be effective in some circumstances at reducing the duration of air leak, presumably by decreasing the airflow (89,90), the absence of suction may be ineffective in draining large air leaks and has been associated with increased risk of other complications (particularly pneumonia and arrhythmia) (91). At The Montreal General Hospital, we employ suction judiciously, with the default choice of water seal.

Digital drainage systems

Digital drainage systems, while expensive, have several advantages over a traditional water seal. They are light, compact, able to objectively quantify the volume of air leak and have a built-in suction pump, so do not need to be attached to wall suction, should suction be required, favouring early patient mobilization (92). Digital air leak tracking and its accuracy can allow chest drain removal criteria using shorter intervals (93). In The Montreal General Hospital we use traditional water seal device.

Pleural fluid drainage

Historically, the threshold for removal of chest tube post-operatively was absence of air leak and less than approximately 200 mL/day, but studies on more aggressive chest drain removal strategies have been shown to be safe. A non-chylous fluid threshold of 450 mL/day after thoracotomy was associated with only a 0.55% readmission rate for recurrent symptomatic pleural effusion (94). A higher threshold of 500 mL/day following VATS lobectomy resulted in an incidence of clinically relevant recurrent effusions (needing drainage or aspiration) in only 2.8% of patients (95). In the last several years we have used in The Montreal General Hospital the threshold of less than 800 mL of non-bloody, non-chylous fluid with low readmissions and complication rate (96).

Number of chest tubes

In recent years there is less use of the traditional 2 chest tubes after lung resection. Several randomized trials have demonstrated that the use of a single chest tube after lobectomy is safe and effective with no differences in residual pleural effusion or the need to reinsert a chest tube but is significantly less painful than 2 drains (97-99). Some surgeons have even reported safely omitting the chest drain or removing it in the operating room in anatomical lung resections (100). However, while this approach is becoming more common in minor thoracic surgeries and wedge resections (96,97), it has yet to demonstrate its safety and gain widespread acceptance in major lung resections. Our standard lobectomy patient will have one chest tube.

Early mobilization

Early mobilization is an important part of ERAS and is encouraged even though it is difficult to prove its benefit as standalone contributor in the post-lung resection recovery (51,101,102). Bed rest is associated with increased pulmonary complications (atelectasis and pneumonia) and increased risk of venous thromboembolism (VTE) (103,104). Our patients are encouraged to walk as soon as possible with our physical therapists, many of them at the day of the surgery.

Incentive spirometry

Post-operative incentive spirometry it is used in many ERAS programs, including ours. Although it has not been shown to reduce post-operative pulmonary complications or LOS when compared to other chest rehabilitation strategies (105), it is a relatively inexpensive intervention that motivates many patients to perform regular breathing exercises without our team help. Incentive spirometry may have a benefit in higher-risk patient populations such as those with COPD, but further studies are required.

Discussion and McGill Enhanced Recovery Program for Lung Surgery

ERAS pathways aim to encompass multiple aspects of the patient trajectory, including the preoperative, perioperative, and postoperative management. The multitude of these steps and variability among centers and surgeons make it challenging to assess the impact of individual interventions or the pathway as a whole. Additionally, some interventions included in lung surgery ERAS protocols are becoming outdated as advancements and new techniques emerge each year (106). For instance, practices regarding the number of chest drains and removal criteria have evolved over time. Similarly, thoracic epidural analgesia, once commonly used in ERAS protocols, is now rarely employed due to the adoption of newer regional block techniques. Even with those limitations, it is clear that ERAS pathways have many advantages without compromising patient care, as elaborated above. Also, it reduces health-care system costs, and the cost burden on the patient and caregiver after discharge (107). ERAS implementation process can be assisted and evaluated by a value-based health care approach as a more comprehensive method of assessing costs and outcome of lung surgery. This approach combines well-defined key-performance indicators of patient outcome and measures them, while taking the costs of care into consideration (108-110).

The MUHC had adopted ERAS pathway for lung surgery in 2012. Funding was provided by the Department of Surgery, providing a full time ERAS nurse. We have shown, for lung as well as other procedures (e.g., esophagectomy, colectomy), the significant economic savings to both the hospital system as well as to the society as a whole by having patients enrolled in ERAS pathways that far outweigh the costs of the enhanced recovery program (107,111,112). Our early results showed reduction in LOS and complications with no difference in readmissions (113). When we looked retrospectively at our VATS lobectomy patients over the years, more of them were discharged home during the first 23 hours after the implementation of ERAS protocols (96). Our ERAS pathways continue to constantly evolve. As an example, our cut-off for removing chest tube has changed from 300 mL/day of non-bloody non-chyle drainage to a more lenient 800 mL/day. VATS surgery is performed where possible, also for many patients with locally advanced disease (stage II/III), and patients after neoadjuvant treatment (114).

Our team is constantly searching for ways to lower complications and LOS, while improving the patient experience. In a trial conducted in The Montreal General Hospital (115), patients were connected to portable drainage devices after anatomical lung resection surgery and underwent clamp test on post-operative day 1 (POD1). Patients who failed the clamp test were discharged home with the portable device and were followed electively at The Montreal General Hospital Thoracic Surgical Clinic. POD1 discharge rate was 72% in Portable drainage group vs. 15% the standard care group. There were no significant differences in length of indwelling chest-tube, rate of discharge with chest-tube, post-operative complications, or readmissions.

In 2023, we conducted a Phase I Safety and Feasibility Pilot Study of Same-Day Discharge after VATS Anatomical Lung or Wedge Resection (VALUE) trial, yet to be published. After consent and education, we aimed for the patients to be discharged home on the day of the surgery with a portable drainage device, and to come back to The Montreal General Hospital Thoracic Surgical Clinic 2 days after discharge for clamp test and chest tube removal when possible. Same day discharge was achieved in 18 (95%) out of 19 patients, with no grade 3–4 complications or readmissions. Thirteen (68%) patients underwent anatomical lung resections (lobectomy or segmentectomy). We plan to assess the 23 hours discharge pathway and same day discharge pathway on a larger scale, aiming to implement them for more of our patients.

Our current pathway principles, as shown in Table 1, illustrate the pre-operative patient education. Patients receive a booklet outlining their expected journey before, during and after their surgery. Figures 1,2 are examples taken from the patient education website (https://www.muhcpatienteducation.ca/DATA/GUIDE/163_en~v~lung-surgery-montreal-general-hospital.pdf).

Figure 1 An example of patient education material from the MUHC lung surgery website, outlining the expected activities, diet and pain management for the day of surgery. MUHC, McGill University Health Centre.

Figure 2 An example of patient education material from the MUHC lung surgery website, explaining the pain intensity scale and highlighting the importance of proper pain management after surgery. MUHC, McGill University Health Centre.

Pain management and early mobilization are crucial components in thoracic surgery enhanced recovery, and many aspects of our protocol aim for these goals. A standard lobectomy patient at The Montreal General Hospital will undergo VATS surgery, with regional anesthesia (erector spinae plane block preoperatively by the anaesthesia team plus intraoperative intercostal block by the surgeon). No urinary catheter is inserted, and patient will have one chest tube which we aim to remove as soon as possible (no air leak and less than 800 mL/day of non-bloody non-chyle fluid). We try to avoid opiates, using them only when needed. Patient education and managing their expectations is also important in advancing them to early mobilization. Complications are documented prospectively and graded using the Ottawa Thoracic Morbidity and Mortality classification system (116).

Conclusions

In recent years, ERAS protocols for lung surgery have been established and studied. However, the wide range of possible interventions and the variability among centers and surgeons make it challenging to evaluate the impact of individual interventions or entire pathways. Despite these limitations, it is evident that ERAS pathways offer significant advantages without compromising patient care. The implementation of ERAS protocols in lung surgery is a multidisciplinary process that is both feasible and safe.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Donna E. Maziak and Patrick J. Villeneuve) for the series “Comprehensive Lung Cancer Care: A Continuum” published in Current Challenges in Thoracic Surgery. The article has undergone external peer review.

Peer Review File: Available at https://ccts.amegroups.com/article/view/10.21037/ccts-24-9/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://ccts.amegroups.com/article/view/10.21037/ccts-24-9/coif). The series “Comprehensive Lung Cancer Care: A Continuum” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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