ERAS and patient reported outcomes in thoracic surgery: a review of current data

Effects of enteral nutrition support combined with enhanced recovery after surgery on the nutritional status, immune function, and prognosis of patients with esophageal cancer after Ivor-Lewis operation

Background

Esophageal cancer (EC) with a high incidence of malnutrition is a highly malignant digestive tract tumor. We investigated the effect of enteral nutrition (EN) support combined with enhanced recovery after surgery (ERAS) on the nutritional status, immune function, and prognosis of patients with EC after Ivor-Lewis operation.

Methods

One hundred patients were randomly divided into the observation group (n=42) and the control group (n=58). The patients in observation group were treated with EN combined with ERAS intervention after Ivor-Lewis operation, and the patients in control group were treated with conventional postoperative EN intervention. The situation of operation, nutritional status, immune function recovery and prognosis between the two groups were compared.

Results

There was no statistically significant difference in operation time or intraoperative blood loss between the two groups (P>0.05). The chest tube removal time and oral feeding time of the observation group after operation were shorter than those of the control group (P<0.05). After intervention, serum albumin (ALB), transferrin (TF), pre-albumin (PA) and hemoglobin (Hb) levels in both groups were significantly decreased. These indexes were significantly higher in the observation group than in the control group (P<0.05). There were no significant changes in the levels of immunoglobulin (Ig) A, IgG, and IgM, or the numbers of CD3⁺, CD4⁺ and CD4⁺/CD8⁺ T cells in the observation group before and after intervention (P>0.05); however those indexes were significantly decreased in the control group after the intervention (P<0.05). Interestingly, the levels of IgA, IgM, IgG, CD3⁺ T cells, CD4⁺ T cells and CD4⁺/CD8⁺ T cells in the observation group were significantly higher than those in the control group after intervention (P<0.05). The incidence of pulmonary infection in the observation group was significantly lower than that in the control group. The postoperative exhaust time, postoperative defecation time and postoperative hospital stay were shorter in the observation group than in the control group (P<0.05). There was no significant difference in hospitalization cost between the two groups (P>0.05).

Conclusions

EN combined with ERAS was more beneficial to the improvement of nutritional status and immune function recovery of patients with EC after Ivor-Lewis operation. It also shortened the length of hospital stay.

Symptom and functional recovery monitoring in thoracic surgery

Curative-intent surgery is the treatment of choice for thoracic malignancies, including lung cancer. There is significant complexity and uncertainty associated with the diagnosis, prognosis, and surgical treatment decision-making in thoracic surgery. From a patient point of view, this complexity and uncertainty can be overwhelming. Therefore, for high-quality cancer care, an emphasis on patient-centered care-including the improvement in quality of life (QOL) through symptom and functional monitoring-is essential. Using the current literature and our previous research, the purpose of this paper is to: (I) review the current evidence on symptom and functional monitoring in surgery; (II) describe strategies to monitor symptoms and functional recovery in surgery; and (III) describe a model of patient-centered care in thoracic surgery.

Early Postoperative Functional Assessment Predicts Non-Home Discharge After Pulmonary Lobectomy

BACKGROUND

Non-home hospital disposition is an important patient-centric quality measure, and is increasingly tied to reimbursements. We sought to determine the value of early postoperative functional assessment to predict non-home discharge.

METHODS

Patients undergoing elective pulmonary lobectomy between May 2017 and December 2018 were identified from The Society of Thoracic Surgery database at a single institution. Early postoperative functional assessment using the Boston University Activity Measure for Post-Acute Care (AM-PAC) basic mobility short form was routinely performed by the inpatient rehabilitation services. The association of baseline patient characteristics and AM-PAC scores with nonhospital discharge was analyzed.

RESULTS

A total of 241 patients (median age 65 years, 59% female) underwent lobectomy. First postoperative functional assessment was performed at a median of 1 day (interquartile range, 1 to 2) after surgery. Median AM-PAC score was 18 (interquartile range, 17 to 19), correlating to a 47% functional impairment in daily activities. Thirteen patients (5.4%) were discharged to an extended care facility instead of home. Non-home discharge was more commonly observed for patients of older age or with prior history of stroke. First postoperative AM-PAC score was able to discriminate hospital disposition (area under the curve 0.714; 95% confidence interval, 0.594 to 0.834; P = .009). Adjusted for patient factors and performance status, first postoperative AM-PAC score was independently associated with non-home discharge (odds ratio 0.54, 95% confidence interval, 0.36 to 0.81; P = .003).

CONCLUSIONS

Early postoperative functional impairment assessment using AM-PAC may be useful to predict non-hospital discharge after pulmonary lobectomy. Attention to these factors may be used to aid early disposition planning, and adjust preventative strategies.

Reducing Unnecessary Chest X-Ray Films After Thoracic Surgery: A Quality Improvement Initiative

BACKGROUND

Previous work has identified that inpatient post-thoracic surgery chest x-ray films (CXR) are overutilized.

METHODS

A three-phase rapid cycle quality improvement initiative was performed to reduce empiric post-thoracic surgery CXR use by 25% over 1 year. We adapted evidence-based guidelines and implemented "plan-do-study-act" (PDSA) cycle methodology. The PDSA cycles included (1) education with literature and preintervention statistics; (2) electronic medical record order-set modification; and (3) audit and feedback with monthly status reports. Each cycle lasted 3 months. Use of CXR was tracked in the post-anesthesia care unit and as a daily rate of non-post-anesthesia care unit CXRs. Cost data were estimated from Centers for Medicare & Medicaid Services fees.

RESULTS

During the initiative, 292 thoracic surgery inpatients were monitored. Before intervention, 99% of patients (69 of 70) received a post-anesthesia care unit CXR, and the daily rate of other CXRs was 1.6. Overall, there was a significant reduction in CXR utilization (P < .001). Post-anesthesia care unit CXRs decreased by 42%, lowering to 89% (68 of 76) to 68% (50 of 74) to 57% (41 of 72) in PDSA cycles 1 through 3, respectively. The daily rate of other CXRs decreased by 38%, lowering to 1.4 to 1.3 to 1.0. Patient perioperative characteristics and health care quality measures were not different between cycles. After quality improvement implementation, cost savings were estimated to be at least $73,292 per year.

CONCLUSIONS

Implementation of our quality improvement initiative safely and systematically reduced empiric CXR use after inpatient thoracic surgery. Results will be used in future quality improvement initiatives to reduce unnecessary postoperative testing.