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Comacchio GM, Mammana M, Cannone G, Zambello G, Silvestrin S, Rebusso A, Nicotra S, Rea F. Impact of a standardized protocol for chest tube management after VATS pulmonary resections on post-operative outcomes and complications. Updates Surg 2023:10.1007/s13304-023-01704-3. [PMID: 38007703 DOI: 10.1007/s13304-023-01704-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 11/07/2023] [Indexed: 11/28/2023]
Abstract
Chest tube management represents a major issue after lung surgery as no protocol is widely accepted and tube management is generally based on local or personal habits. Aim of this study is to evaluate the impact of a standardized protocol for chest tube management after pulmonary resections on the post-operative outcomes. We performed a single center retrospective analysis of all adult patients undergoing thoracoscopic pulmonary resection from January 2020 to December 2021. Starting from January 2021 a standardized protocol of chest tube management was applied after all procedures. Patients were divided into two groups according to the chest tube management strategy. he two groups had similar pre-operative characteristics and the extent of lung resection was comparable. Intervention group had significantly shorter time to chest tube removal (median 1 vs 3 days, p < 0.001) and post-operative length of stay (median 3 vs 4 days, p < 0.001). Despite earlier chest tube removal, there was not an increased incidence of post-removal complications. On multivariable analysis, the new chest drain management strategy was an independent predictor of earlier chest tube removal. A standardized protocol of chest tube management allows for an earlier chest tube removal and a shorter hospital stay, without an increase in post-operative complications.
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Affiliation(s)
- Giovanni M Comacchio
- Thoracic Surgery and Lung Transplant Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University Hospital of Padua, Via Giustiniani 2, 35128, Padua, Italy.
| | - Marco Mammana
- Thoracic Surgery and Lung Transplant Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University Hospital of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Giorgio Cannone
- Thoracic Surgery and Lung Transplant Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University Hospital of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Giovanni Zambello
- Thoracic Surgery and Lung Transplant Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University Hospital of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Stefano Silvestrin
- Thoracic Surgery and Lung Transplant Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University Hospital of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Alessandro Rebusso
- Thoracic Surgery and Lung Transplant Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University Hospital of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Samuele Nicotra
- Thoracic Surgery and Lung Transplant Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University Hospital of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Federico Rea
- Thoracic Surgery and Lung Transplant Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University Hospital of Padua, Via Giustiniani 2, 35128, Padua, Italy
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Turna A, Özçıbık Işık G, Ekinci Fidan M, Sarbay İ, Kılıç B, Kara HV, Erşen E, Kaynak MK. Can postoperative complications be reduced by the application of ERAS protocols in operated non-small cell lung cancer patients? TURK GOGUS KALP DAMAR CERRAHISI DERGISI 2023; 31:256-268. [PMID: 37484631 PMCID: PMC10357847 DOI: 10.5606/tgkdc.dergisi.2023.23514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/11/2022] [Indexed: 07/25/2023]
Abstract
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.
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Affiliation(s)
- Akif Turna
- Department of Thoracic Surgery, Istanbul University-Cerrahpaşa Cerrahpaşa Medical Faculty, Istanbul, Türkiye
| | - Gizem Özçıbık Işık
- Department of Thoracic Surgery, Istanbul University-Cerrahpaşa Cerrahpaşa Medical Faculty, Istanbul, Türkiye
| | - Merve Ekinci Fidan
- Department of Thoracic Surgery, Istanbul University-Cerrahpaşa Cerrahpaşa Medical Faculty, Istanbul, Türkiye
| | - İsmail Sarbay
- Department of Thoracic Surgery, Istanbul University-Cerrahpaşa Cerrahpaşa Medical Faculty, Istanbul, Türkiye
| | - Burcu Kılıç
- Department of Thoracic Surgery, Istanbul University-Cerrahpaşa Cerrahpaşa Medical Faculty, Istanbul, Türkiye
| | - Hasan Volkan Kara
- Department of Thoracic Surgery, Istanbul University-Cerrahpaşa Cerrahpaşa Medical Faculty, Istanbul, Türkiye
| | - Ezel Erşen
- Department of Thoracic Surgery, Istanbul University-Cerrahpaşa Cerrahpaşa Medical Faculty, Istanbul, Türkiye
| | - Mehmet Kamil Kaynak
- Department of Thoracic Surgery, Istanbul University-Cerrahpaşa Cerrahpaşa Medical Faculty, Istanbul, Türkiye
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Analysis of Outcomes for Robotic-Assisted Lobectomy with an Enhanced Recovery after Surgery Protocol. Ann Thorac Surg 2022; 115:1353-1359. [PMID: 36075397 DOI: 10.1016/j.athoracsur.2022.08.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/17/2022] [Accepted: 08/22/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND The impact on cost relative to clinical efficacy of Enhanced Recovery after Surgery (ERAS) protocols for patients who undergo robotic-assisted lobectomy is currently unknown. The objective of this study was to compare cost and perioperative outcomes of robotic-assisted lobectomy before and after implementation of an ERAS protocol. METHODS This is a retrospective analysis of 574 patients who underwent robotic-assisted lobectomy for primary lung carcinoma from May 1, 2017 - June 1, 2021. The ERAS protocol was implemented on October 17, 2019. Inverse probability of treatment weighting (IPTW) of propensity scores was used to balance baseline characteristics. The primary outcomes of the study were mean direct and indirect hospital costs, complication rates, and hospital length of stay. RESULTS A total of 315 patients underwent robotic-assisted lobectomy prior to implementation of the ERAS protocol and 259 patients were enrolled on the protocol. A significantly higher percentage of patients were discharged home in less than 3 days following the ERAS protocol implementation [24.5% vs 9.8% (p =0.001)]. There was a significant decrease in the IPTW adjusted mean direct hospital costs (p< 0.001) and mean indirect costs (p= 0.018) for the total hospital stay after ERAS protocol implementation. The mean initial discharge opioid medication dose (Morphine Equivalent Dose) was significantly lower (p< 0.001) following the ERAS protocol. CONCLUSIONS Increased early discharge and decreased hospital costs were observed for robotic-assisted lobectomy after implementation of an ERAS protocol. There was also an observed significant decrease in the discharge opioid medication doses prescribed.
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Thompson C, Mattice AMS, Al Lawati Y, Seyednejad N, Lee A, Maziak DE, Gilbert S, Sundaresan S, Villeneuve J, Shamji F, Brehaut J, Ramsay T, Seely AJE. The longitudinal impact of division-wide implementation of an enhanced recovery after thoracic surgery programme. Eur J Cardiothorac Surg 2021; 61:1223-1229. [PMID: 34849684 DOI: 10.1093/ejcts/ezab492] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 10/13/2021] [Accepted: 10/18/2021] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES Data regarding enhanced recovery after thoracic surgery (ERATS) are sparse and inconsistent. This study aims to evaluate the effects of implementing an enhanced ERATS programme on postoperative outcomes, patient experience and quality of life (QOL). METHODS We conducted a prospective, longitudinal study evaluating 9 months before (pre-ERATS) and 9 months after (post-ERATS) a 3-month implementation of an ERATS programme in a single academic tertiary care centre. All patients undergoing major thoracic surgeries were included. The primary outcomes included length of stay (LOS), adverse events (AEs), 6-min walk test scores at 4 weeks, 30-day emergency room visits (without admission) and 30-day readmissions. The process-of-care outcomes included time to 'out-of-bed', independent ambulation, successful fluid intake, last chest tube removal and removal of urinary catheter. Perioperative anaesthesia-related outcomes were examined as well as patient experience and QOL scores. RESULTS The pre-ERATS group (n = 352 patients) and post-ERATS group (n = 352) demonstrated no differences in demographics. Post-ERATS patients had improved LOS (4.7 vs 6.2 days, P < 0.02), 6-min walk test scores (402 vs 371 m, P < 0.05) and 30-day emergency room visits (13.7% vs 21.6%, P = 0.03) with no differences in AEs and 30-day readmissions. Patients experienced shorter mean time to 'out-of-bed', independent ambulation, successful fluid intake, last chest tube removal and urinary catheter removal. There were no differences in postoperative analgesia administration, patient satisfaction and QOL scores. CONCLUSIONS ERATS implementation was associated with improved LOS, expedited feeding, ambulation and chest tube removal, without increasing AEs or readmissions, while maintaining a high level of patient satisfaction and QOL.
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Affiliation(s)
- Calvin Thompson
- Dept. of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Amanda M S Mattice
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Yaseen Al Lawati
- Division of Thoracic Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Nazgol Seyednejad
- Division of Thoracic Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Alex Lee
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Donna E Maziak
- Division of Thoracic Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Sebastian Gilbert
- Division of Thoracic Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Sudhir Sundaresan
- Division of Thoracic Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - James Villeneuve
- Division of Thoracic Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Farid Shamji
- Division of Thoracic Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Jamie Brehaut
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Tim Ramsay
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Andrew J E Seely
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.,Division of Thoracic Surgery, The Ottawa Hospital, Ottawa, ON, Canada
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Senturk M, Sungur Z. Enhanced recovery after thoracic anesthesia. Saudi J Anaesth 2021; 15:348-355. [PMID: 34764842 PMCID: PMC8579505 DOI: 10.4103/sja.sja_1182_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 11/14/2022] Open
Abstract
In recent years, the concept of “Perioperative Medicine” has been evolved to a more concrete and sophisticated approach called “Enhanced Recovery After Surgery” (ERAS). ERAS has been first introduced in colorectal surgery by a dedicated leading ERAS® society, ERAS-criteria has been subsequently extended into several types of surgery, including thoracic surgery. Anesthesiology has always been one of the most important components of the multidisciplinary perioperative approaches, which is also valid for ERAS. There are several guidelines published on the enhanced recovery after thoracic surgery (ERATS). This article focuses on the “official” ERATS protocols of a joint consensus of two different societies. Regarding thoracic anesthesia, there are some challenges to be dealt with. The first challenge, although there is a large number of studies published on thoracic anesthesia, only a very few of them have studied the overall outcome and quality of recovery; and only few of them were powered enough to provide sufficient evidence. This has led to the fact that some components of the protocol are debatable. The second challenge, the adherence to individual elements and the overall compliance are poorly reported and also hard to apply even in the best organized centers. This article explains and discusses the debatable viewpoints on the elements of the ERATS protocol published in 2019 aiming to achieve a list for the future steps required for a more effective and evidence-based ERATS protocol.
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Affiliation(s)
- Mert Senturk
- Department of Anesthesiology and Reanimation, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Zerrin Sungur
- Department of Anesthesiology and Reanimation, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
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Abrão FC, Araujo de França S, de Abreu IRLB, das Neves Pereira JC, Del Massa EC, Oliver A, Cavalcante MGC. Enhanced recovery after surgery (ERAS ®) protocol adapted to the Brazilian reality: a prospective cohort study for thoracic patients. J Thorac Dis 2021; 13:5439-5447. [PMID: 34659810 PMCID: PMC8482344 DOI: 10.21037/jtd-21-920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 08/06/2021] [Indexed: 11/28/2022]
Abstract
Background In Low-Middle Income Countries (LMICs), resource optimization and infrastructure availability are recurrently in debate. In order to assist the development and implementation of guidelines, LMICs often exemplify from High-Income Countries protocols. At the final, it will be: content adaption is often needed. In this study, we demonstrated the preliminary analysis of the Brazilian experience by adapting the ERAS® Protocol for thoracic surgery patients (PROSM). Methods Patients’ data were extracted from the surgical group database that operated in the city of Sao Paulo. Patients’ data were organized for analysis after the institution’s ethics committee gave their approval. Patients’ variables were analyzed and compared to a control group. Subgroup analysis included patients without ICU Admission. Results PROSM patients had reduced ICU length of stay (LOS) (Mean of 0.3±0.58 days, 1.2±1.65 days, P=0.001), Hospital LOS (Mean of 1.6±1.32 days, 3.9±3.25 days, P=0.001) and Chest Drain duration (Median 1.0±1.00 days, 3.0±3.00 days, P=0.001). Analyses of patients that were not admitted to the ICU demonstrated reduced Hospital LOS and Chest drain duration. Cost analysis, such as procedure, daily, and post-surgical costs were also significantly lower towards PROSM group. Conclusions This study revealed important aspects for improvement of the delivered care quality and opportunity for expenditure management. We expect to assist more countries to improve knowledge under the implementation of enhanced protocols.
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Affiliation(s)
- Fernando C Abrão
- Thoracic Surgery Department, Hospital Santa Marcelina, São Paulo, Brazil.,Thoracic Department, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Sabrina Araujo de França
- IPSPAC Research Department - Instituto Paulista de Saúde para Alta Complexidade, Santo Andre, Brazil
| | - Igor R L B de Abreu
- Thoracic Surgery Department, Hospital Santa Marcelina, São Paulo, Brazil.,Thoracic Surgery Department, Hospital São Camilo, São Paulo, Brazil
| | | | | | - Andréa Oliver
- Physiotherapy Department, Hospital Santa Marcelina, São Paulo, Brazil
| | - Maria Gabriela C Cavalcante
- Thoracic Surgery Department, Hospital Santa Marcelina, São Paulo, Brazil.,Thoracic Surgery Department, Hospital São Camilo, São Paulo, Brazil
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Khoury AL, McGinigle KL, Freeman NL, El-Zaatari H, Feltner C, Long JM. Enhanced recovery after thoracic surgery: Systematic review and meta-analysis. JTCVS OPEN 2021; 7:370-391. [PMID: 36003715 PMCID: PMC9390629 DOI: 10.1016/j.xjon.2021.07.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 07/08/2021] [Indexed: 12/29/2022]
Abstract
ERATS decreased length of stay, postoperative complications, and readmission.
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Affiliation(s)
- Audrey L Khoury
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC.,Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC.,Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Katharine L McGinigle
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Nikki L Freeman
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Helal El-Zaatari
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Cynthia Feltner
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC.,Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jason M Long
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
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Enhanced Recovery After Surgery Protocol Minimizes Intensive Care Unit Utilization and Improves Outcomes Following Pulmonary Resection. World J Surg 2021; 45:2955-2963. [PMID: 34350489 PMCID: PMC8336670 DOI: 10.1007/s00268-021-06259-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2021] [Indexed: 11/14/2022]
Abstract
Background Enhanced recovery after surgery (ERAS) protocols have been associated with improved postoperative outcomes but require further validation in thoracic surgery. This study evaluated outcomes of patients undergoing pulmonary resection before and after implementation of an ERAS protocol. Methods Electronic medical records were queried for all patients undergoing pulmonary resection between April 2017 and April 2019. Patients were grouped into pre- and post-ERAS cohorts based on dates of operation. The ERAS protocol prioritized early mobilization, limited invasive monitoring, euvolemia, and non-narcotic analgesia. Primary outcome measures included intensive care unit (ICU) utilization, postoperative pain metrics, and perioperative morbidity. Regression analyses were performed to identify predictors of morbidity. Subgroup analyses were performed by pulmonary risk profile and surgical approach. Results A total of 64 pre- and 67 post-ERAS patients were included in the study. ERAS implementation was associated with reduced postoperative ICU admission (pre: 65.6% vs. post: 19.4%, p < 0.0001), shorter ICU median length of stay (LOS) (pre: 1 vs. post: 0, p < 0.0001), and decreased opioid usage measured by median morphine milligram equivalents (pre: 40.5 vs. post: 20.0, p < 0.0001). Post-ERAS patients also reported lower visual analog scale (VAS) pain scores on postoperative days (POD) 1 and 2 (pre: 6.3/5.6 vs. post: 5.3/4.2, p = 0.04/0.01) as well as average VAS pain score over POD0-2 (pre: 6.2 vs. post: 5.2, p = 0.005). Conclusions Implementation of an ERAS protocol for pulmonary resection, which dictated reduced ICU admissions, did not increase major postoperative morbidity. Additionally, ERAS-enrolled patients reported improved postoperative pain control despite decreased opioid utilization. Supplementary Information The online version contains supplementary material available at 10.1007/s00268-021-06259-1.
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Forster C, Perentes JY, Ojanguren A, Abdelnour-Berchtold E, Zellweger M, Bouchaab H, Peters S, Krueger T, Gonzalez M. Early discharge after thoracoscopic anatomical pulmonary resection for non-small-cell lung cancer. Interact Cardiovasc Thorac Surg 2021; 33:892-898. [PMID: 34279040 DOI: 10.1093/icvts/ivab187] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 04/13/2021] [Accepted: 06/03/2021] [Indexed: 12/25/2022] Open
Abstract
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.
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Affiliation(s)
- Céline Forster
- Service of Thoracic Surgery, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Jean Yannis Perentes
- Service of Thoracic Surgery, Lausanne University Hospital (CHUV), Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Amaya Ojanguren
- Service of Thoracic Surgery, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | | | - Matthieu Zellweger
- Service of Thoracic Surgery, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Hasna Bouchaab
- Service of Oncology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Solange Peters
- Faculty of Biology and Medicine, University of Lausanne (UNIL), Lausanne, Switzerland.,Service of Oncology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Thorsten Krueger
- Service of Thoracic Surgery, Lausanne University Hospital (CHUV), Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Michel Gonzalez
- Service of Thoracic Surgery, Lausanne University Hospital (CHUV), Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne (UNIL), Lausanne, Switzerland
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Benzaquen E, Wang Y, Wiseman S, Rosenfeld V, Sideris L, Dubé P, Pelletier JS, Vanounou T. Morbidity associated with the use of oxaliplatin versus mitomycin C in hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis of colorectal or appendiceal origin: a multi-institutional comparative study. Can J Surg 2021; 64:E111-E118. [PMID: 33651573 PMCID: PMC8064255 DOI: 10.1503/cjs.001619] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background The raw costs of mitomycin C (MMC) and oxaliplatin for hyperthermic intraperitoneal chemotherapy (HIPEC) differ substantially. We sought to compare the morbidity and toxicity profiles associated with the use of oxaliplatin and MMC in patients undergoing cytoreductive surgery (CRS) and HIPEC for peritoneal carcinomatosis (PC) of colorectal or appendiceal origin, to evaluate whether the cost-effectiveness of these 2 agents should dictate drug choice. Methods We conducted a retrospective multi-institutional study of all patients with PC of colorectal or appendiceal origin treated with CRS-HIPEC using MMC or oxaliplatin from 2010 to 2015. Demographic, perioperative, morbidity, toxicity and cost data were compared between the 2 treatment groups and between cancer-origin subgroups. Results Forty-two patients treated with MMC and 76 treated with oxaliplatin were included in the study. Baseline demographic and tumour characteristics were comparable in the 2 groups, except that the patients treated with MMC had higher Charlson Comorbidity Index scores. The MMC group had a higher rate of cancer of colorectal origin (76.2% v. 57.9%, p = 0.047) and longer operative times (553 v. 320 min, p < 0.001). In the subgroup of patients whose cancer was of colorectal origin, patients treated with MMC had a higher transfusion rate (50.0% v. 28.6%, p = 0.023) and lower postoperative baseline hemoglobin level (100 v. 119 g/L, p = 0.002) than those treated with oxaliplatin. There was no difference in hematologic toxicity scores after controlling for postoperative anemia. There was no difference in the rates of major complications and 90-day mortality. However, MMC was less costly than oxaliplatin ($724 v. $8928). Conclusion MMC and oxaliplatin are both suitable agents for HIPEC and are associated with comparable morbidity and toxicity profiles, regardless of cancer origin. Thus, we propose that cost-effectiveness should ultimately dictate drug selection.
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Affiliation(s)
- Ella Benzaquen
- From the Division of General Surgery, Jewish General Hospital, Montréal, Que. (Benzaquen, Wang, Wiseman, Rosenfeld, Pelletier, Vanounou); and the Division of Surgical Oncology, Hôpital Maisonneuve-Rosemont, Montréal, Que. (Sideris, Dubé)
| | - Yifan Wang
- From the Division of General Surgery, Jewish General Hospital, Montréal, Que. (Benzaquen, Wang, Wiseman, Rosenfeld, Pelletier, Vanounou); and the Division of Surgical Oncology, Hôpital Maisonneuve-Rosemont, Montréal, Que. (Sideris, Dubé)
| | - Stephanie Wiseman
- From the Division of General Surgery, Jewish General Hospital, Montréal, Que. (Benzaquen, Wang, Wiseman, Rosenfeld, Pelletier, Vanounou); and the Division of Surgical Oncology, Hôpital Maisonneuve-Rosemont, Montréal, Que. (Sideris, Dubé)
| | - Velka Rosenfeld
- From the Division of General Surgery, Jewish General Hospital, Montréal, Que. (Benzaquen, Wang, Wiseman, Rosenfeld, Pelletier, Vanounou); and the Division of Surgical Oncology, Hôpital Maisonneuve-Rosemont, Montréal, Que. (Sideris, Dubé)
| | - Lucas Sideris
- From the Division of General Surgery, Jewish General Hospital, Montréal, Que. (Benzaquen, Wang, Wiseman, Rosenfeld, Pelletier, Vanounou); and the Division of Surgical Oncology, Hôpital Maisonneuve-Rosemont, Montréal, Que. (Sideris, Dubé)
| | - Pierre Dubé
- From the Division of General Surgery, Jewish General Hospital, Montréal, Que. (Benzaquen, Wang, Wiseman, Rosenfeld, Pelletier, Vanounou); and the Division of Surgical Oncology, Hôpital Maisonneuve-Rosemont, Montréal, Que. (Sideris, Dubé)
| | - Jean-Sebastien Pelletier
- From the Division of General Surgery, Jewish General Hospital, Montréal, Que. (Benzaquen, Wang, Wiseman, Rosenfeld, Pelletier, Vanounou); and the Division of Surgical Oncology, Hôpital Maisonneuve-Rosemont, Montréal, Que. (Sideris, Dubé)
| | - Tsafrir Vanounou
- From the Division of General Surgery, Jewish General Hospital, Montréal, Que. (Benzaquen, Wang, Wiseman, Rosenfeld, Pelletier, Vanounou); and the Division of Surgical Oncology, Hôpital Maisonneuve-Rosemont, Montréal, Que. (Sideris, Dubé)
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Khoury AL, Kolarczyk LM, Strassle PD, Feltner C, Hance LM, Teeter EG, Haithcock BE, Long JM. Thoracic Enhanced Recovery After Surgery: Single Academic Center Observations After Implementation. Ann Thorac Surg 2021; 111:1036-1043. [DOI: 10.1016/j.athoracsur.2020.06.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/23/2020] [Accepted: 06/03/2020] [Indexed: 01/01/2023]
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Berna P, Quesnel C, Assouad J, Bagan P, Etienne H, Fourdrain A, Le Guen M, Leone M, Lorne E, Nguyen YNL, Pages PB, Roz H, Garnier M. Guidelines on enhanced recovery after pulmonary lobectomy. Anaesth Crit Care Pain Med 2021; 40:100791. [PMID: 33451912 DOI: 10.1016/j.accpm.2020.100791] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To establish recommendations for optimisation of the management of patients undergoing pulmonary lobectomy, particularly Enhanced Recovery After Surgery (ERAS). DESIGN A consensus committee of 13 experts from the French Society of Anaesthesia and Intensive Care Medicine (Soci,t, franOaise d'anesth,sie et de r,animation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Soci,t, franOaise de chirurgie thoracique et cardiovasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence. METHODS Five domains were defined: 1) patient pathway and patient information; 2) preoperative management and rehabilitation; 3) anaesthesia and analgesia for lobectomy; 4) surgical strategy for lobectomy; and 5) enhanced recovery after surgery. For each domain, the objective of the recommendations was to address a number of questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). An extensive literature search on these questions was carried out and analysed using the GRADE® methodology. Recommendations were formulated according to the GRADE® methodology, and were then voted by all experts according to the GRADE grid method. RESULTS The SFAR/SFCTCV guideline panel provided 32 recommendations on the management of patients undergoing pulmonary lobectomy. After two voting rounds and several amendments, a strong consensus was reached for 31 of the 32 recommendations and a moderate consensus was reached for the last recommendation. Seven of these recommendations present a high level of evidence (GRADE 1+), 23 have a moderate level of evidence (18 GRADE 2+ and 5 GRADE 2-), and 2 correspond to expert opinions. Finally, no recommendation was provided for 2 of the questions. CONCLUSIONS A strong consensus was expressed by the experts to provide recommendations to optimise the whole perioperative management of patients undergoing pulmonary lobectomy.
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Affiliation(s)
- Pascal Berna
- Department of Thoracic Surgery, Amiens University Hospital, 80000 Amiens, France
| | - Christophe Quesnel
- Sorbonne Universit,, APHP, DMU DREAM, Service d'Anesth,sie-R,animation et M,decine P,riop,ratoire, H"pital Tenon, 75020 Paris, France
| | - Jalal Assouad
- Department of Thoracic Surgery, Tenon University Hospital, Sorbonne Universit,, 75020 Paris, France
| | - Patrick Bagan
- Department of Thoracic and Vascular Surgery, Victor Dupouy Hospital, 95100 Argenteuil, France
| | - Harry Etienne
- Department of Thoracic Surgery, Tenon University Hospital, Sorbonne Universit,, 75020 Paris, France
| | - Alex Fourdrain
- Department of Thoracic Surgery, Amiens University Hospital, 80000 Amiens, France
| | - Morgan Le Guen
- D,partement d'Anesth,sie, H"pital Foch, Universit, Versailles Saint Quentin, 92150 Suresnes, France; INRA UMR 892 VIM, 78350 Jouy-en-Josas, France
| | - Marc Leone
- Aix Marseille Universit, - Assistance Publique H"pitaux de Marseille - Service d'Anesth,sie et de R,animation - H"pital Nord - 13005 Marseille, France
| | - Emmanuel Lorne
- Departement d'Anesth,sie-R,animation, Clinique du Mill,naire, 34000 Montpellier, France
| | - Y N-Lan Nguyen
- Anaesthesiology and Critical Care Department, APHP Centre, Paris University, 75000 Paris, France
| | - Pierre-Benoit Pages
- Department of Thoracic Surgery, Dijon Burgundy University Hospital, 21000 Dijon, France; INSERM UMR 1231, Dijon Burgundy University Hospital, University of Burgundy, 21000 Dijon, France
| | - Hadrien Roz
- Unit, d'Anesth,sie R,animation Thoracique, H"pital Haut Leveque, CHU de Bordeaux, 33000 Bordeaux, France
| | - Marc Garnier
- Sorbonne Universit,, APHP, DMU DREAM, Service d'Anesth,sie-R,animation et M,decine P,riop,ratoire, H"pital Tenon, 75020 Paris, France.
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Forster C, Doucet V, Perentes JY, Abdelnour-Berchtold E, Zellweger M, Faouzi M, Bouchaab H, Peters S, Marcucci C, Krueger T, Rosner L, Gonzalez M. Impact of an enhanced recovery after surgery pathway on thoracoscopic lobectomy outcomes in non-small cell lung cancer patients: a propensity score-matched study. Transl Lung Cancer Res 2021; 10:93-103. [PMID: 33569296 PMCID: PMC7867780 DOI: 10.21037/tlcr-20-891] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Céline Forster
- Service of Thoracic Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Valérie Doucet
- Service of Thoracic Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Jean Yannis Perentes
- Service of Thoracic Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland.,University of Lausanne, Lausanne, Switzerland
| | | | - Matthieu Zellweger
- Service of Thoracic Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Mohamed Faouzi
- Division of Biostatistics, Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Hasna Bouchaab
- Service of Medical Oncology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Solange Peters
- University of Lausanne, Lausanne, Switzerland.,Service of Medical Oncology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Carlo Marcucci
- University of Lausanne, Lausanne, Switzerland.,Service of Anesthesiology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Thorsten Krueger
- Service of Thoracic Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland.,University of Lausanne, Lausanne, Switzerland
| | - Lorenzo Rosner
- Service of Anesthesiology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Michel Gonzalez
- Service of Thoracic Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland.,University of Lausanne, Lausanne, Switzerland
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Haywood N, Nickel I, Zhang A, Byler M, Scott E, Julliard W, Blank RS, Martin LW. Enhanced Recovery After Thoracic Surgery. Thorac Surg Clin 2020; 30:259-267. [DOI: 10.1016/j.thorsurg.2020.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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15
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Dumitra TC, Molina JC, Mouhanna J, Nicolau I, Renaud S, Aubin L, Siblini A, Mulder D, Ferri L, Spicer J. Feasibility analysis for the development of a video-assisted thoracoscopic (VATS) lobectomy 23-hour recovery pathway. Can J Surg 2020; 63:E349-E358. [PMID: 32735430 DOI: 10.1503/cjs.002219] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background Video-assisted thoracoscopic (VATS) lobectomy has been demonstrated to offer several benefits over open surgery. The purpose of this study was to assess the feasibility and safety of an ultra-fast-track 23-hour recovery pathway for VATS lobectomy. Methods A prospectively maintained institutional database was queried for patients who underwent VATS lobectomy from 2006 to 2016 at the McGill University Health Centre in Montreal, Quebec, and data were supplemented with focused chart review. Patients discharged with a length of stay (LOS) of 23 hours or less were compared with those with an LOS of 2 days or more. Logistic regression was performed to identify predictors of LOS of 23 hours or less. Results Two hundred and five patients were included in the study. Perioperative 30-day mortality for our cohort was 0% and the major complication rate was 8.3%. The median LOS was 3 days (interquartile range [IQR] 2-4 d). Thirty-four patients were discharged within 23 hours and none of them required readmission; 171 patients were discharged on postoperative day 2 or later and 9 of them (5.3%) required readmission (p = 0.36). The proportion of patients discharged within 23 hours increased in 2016 compared with previous years (25.8% v. 12.0%, p = 0.05). Patients discharged within 23 hours had shorter chest tube duration (odds ratio [OR] 0.20, 95% confidence interval [CI] 0.09-0.46, p < 0.001), lower clinical stage disease (stages II-III v. stage I OR 0.07, 95% CI 0.01-0.52, p = 0.011), lower pathologic stage lesions (stages II-III v. stage I OR 0.26, 95% CI 0.07-0.91, p = 0.035), fewer surgical complications (OR 0.04, 95% CI 0.01-0.30, p = 0.002) and shorter operative time (surgery duration > 120 min OR 0.42, 95% CI 0.18-0.95, p = 0.04). Our exploratory prediction modelling showed that chest tube duration, clinical stage and surgeon were the most influential predictors of discharge within 23 hours. Conclusion The only preoperative factors that predicted shorter LOS in our cohort were clinical stage and surgeon. A significant proportion of patients can be discharged safely by adopting a VATS lobectomy 23-hour enhanced recovery pathway.
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Affiliation(s)
- Teodora-Cristiana Dumitra
- From the Division of Thoracic and Upper Gastrointestinal Surgery, Department of Surgery, McGill University Health Centre, Montréal, Que
| | - Juan-Carlos Molina
- From the Division of Thoracic and Upper Gastrointestinal Surgery, Department of Surgery, McGill University Health Centre, Montréal, Que
| | - Jack Mouhanna
- From the Division of Thoracic and Upper Gastrointestinal Surgery, Department of Surgery, McGill University Health Centre, Montréal, Que
| | - Ioana Nicolau
- From the Division of Thoracic and Upper Gastrointestinal Surgery, Department of Surgery, McGill University Health Centre, Montréal, Que
| | - Stephane Renaud
- From the Division of Thoracic and Upper Gastrointestinal Surgery, Department of Surgery, McGill University Health Centre, Montréal, Que
| | - Ludovic Aubin
- From the Division of Thoracic and Upper Gastrointestinal Surgery, Department of Surgery, McGill University Health Centre, Montréal, Que
| | - Aya Siblini
- From the Division of Thoracic and Upper Gastrointestinal Surgery, Department of Surgery, McGill University Health Centre, Montréal, Que
| | - David Mulder
- From the Division of Thoracic and Upper Gastrointestinal Surgery, Department of Surgery, McGill University Health Centre, Montréal, Que
| | - Lorenzo Ferri
- From the Division of Thoracic and Upper Gastrointestinal Surgery, Department of Surgery, McGill University Health Centre, Montréal, Que
| | - Jonathan Spicer
- From the Division of Thoracic and Upper Gastrointestinal Surgery, Department of Surgery, McGill University Health Centre, Montréal, Que
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16
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Forster C, Doucet V, Perentes JY, Abdelnour-Berchtold E, Zellweger M, Marcucci C, Krueger T, Rosner L, Gonzalez M. Impact of Compliance With Components of an ERAS Pathway on the Outcomes of Anatomic VATS Pulmonary Resections. J Cardiothorac Vasc Anesth 2020; 34:1858-1866. [DOI: 10.1053/j.jvca.2020.01.038] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 01/15/2020] [Accepted: 01/20/2020] [Indexed: 12/13/2022]
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17
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Tahiri M, Goudie E, Jouquan A, Martin J, Ferraro P, Liberman M. Enhanced recovery after video-assisted thoracoscopic surgery lobectomy: a prospective, historically controlled, propensity-matched clinical study. Can J Surg 2020; 63:E233-E240. [PMID: 32386474 DOI: 10.1503/cjs.001919] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background Enhanced recovery pathways or fast-tracking following surgery can decrease the rate of postoperative complications and hospital length of stay. The objectives of this study were to implement an enhanced recovery after surgery (ERAS) pathway for patients undergoing a video-assisted thoracoscopic surgery (VATS) lobectomy, to assess the safety and efficiency of this protocol by measuring associated postoperative outcomes, and to compare the outcomes for patients in the ERAS group with the outcomes for patients in a propensity-matched control group. Methods The study was a prospective clinical trial. Patients who were scheduled to undergo VATS lobectomy at the Centre hospitalier de l'Université de Montréal in Montréal, Quebec, Canada, were enrolled between November 2015 and October 2016. The ERAS pathway was used for all enrolled patients. The primary outcome was the number and severity of complications measured by the Comprehensive Complication Index. Secondary outcomes included length of stay, readmission and recovery. Recovery of patients was measured using EQ-5D-5L preoperatively and at 1 week, 1 month and 4 months after surgery. Prospectively enrolled patients were propensity matched to historical controls. Results Ninety-eight patients (36 men and 62 women) in the ERAS group and 98 patients in the control group (29 men and 69 women) were included in the analysis. The mean age was 65.2 ± 9.3 years, the mean body mass index (BMI) was 26.9 ± 5.9 kg/m2 and the median Charlson Comorbidity Index score was 2 (interquartile range [IQR] 2-3) in the ERAS group. In the control group, the mean age was 66.2 ± 9.4 years, the mean BMI was 27.4 ± 5.6 kg/m2 and the median Charlson Comorbidity Index score was 3 (IQR 2-3). A total of 23 patients (23.4%) in the ERAS group and 28 (28.6%) in the control group experienced 1 or more postoperative complications. The mean Comprehensive Complication Index score was 7.4 ± 16.8 in the ERAS group compared with 8.0 ± 14.3 in the control group (p = 0.79). The median postoperative length of stay was 3 days in the ERAS group and 5 days in the control group (p < 0.001). Five patients in the ERAS group and 4 patients in the control group were readmitted. The protocol adherence rate was 64.3%. Conclusion It is feasible to implement an enhanced recovery protocol after VATS lobectomy. Although the pathway is still early in its development in Canada, implementation of an ERAS pathway after VATS lobectomy was associated with decreased length of stay, with no observable increase in complication or readmission rates.
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Affiliation(s)
- Mehdi Tahiri
- From the Division of Thoracic Surgery, Université de Montréal, Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman); and the CHUM Endoscopic Tracheobronchial and Oesophageal Centre (CETOC), Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman)
| | - Eric Goudie
- From the Division of Thoracic Surgery, Université de Montréal, Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman); and the CHUM Endoscopic Tracheobronchial and Oesophageal Centre (CETOC), Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman)
| | - Adeline Jouquan
- From the Division of Thoracic Surgery, Université de Montréal, Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman); and the CHUM Endoscopic Tracheobronchial and Oesophageal Centre (CETOC), Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman)
| | - Jocelyne Martin
- From the Division of Thoracic Surgery, Université de Montréal, Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman); and the CHUM Endoscopic Tracheobronchial and Oesophageal Centre (CETOC), Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman)
| | - Pasquale Ferraro
- From the Division of Thoracic Surgery, Université de Montréal, Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman); and the CHUM Endoscopic Tracheobronchial and Oesophageal Centre (CETOC), Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman)
| | - Moishe Liberman
- From the Division of Thoracic Surgery, Université de Montréal, Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman); and the CHUM Endoscopic Tracheobronchial and Oesophageal Centre (CETOC), Montreal, Que. (Tahiri, Goudie, Jouquan, Thiffault, Martin, Ferraro, Liberman)
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Krebs ED, Mehaffey JH, Sarosiek BM, Blank RS, Lau CL, Martin LW. Is less really more? Reexamining video-assisted thoracoscopic versus open lobectomy in the setting of an enhanced recovery protocol. J Thorac Cardiovasc Surg 2020; 159:284-294.e1. [PMID: 31610965 PMCID: PMC10732414 DOI: 10.1016/j.jtcvs.2019.08.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 08/04/2019] [Accepted: 08/17/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Video-assisted thoracoscopic surgery lobectomy has been associated with improved pain, length of stay, and outcomes compared with open lobectomy. However, enhanced recovery protocols improve outcomes after both procedures. We aimed to compare video-assisted thoracoscopic surgery and open lobectomy in the setting of a comprehensive enhanced recovery protocol. METHODS All patients undergoing lobectomy for lung cancer at a single institution since the adoption of an enhanced recovery protocol (May 2016 to December 2018) were stratified by video-assisted thoracoscopic surgery versus open status and compared. Demographics and outcomes, including length of stay, daily pain scores, and short-term operative complications, were compared using standard univariate statistics and multivariable models. RESULTS A total of 130 patients underwent lobectomy, including 71 (54.6%) undergoing video-assisted thoracoscopic surgery and 59 (45.4%) undergoing open surgery. Video-assisted thoracoscopic surgery versus open cases exhibited similar length of stay (median 4 days for both, P = .07), opioid requirement (33.2 vs 30.8 mg morphine equivalents, P = .86), and pain scores at 0, 1, 2, and 3 days after surgery (4.3 vs 2.8, P = .12; 4.4 vs 3.7, P = .27; 3.9 vs 3.5, P = .83; and 3.4 vs 3.5, P = .98, respectively). Patients undergoing video-assisted thoracoscopic surgery lobectomy exhibited lower rates of readmission (1.4% vs 17.0%, P < .01), postoperative transfusion requirement (0% vs 10.2%, P < .01), and pneumonia (1.4% vs 10.2%, P = .05). After risk adjustment, an open procedure (vs video-assisted thoracoscopic surgery status) did not significantly affect the length of stay (effect 0.18; P = .10) or overall complication rate (odds ratio, 1.9; P = .12). CONCLUSIONS In the setting of a comprehensive enhanced recovery protocol, patients undergoing video-assisted thoracoscopic surgery versus open lobectomy exhibited similar short-term outcomes. Surgical incision may have less impact on outcomes in the setting of a comprehensive thoracic enhanced recovery protocol.
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Affiliation(s)
| | | | | | - Randal S Blank
- Department of Anesthesiology, University of Virginia, Charlottesville, Va
| | - Christine L Lau
- Department of Surgery, University of Virginia, Charlottesville, Va
| | - Linda W Martin
- Department of Surgery, University of Virginia, Charlottesville, Va.
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Perioperative Lung Resection Outcomes After Implementation of a Multidisciplinary, Evidence-based Thoracic ERAS Program. Ann Surg 2019; 274:e1008-e1013. [DOI: 10.1097/sla.0000000000003719] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Nunns M, Shaw L, Briscoe S, Thompson Coon J, Hemsley A, McGrath JS, Lovegrove CJ, Thomas D, Anderson R. Multicomponent hospital-led interventions to reduce hospital stay for older adults following elective surgery: a systematic review. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07400] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BackgroundElective older adult inpatient admissions are increasingly common. Older adults are at an elevated risk of adverse events in hospital, potentially increasing with lengthier hospital stay. Hospital-led organisational strategies may optimise hospital stay for elective older adult inpatients.ObjectivesTo evaluate the effectiveness and cost-effectiveness of hospital-led multicomponent interventions to reduce hospital stay for older adults undergoing elective hospital admissions.Data sourcesSeven bibliographic databases (MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Health Management Information Consortium, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature and Allied and Complementary Medicine Database) were searched from inception to date of search (August 2017), alongside carrying out of web searches, citation searching, inspecting relevant reviews, consulting stakeholders and contacting authors. This search was duplicated, with an additional cost-filter, to identify cost-effectiveness evidence.Review methodsComparative studies were sought that evaluated the effectiveness or cost-effectiveness of relevant interventions in elective inpatients with a mean or median age of ≥ 60 years. Study selection, data extraction and quality assessment were completed independently by two reviewers. The main outcome was length of stay, but all outcomes were considered. Studies were sorted by procedure, intervention and outcome categories. Where possible, standardised mean differences or odds ratios were calculated. Meta-analysis was performed when multiple randomised controlled trials had the same intervention, treatment procedure, comparator and outcome. Findings were explored using narrative synthesis.FindingsA total of 218 articles were included, with 80 articles from 73 effectiveness studies (n = 26,365 patients) prioritised for synthesis, including 34 randomised controlled trials conducted outside the UK and 39 studies from the UK, of which 12 were randomised controlled trials. Fifteen studies included cost-effectiveness data. The evidence was dominated by enhanced recovery protocols and prehabilitation, implemented to improve recovery from either colorectal surgery or lower limb arthroplasty. Six other surgical categories and four other intervention types were identified. Meta-analysis found that enhanced recovery protocols were associated with 1.5 days’ reduction in hospital stay among patients undergoing colorectal surgery (Cohen’sd = –0.51, 95% confidence interval –0.78 to –0.24;p < 0.001) and with 5 days’ reduction among those undergoing upper abdominal surgery (Cohen’sd = –1.04, 95% confidence interval –1.55 to –0.53;p < 0.001). Evidence from the UK was not pooled (owing to mixed study designs), but it echoed findings from the international literature. Length of stay usually was reduced with intervention or was no different. Other clinical outcomes also improved or were no worse with intervention. Patient-reported outcomes were not frequently reported. Cost and cost-effectiveness evidence came from 15 highly heterogeneous studies and was less conclusive.LimitationsStudies were usually of moderate or weak quality. Some intervention or treatment types were under-reported or absent. The reporting of variance data often precluded secondary analysis.ConclusionsEnhanced recovery and prehabilitation interventions were associated with reduced hospital stay without detriment to other clinical outcomes, particularly for patients undergoing colorectal surgery, lower limb arthroplasty or upper abdominal surgery. The impacts on patient-reported outcomes, health-care costs or additional service use are not well known.Future workFurther studies evaluating of the effectiveness of new enhanced recovery pathways are not required in colorectal surgery or lower limb arthroplasty. However, the applicability of these pathways to other procedures is uncertain. Future studies should evaluate the implementation of interventions to reduce service variation, in-hospital patient-reported outcomes, impacts on health and social care service use, and longer-term patient-reported outcomes.Study registrationThis study is registered as PROSPERO CRD42017080637.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Michael Nunns
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Liz Shaw
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Simon Briscoe
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Jo Thompson Coon
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Anthony Hemsley
- Department of Healthcare for Older People, Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - John S McGrath
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
- Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - Christopher J Lovegrove
- Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
- School of Health Professions, Faculty of Health & Human Sciences, University of Plymouth, Plymouth, UK
| | - David Thomas
- Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - Rob Anderson
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
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Abbas AE. Commentary: Winning the race after lung surgery: The tortoise or the hare? J Thorac Cardiovasc Surg 2019; 159:679-680. [PMID: 31679708 DOI: 10.1016/j.jtcvs.2019.08.109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 08/28/2019] [Accepted: 08/29/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Abbas E Abbas
- Division of Thoracic Surgery, Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pa.
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Clark JM, Cooke DT, Chin DL, Utter GH, Brown LM, Nuño M. Does one size fit all? An evaluation of the 2018 Leapfrog Group minimal hospital and surgeon volume thresholds for lung surgery. J Thorac Cardiovasc Surg 2019; 159:2071-2079.e2. [PMID: 31740117 DOI: 10.1016/j.jtcvs.2019.09.082] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 09/16/2019] [Accepted: 09/18/2019] [Indexed: 01/30/2023]
Abstract
BACKGROUND In 2018, the Leapfrog Group set minimum annual lung cancer surgery hospital and surgeon volume thresholds of 40 and 15, respectively. We examined whether outcomes associated with these Leapfrog Group volume thresholds are comparable for patients at the extremes of age and comorbidities. METHODS We assessed lung cancer patients undergoing lobectomy or pneumonectomy in the New York and Florida State Inpatient Databases for 2007 to 2013. Multivariate logit models evaluated in-hospital mortality, complications, and prolonged length of stay. Median surgeon and hospital volumes were compared between "younger-healthier" (age 18-60 years, Elixhauser Comorbidity Index <1) and "older-sicker" patients (age >77 years, Elixhauser Comorbidity Index >3). RESULTS The 27,841 patients included 13,277 men (48%). The median patient age was 69 years (interquartile range, 61-77), and mortality was 2.1%. Patients treated by both low-volume surgeons (<15 annual cases) and at low-volume hospitals (<40) had the greatest risk of mortality (2.5%), except for the cohort of younger-healthier patients (mortality <2%). Mortality for older-sicker patients was highest for high-volume surgeons (12%), although higher hospital volume was protective. Increasing hospital volume was associated with decreased mortality (odds ratio [OR], 0.997; 95% confidence interval [CI], 0.995-0.998; P = .0103), complications (OR, 0.998; 95% CI, 0.997-0.999; P < .001), and prolonged length of stay (OR, 0.998; 95% CI, 0.997-1.00; P = .01); similarly, higher surgeon volume was associated with decreased mortality (OR, 0.997; 95% CI, 0.99-1.00; P = .03), complications (OR, 0.997; 95% CI, 0.994-1.00; P = .02), and prolonged length of stay (OR, 0.991; 95% CI, 0.986-0.995; P < .01). CONCLUSIONS Hospital volume has a greater effect on morbidity and mortality than surgeon volume especially for older-sicker patients, suggesting that Leapfrog Group volume guidelines should emphasize hospital volume over surgeon volume and may be less relevant for younger-healthier patients.
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Affiliation(s)
- James M Clark
- Section of General Thoracic Surgery, Department of Surgery, University of California, Davis, Calif
| | - David T Cooke
- Section of General Thoracic Surgery, Department of Surgery, University of California, Davis, Calif; Department of Surgery, Outcomes Research Group, University of California, Davis, Calif
| | - David L Chin
- Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts, Amherst, Mass
| | - Garth H Utter
- Department of Surgery, Outcomes Research Group, University of California, Davis, Calif; Division of Trauma, Department of Surgery, Acute Care Surgery, and Surgical Critical Care, University of California, Davis, Calif
| | - Lisa M Brown
- Section of General Thoracic Surgery, Department of Surgery, University of California, Davis, Calif; Department of Surgery, Outcomes Research Group, University of California, Davis, Calif
| | - Miriam Nuño
- Department of Surgery, Outcomes Research Group, University of California, Davis, Calif; Center for Healthcare Policy and Research, University of California, Davis, Calif; Division of Biostatistics, Department of Public Health Sciences, University of California, Davis, Calif.
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Impact of enhanced recovery after surgery on outcomes of elderly patients undergoing open thoracic surgery. Gen Thorac Cardiovasc Surg 2019; 67:867-875. [PMID: 30929139 DOI: 10.1007/s11748-019-01099-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 02/26/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE An enhanced recovery after surgery (ERAS) program might be effective for postoperative recovery in elderly patients undergoing thoracic surgery. This study aimed to clarify the impact of ERAS on the post-operative recovery of elderly patients, with regard to shortening hospital stay and reducing complications after open thoracic surgery. METHODS We used a prospectively collected database and retrospectively accessed the data of patients who underwent lobectomies or segmentectomies for pulmonary malignancies from April 2013 to March 2018 and evaluated outcomes after implementation of ERAS. ERAS patients were those who completed an ERAS program. The control patients were those who underwent surgery before June 2015 and later operated patients who did not receive ERAS. Propensity score matching was performed to balance the characteristics of patients in both groups. Patients were also divided into the following three groups for evaluating the efficacy of ERAS: patients aged < 65 years, 65-74 years of age, and ≥ 75 years of age. RESULTS Before propensity score matching, the ERAS patients had shorter postoperative stay, shorter duration of chest tube drainage, and lower rate of postoperative complications than the patients without ERAS. The difference between readmission rates was not significant. After matching, the ERAS patients had shorter postoperative stay. The difference between readmission rates was not significant. After matching, the postoperative hospital stay was shorter in the patients aged ≥ 65 years. CONCLUSIONS ERAS shortened the length of postoperative hospital stay in patients aged ≥ 65 years and did not increase readmission rates.
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Chevrollier GS, Nemecz AK, Devin C, Go KV, Yi M, Keith SW, Cowan SW, Evans NR. Early Discharge Does Not Increase Readmission Rates After Minimally Invasive Anatomic Lung Resection. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2019; 14:218-226. [DOI: 10.1177/1556984519836821] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Objective Enhanced recovery pathways reduce length of stay and costs following lung resection. However, many fear that early discharge may lead to increased hospital readmissions. In this study, we aimed to determine whether early discharge was associated with increased readmission following anatomic lung resection. Methods Using the lung resection database approved by our institutional review board, we identified all patients undergoing minimally invasive lobectomy and segmentectomy between January 2010 and March 2017 at our institution, where an enhanced recovery pathway is well established. Thirty-day readmissions were compared between patients with short- and average length of stay, defined as 1 to 2 days and 3 to 5 days, respectively. Multivariable logistic regression analysis of patients matched by propensity scores was performed to determine odds of 30-day readmission for each group. Significance was set at P < 0.05. Results A total of 296 patients met inclusion criteria. Unadjusted analysis revealed a 3-fold increased rate of readmission in the group with average length of stay (9%, n = 12) versus the group with short length of stay (3%, n = 5; P < 0.01). At baseline, patients with average length of stay had increased rates of preoperative chemotherapy (13%, n = 18 vs. 4%, n = 6; P < 0.01) and radiation (12%, n = 16 vs. 3%, n = 5). Patients with average length of stay also had higher rates of lobectomy (95%, n = 127 vs. 86%, n = 140; P = 0.02) and postoperative complications (31%, n = 41 vs. 4%, n = 7; P < 0.01). On multivariable analysis, patients with average length of stay had a 2.3-fold greater odds of readmission, which was not statistically significant (OR = 2.33; 95% CI, 0.60 to 9.02; P = 0.22). Conclusions Early discharge following minimally invasive anatomic lung resection does not increase the risk of hospital readmission in patients treated within an enhanced recovery pathway.
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Affiliation(s)
- Guillaume S. Chevrollier
- Department of Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Amanda K. Nemecz
- Department of Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Courtney Devin
- Department of Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Kendrick V. Go
- Department of Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Misung Yi
- Department of Pharmacology and Experimental Therapeutics, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Scott W. Keith
- Department of Pharmacology and Experimental Therapeutics, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Scott W. Cowan
- Department of Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Nathaniel R. Evans
- Department of Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
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Comacchio GM, Monaci N, Verderi E, Schiavon M, Rea F. Enhanced recovery after elective surgery for lung cancer patients: analysis of current pathways and perspectives. J Thorac Dis 2019; 11:S515-S522. [PMID: 31032070 DOI: 10.21037/jtd.2019.01.99] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The concept of enhanced recovery after surgery (ERAS), initially introduced in the field of colorectal surgery, has been developed in order to optimize the postoperative course. In recent years the number of authors analyzing the role of ERAS in lung cancer surgery is increasing, highlighting several interventions with positive effects on the postoperative course. Yet it is still difficult to draw definite conclusions and specific guidelines, as most of these studies largely differ for their methodological aspects and study populations. Herein we focus on the key elements of each single intervention, trying to identify what we can apply in a common pathway, and which aspects are still to be evaluated for the validation of an ERAS program.
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Affiliation(s)
- Giovanni Maria Comacchio
- Thoracic Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Nicola Monaci
- Thoracic Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Enrico Verderi
- Thoracic Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Marco Schiavon
- Thoracic Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Federico Rea
- Thoracic Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
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Van Haren RM, Atay SM. Enhancing the study of enhanced recovery after thoracic surgery: methodology and population-based approaches for the future. J Thorac Dis 2019; 11:S612-S618. [PMID: 31032079 DOI: 10.21037/jtd.2019.01.81] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Achieving optimal outcomes following thoracic surgery requires a complex multidisciplinary effort spanning the entire peri-operative period. Enhanced recovery after surgery (ERAS) protocols aim to codify essential elements in care across all perioperative settings. As thoracic surgeons have begun to embrace ERAS, identification of optimal protocol elements and novel study endpoints is necessary. In this review we will briefly review the current available evidence for ERAS in thoracic surgery, while focusing on study methods and design. We will discuss methodology for future studies and how a population-based approach can improve the current level of evidence supporting broad implementation of ERAS to thoracic surgery.
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Affiliation(s)
- Robert M Van Haren
- Division of Thoracic Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Scott M Atay
- Division of Thoracic Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Kneuertz PJ, Singer E, D'Souza DM, Moffatt-Bruce SD, Merritt RE. Postoperative complications decrease the cost-effectiveness of robotic-assisted lobectomy. Surgery 2019; 165:455-460. [DOI: 10.1016/j.surg.2018.08.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 08/07/2018] [Accepted: 08/30/2018] [Indexed: 12/17/2022]
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Eustache J, Ferri LE, Feldman LS, Lee L, Spicer JD. Enhanced recovery after pulmonary surgery. J Thorac Dis 2018; 10:S3755-S3760. [PMID: 30505562 DOI: 10.21037/jtd.2018.09.61] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The concept of surgical recovery encompasses the entire perioperative phase of the patient, beginning with the preoperative baseline and culminating in the long-term rehabilitation of the patient in the post-operative phase. Enhanced recovery pathways (ERPs) aim to encompass all phase of the patient trajectory, including the preoperative, perioperative, and postoperative management of surgical patients. While significant literature exists on standardizing and optimizing the perioperative phase, standardizing the pre and post-operative phases remains a topic of debate. Furthermore, with regards to pulmonary surgery, the available data on enhanced recovery remains limited, with no consensus on which components to include within the ERP. The difficulty in identifying specific factors to include within a pathway is in part due to the lack of representative metrics of recovery. Secondly, the strength of ERPs usually lies in the agglomeration of multiple components rather than the individual components themselves. This review provides a brief review on current developments in ERPs in pulmonary surgery, emphasizing novel components in the pre and post-operative care of patients. Furthermore, we discuss the limitations of current metrics used to study recovery, and what steps can be taken to direct future studies that aim to enhance patient recovery after pulmonary surgery.
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Affiliation(s)
- Jules Eustache
- Department of General Surgery, McGill University Health Centre, Montreal, Canada
| | - Lorenzo E Ferri
- Division of Thoracic Surgery, McGill University Health Centre, Montreal, Canada
| | - Liane S Feldman
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Canada
| | - Lawrence Lee
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Canada
| | - Jonathan D Spicer
- Division of Thoracic Surgery, McGill University Health Centre, Montreal, Canada
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Gonzalez M, Abdelnour-Berchtold E, Perentes JY, Doucet V, Zellweger M, Marcucci C, Ris HB, Krueger T, Gronchi F. An enhanced recovery after surgery program for video-assisted thoracoscopic surgery anatomical lung resections is cost-effective. J Thorac Dis 2018; 10:5879-5888. [PMID: 30505496 DOI: 10.21037/jtd.2018.09.100] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Background Enhanced recovery after surgery (ERAS) programs have been reported to decrease complications and shorten hospital stays after lung resections, but their implementation requires time and financial investment with dedicated staff. The aim of this study was to evaluate the clinical and economic outcomes of video-assisted thoracoscopic surgery (VATS) anatomical pulmonary resections before and after implementation of an ERAS program. Methods The first 50 consecutive patients undergoing VATS lobectomy or segmentectomy for malignancy after implementation of an ERAS program were compared with 50 consecutive patients treated before its introduction. The ERAS protocol included preoperative counseling, reduced preoperative fasting with concomitant carbohydrate loading, avoidance of premedication, standardized surgery, anesthesia and postoperative analgesia, early removal of chest tube, nutrition and mobilization. Length of stay, readmissions and cardio-pulmonary complications within 30 days were compared. Total costs were collected for each patient and a cost-minimization analysis integrating ERAS-specific costs was performed. Results Both groups were similar in terms of demographics and surgical characteristics. The ERAS group had significantly shorter postoperative length of stay (median: 4 vs. 7 days, P<0.0001), decreased pulmonary complications (16% vs. 38%; P=0.01) and decreased overall post-operative complications (24% vs. 48%, P=0.03). One patient in each group was readmitted and there was no 30-day mortality. ERAS-specific costs were calculated at €729 per patient including the clinical nurse and database costs. Average total hospitalization costs were significantly lower in ERAS group (€15,945 vs. €20,360, P<0.0001), mainly due to lower costs during the post-operative period (€7,449 vs. €11,454, P<0.0001) in comparison with the intra-operative period (€8,496 vs. €8,906, P=0.303). Cost-minimization analysis showed a mean saving in the ERAS group of €3,686 per patient. Conclusions An ERAS program for VATS anatomical lung resection is cost-effective and is associated with a lower complication rate and a shorter postoperative hospitalization.
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Affiliation(s)
- Michel Gonzalez
- Service of Thoracic Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | | | - Jean Yannis Perentes
- Service of Thoracic Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Valérie Doucet
- Service of Thoracic Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Mathieu Zellweger
- Service of Thoracic Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Carlos Marcucci
- Service of Anesthesiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Hans-Beat Ris
- Service of Thoracic Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Thorsten Krueger
- Service of Thoracic Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Fabrizio Gronchi
- Service of Anesthesiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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Martin LW, Sarosiek BM, Harrison MA, Hedrick T, Isbell JM, Krupnick AS, Lau CL, Mehaffey JH, Thiele RH, Walters DM, Blank RS. Implementing a Thoracic Enhanced Recovery Program: Lessons Learned in the First Year. Ann Thorac Surg 2018; 105:1597-1604. [DOI: 10.1016/j.athoracsur.2018.01.080] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 01/24/2018] [Accepted: 01/26/2018] [Indexed: 01/23/2023]
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Affiliation(s)
- Christopher W Seder
- Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, IL, USA
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Kumar R, Donahue JM. Editorial for economic impact of an enhanced recovery pathway for lung resection. J Thorac Dis 2018; 10:7-9. [PMID: 29600009 DOI: 10.21037/jtd.2017.12.73] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Rajat Kumar
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - James M Donahue
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
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Li S, Zhou K, Che G, Yang M, Su J, Shen C, Yu P. Enhanced recovery programs in lung cancer surgery: systematic review and meta-analysis of randomized controlled trials. Cancer Manag Res 2017; 9:657-670. [PMID: 29180901 PMCID: PMC5695257 DOI: 10.2147/cmar.s150500] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background Enhanced recovery after surgery (ERAS) program is an effective evidence-based multidisciplinary protocol of perioperative care, but its roles in thoracic surgery remain unclear. This systematic review of randomized controlled trials (RCTs) aims to investigate the efficacy and safety of the ERAS programs for lung cancer surgery. Materials and methods We searched the PubMed and EMBASE databases to identify the RCTs that implemented an ERAS program encompassing more than four care elements within at least two phases of perioperative care in lung cancer surgery. The heterogeneity levels between studies were estimated by the Cochrane Collaborations. A qualitative review was performed if considerable heterogeneity was revealed. Relative risk (RR) and weighted mean difference served as the summarized statistics for the meta-analyses. Additional analyses were also performed to perceive potential bias risks. Results A total of seven RCTs enrolling 486 patients were included. The meta-analysis indicated that the ERAS group patients had significantly lower morbidity rates (RR=0.64; p<0.001), especially the rates of pulmonary (RR=0.43; p<0.001) and surgical complications (RR=0.46; p=0.010), than those of control group patients. No significant reduction was found in the in-hospital mortality (RR=0.70; p=0.58) or cardiovascular complications (RR=1.46; p=0.25). In the qualitative review, most of the evidence reported significantly shortened length of hospital and intensive care unit stay and decreased hospitalization costs in the ERAS-treated patients. No significant publication bias was detected in the meta-analyses. Conclusion Our review demonstrates that the implementation of an ERAS program for lung cancer surgery can effectively accelerate postoperative recovery and save hospitalization costs without compromising patients’ safety. A worldwide consensus guideline is urgently required to standardize the ERAS protocols for elective lung resections in the future.
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Affiliation(s)
| | | | | | | | - Jianhua Su
- Department of Rehabilitation, Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, China
| | | | - Pengming Yu
- Department of Rehabilitation, Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, China
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