Five-Year Sustained Impact of a Thoracic Enhanced Recovery After Surgery Program

Associations between postoperative pulmonary interventions based on enhanced recovery programs and outcomes in patients with lung cancer: A retrospective propensity score matching study

PURPOSE

The purpose of the study was to assess the impact of postoperative pulmonary interventions based on enhanced recovery programs (PPIE) on patients undergoing lung cancer surgery using a retrospective propensity score matching (PSM).

METHODS

The non-PPIE group only received the enhanced recovery programs, while the PPIE group received additional postoperative pulmonary interventions, including the active cycle of breathing techniques, oscillatory positive expiratory pressure therapy, incentive spirometry training, and early mobilization, conducted by nurses.

RESULTS

656 patients with lung cancer were identified from January 2020 to December 2022. PSM resulted in 253 patients in each group. The PPIE group showed significant improvements in the presence of postoperative pulmonary complications within the first 30-day (4.7% vs. 11.9%, OR 0.37, 95% CI 0.19-0.74, p = 0.004) and in-hospital postoperative pulmonary complications (3.2% vs. 11.1%, OR 0.26, 95% CI 0.12-0.59, p = 0.001). PPIE was associated with an estimated median reduction in the postoperative hospital length of stay by 1 day (P < 0.001). Moreover, the duration of chest tube indwelling didn't significantly differ between groups (p = 0.394).

CONCLUSION

PPIE is beneficial to the outcomes of patients after lung cancer surgery, except for the duration of postoperative chest tube indwelling. Postoperative pulmonary interventions could be integrated into the ERPs to enhance rehabilitation. Moreover, nurses play a role in facilitating the recovery of patients who have undergone lung cancer surgery.

Why do patients stay in hospital after enhanced recovery thoracoscopic wedge resection? A prospective observational study

OBJECTIVES

This single-centre prospective observational study aimed to investigate reasons for prolonged hospitalization [over the median length of stay (LOS)] after enhanced recovery thoracoscopic [ERAS 3-port video-assisted thoracoscopic surgery (VATS)] wedge resection.

METHODS

All patients were evaluated twice-daily by an investigator for reasons of hospitalization. Each reason was analysed individually. Predictors for prolonged hospitalization were identified using a multivariable backward stepwise logistic regression model.

RESULTS

A total of 150 consecutive patients (lymphadenectomy 8.7%) were included from November 2022 to December 2023, with a median LOS of 1 (interquartile range 1-2) day. Of these, 55 patients (36.7%) experienced prolonged hospitalization. The main reasons included postoperative pain (16.0%), air leak (14.7%) and social factors (14.7%), followed by oxygen dependency (7.3%), gastrointestinal factors (5.3%), urinary factors (4.7%), pneumonia (1.3%), pleural effusion (1.3%), chylothorax (0.7%), atrial fibrillation (0.7%), confusion (0.7%) and fatigue (0.7%). Multivariable analysis revealed that an increase in the percentage of predicted forced expiratory volume in 1 s (FEV1%pre) by 1% [odds ratio (OR) 0.41, P = 0.023) and percentage of predicted diffusing capacity for carbon monoxide (DLCO%pre) by 1% (OR 0.95, P = 0.002) decreased likelihood of prolonged hospitalization. Conversely, each additional pack-year (OR 1.01, P = 0.028) and living alone (OR 3.55, P = 0.005) increased the risk of prolonged hospitalization.

CONCLUSIONS

Prolonged hospitalization (LOS > 1 day) after ERAS 3-port VATS wedge resection, with 8.7% lymphadenectomy, was mainly due to pain, air leak and social factors. Smokers with decreased FEV1%pre or DLCO%pre and patient living alone were at increased risk.

CLINICAL TRIAL REGISTRATION NUMBER

ClinicalTrials.gov: NCT06118593 (https://clinicaltrials.gov/study/NCT06118593?cond=why%20in%20hospital&rank=2).

Improving care in lung cancer surgery: a review of quality measures and evolving standards

PURPOSE OF REVIEW

Lung cancer is the leading cause of cancer-related death in the United States. Pulmonary resection, in addition to perioperative systemic therapies, is a cornerstone of treatment for operable patients with early-stage and locoregional disease. In recent years, increased emphasis has been placed on surgical quality metrics: specific and evidence-based structural, process, and outcome measures that aim to decrease variation in lung cancer care and improve long term outcomes. These metrics can be divided into potential areas of intervention or improvement in the preoperative, intraoperative, and postoperative phases of care and form the basis of guidelines issued by organizations including the National Cancer Center Network (NCCN) and Society of Thoracic Surgeons (STS). This review focuses on established quality metrics associated with lung cancer surgery with an emphasis on the most recent research and guidelines.

RECENT FINDINGS

Over the past 18 months, quality metrics across the peri-operative care period were explored, including optimal invasive mediastinal staging preoperatively, the extent of intraoperative lymphadenectomy, surgical approaches related to minimally invasive resection, and enhanced recovery pathways that facilitate early discharge following pulmonary resection.

SUMMARY

Quality metrics in lung cancer surgery is an exciting and important area of research. Adherence to quality metrics has been shown to improve overall survival and guidelines supporting their use allows targeted quality improvement efforts at a local level to facilitate more consistent, less variable oncologic outcomes across centers.

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

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