Enhanced Recovery After Lung Resection Surgery: Knowing What We Can Do… and Doing It

Abstract

THE CONCEPT of enhanced recovery after surgery (ERAS) was initially raised nearly 2 decades ago, with the aim to improve patient recovery and outcomes after surgery and improve use of available healthcare resources. ERAS programs achieve this through standardization of a number of preoperative, intraoperative, and postoperative clinical management points, based on best evidence and practice guidelines. The initial ERAS experience began in colorectal surgery1Fearon KCH Ljungqvist O Von Meyenfeldt M et al.Enhanced recovery after surgery: A consensus review of clinical care for patients undergoing colonic resection.Clin Nutr. 2005; 24: 466-477Abstract Full Text Full Text PDF PubMed Scopus (1000) Google Scholar and culminated in the formation of the ERAS Society in 2010. Since then, ERAS initiatives have been undertaken in other surgical specialties, including upper abdominal, urologic, gynecologic, and orthopedic surgeries. The benefits of ERAS protocols appear to rise from the cumulative impact of combining several clinical management points, which individually would not have significant effects on patient outcomes. The role of the perioperative team, including the anesthesiologist, is paramount to success in ERAS programs. ERAS protocols have been shown to improve complication rates and reduce length of hospitalization by 30% to 50% in a number of studies.2Nicholson A Lowe MC Parker J et al.Systematic review and meta-analysis of enhanced recovery programmes in surgical patients.Br J Surg. 2014; 101: 172-188Crossref PubMed Scopus (290) Google Scholar3Ljungqvist O Scott M Fearon KC Enhanced recovery after surgery.JAMA Surgery. 2017; 152: 292Crossref PubMed Scopus (1376) Google Scholar In this issue of the Journal of Cardiothoracic and Vascular Anesthesia, Forster et al.4Forster C Doucet V Perentes JY et al.Impact of compliance with components of an ERAS pathway on the outcomes of anatomical VATS pulmonary resections.J Cardiothorac Vasc Anesth. 2020; 34: 1858-1866Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar examine the impact of compliance with an ERAS protocol on outcomes of patients presenting for elective Video-Assisted Thoracic Surgery (VATS) for anatomic lung resections. Despite early interest dating back to the early 2000s,5Cerfolio RJ Pickens A Bass C et al.Fast-tracking pulmonary resections.J Thorac Cardiovasc Surg. 2001; 122: 318-324Abstract Full Text Full Text PDF PubMed Scopus (137) Google Scholar ERAS protocols for thoracic surgery have been slower to develop compared with other surgical specialties. This is in large part owing to heterogeneity in early protocols and limited evidence concerning effective interventions.6Oprea AD Perrino AC Popescu WM Enhanced recovery after lung surgery: Fad or fashion?.J Cardiothorac Vasc Anesth. 2019; 33: 2445-2447Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar However, recent published studies have improved our understanding of ERAS in thoracic surgery, culminating in the development of “Guidelines for Enhanced Recovery after Lung Surgery” by the ERAS Society and European Society of Thoracic Surgeons (ESTS) in 2019.7Batchelor TJP Rasburn NJ Abdelnour-Berchtold E et al.Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced Recovery After Surgery (ERAS(R)) Society and the European Society of Thoracic Surgeons (ESTS).Eur J Cardiothorac Surg. 2019; 55: 91-115Crossref PubMed Scopus (368) Google Scholar In their study, Forster et al.4Forster C Doucet V Perentes JY et al.Impact of compliance with components of an ERAS pathway on the outcomes of anatomical VATS pulmonary resections.J Cardiothorac Vasc Anesth. 2020; 34: 1858-1866Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar performed a retrospective analysis of prospectively collected data on 192 adult patients presenting for VATS anatomic pulmonary resection. These patients were subject to an ERAS protocol comprising 16 process elements, a number of which also are included in the aforementioned ERAS for lung surgery guidelines. The impact of high compliance (≥13 ERAS process elements met ≥75% adherence) versus low compliance (<13 ERAS process elements met <75% adherence) postoperative outcomes was assessed. High compliance, which accounted for 48.4% of patients, was associated with fewer pulmonary, and overall complications, as well as a reduced rate of delayed discharge from hospital. There were no differences in reoperation and readmission rates between high compliance and low compliance patients. Finally, early removal of chest tubes (by postoperative day 2) and cessation of opioids (by postoperative day 3) were identified as factors correlated with reduced postoperative complications and delay in discharge. The findings of this study are important, and further our understanding of key factors in developing successful ERAS protocols in thoracic surgery. However, the reported findings also highlight ongoing areas where questions remain. Specifically, more questions arise concerning ERAS protocol compliance, as well as identification of ERAS elements that carry significant impact on postoperative outcomes. Concerning compliance, Forster et al.4Forster C Doucet V Perentes JY et al.Impact of compliance with components of an ERAS pathway on the outcomes of anatomical VATS pulmonary resections.J Cardiothorac Vasc Anesth. 2020; 34: 1858-1866Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar clearly demonstrate that higher adherence to ERAS elements is associated with better postoperative outcomes. These findings echo those of Rogers et al.8Rogers LJ Bleetman D Messenger DE et al.The impact of enhanced recovery after surgery (ERAS) protocol compliance on morbidity from resection for primary lung cancer.J Thorac Cardiovasc Surg. 2018; 155: 1843-1852Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar, who demonstrated a clear inverse relationship between ERAS protocol compliance and postoperative morbidity in a large group of patients presenting for oncologic lung resection. Compliance to predetermined management protocols are influenced by patient, clinician, and institutional factors, and relies on all 3 for success. First, the more complex a protocol (ie, more elements), the higher the likelihood of difficulties with compliance. Additionally, medically complex patients are less likely to achieve aggressive ERAS pathway elements and are already at a greater likelihood for perioperative complications and longer duration of hospitalization. Furthermore, any patient subject to a postoperative complication is more likely to deviate from the ERAS pathway. In their analysis, Forster et al.4Forster C Doucet V Perentes JY et al.Impact of compliance with components of an ERAS pathway on the outcomes of anatomical VATS pulmonary resections.J Cardiothorac Vasc Anesth. 2020; 34: 1858-1866Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar report that 48.4% of patients met the criteria for “high compliance” and an overall compliance of 75%, suggesting a significant number of patients not meeting many ERAS elements. Barriers and reasons for noncompliance were not reported and are likely outside the scope of this retrospective analysis to identify. All patients in their study were ASA Physical Status Classification II or III, with no statistically significant differences in breakdown of ASA classification or reported comorbidities. However, preoperative education and counselling was reported among the elements with the lowest compliance (53%) and has been shown to play an important role in patient understanding and engagement in ERAS protocols.9Kahokehr A Sammour T Zargar-Shoshtari K et al.Implementation of ERAS and how to overcome the barriers.Int J Surg. 2009; 7: 16-19Crossref PubMed Scopus (110) Google Scholar Success of an ERAS protocol relies on both devising an adoptable and applicable set of management elements, selection of appropriate patients, and ensuring minimization of barriers to compliance. Another question arising from this report concerns the selection of applicable ERAS elements that can be optimized or maximized for successful achievement. The authors’ multivariable analysis revealed that early removal of chest tubes by postoperative day 2 and cessation of opioid administration on postoperative day 3 were both correlated with reduced postoperative complications and reduced delayed discharge. However, these findings are confounded. Indeed, the presence of a chest drain after thoracic surgery has been shown to significantly worsen pain and pulmonary function,10Refai M Brunelli A Salati M et al.The impact of chest tube removal on pain and pulmonary function after pulmonary resection.Eur J Cardiothorac Surg. 2012; 41: 820-823Crossref PubMed Scopus (86) Google Scholar and although clinicians advocate for the fewest number of chest tubes for the shortest duration possible, chest tube management remains a highly variable area rooted in surgeon habit and tradition.11Brunelli A Beretta E Cassivi SD et al.Consensus definitions to promote an evidence-based approach to management of the pleural space.A collaborative proposal by ESTS, AATS, STS, and GTSC. Eur J Cardiothorac Surg. 2011; 40: 291-297Crossref PubMed Scopus (85) Google Scholar ERAS may therefore challenge chest tube management dogma and encourage the safe early removal of chest tubes. In that context, ERAS is clearly beneficial. However, other factors that influence the duration of chest tube drainage such as air or fluid leak and unanticipated complications cannot be significantly influenced or modified by ERAS and would clearly affect postoperative complications and delayed discharge. As such, despite its demonstrated importance as an ERAS component, early removal of chest drains is a multifactorial consideration. Concurrently, multimodal pain management and opioid cessation by postoperative day 3 was also identified as an important factor in reducing complications and facilitating discharge. As mentioned previously, persistent presence of a chest tube and postoperative pain have been shown to be inextricably linked. Both pain at rest and movement have been shown to decrease by 40% after removal of a chest tube after both open and VATS lung resections.10Refai M Brunelli A Salati M et al.The impact of chest tube removal on pain and pulmonary function after pulmonary resection.Eur J Cardiothorac Surg. 2012; 41: 820-823Crossref PubMed Scopus (86) Google Scholar Failure to remove a chest tube by postoperative day 2 increases the likelihood of requiring opioids on postoperative day 3, as was seen by the authors. The approach to post-VATS analgesia taken by the authors’ pathway is similar to that across many institutions, using intercostal nerve blocks intraoperatively, and systemic opioids and multimodal adjuncts postoperatively. The ESTS/ERAS Society guidelines outline the potential role of regional/neuraxial techniques for pain management in post-lung surgery ERAS pathways.7Batchelor TJP Rasburn NJ Abdelnour-Berchtold E et al.Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced Recovery After Surgery (ERAS(R)) Society and the European Society of Thoracic Surgeons (ESTS).Eur J Cardiothorac Surg. 2019; 55: 91-115Crossref PubMed Scopus (368) Google Scholar Although effective for analgesia and opioid-sparing, techniques such as thoracic epidural or paravertebral analgesia carry with them procedural risks, side-effects, and added complexity to postoperative venous thromboembolism prophylaxis, making them less favorable for VATS lung surgery by many clinicians. However, emerging interest and investigation of myofascial plane blocks such as the Erector Spinae Plane Block (ESPB) and Serratus Anterior Plane Block (SAPB) have demonstrated them to be viable alternatives. Both ESPB and SAPB have been shown to provide safe and effective analgesia, reduced opioid consumption, and minimize adverse effects in VATS patients.12Ciftci B Ekinci M Celik EC et al.Efficacy of an ultrasound-guided erector spinae plane block for postoperative analgesia management after video-assisted thoracic surgery: A prospective randomized study.J Cardiothorac Vas Anesth. 2020; 34: 444-449Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar,13Gaballah KM Soltan WA Bahgat NM Ultrasound-guided serratus plane block versus erector spinae block for postoperative analgesia after video-assisted thoracoscopy: A pilot randomized controlled trial.J Cardiothorac Vasc Anesth. 2019; 33: 1946-1953Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar Combined with a catheter-based technique, both the SAPB and ESPB provide effective analgesic options that can minimize opioid use until after pain inciting events, such as the presence of a chest tube. In addition to elements identified in this report, recent developments in key areas of thoracic anesthesia soon may influence ERAS pathway development as well. Forster et al. employed a fluid management approach that minimized intraoperative fluid administration to less than 1 L of crystalloid to avoid fluid overload. This approach did not appear to influence postoperative complications. A fluid restrictive approach has long been the standard of practice in lung surgery to minimize pulmonary edema and lung injury, potentially at the peril of end-organ dysfunction. ERAS protocols in other major surgical patient populations have begun to adopt goal-directed fluid management approaches with the goal of maintaining euvolemia. Though there is a paucity of large studies examining this in thoracic surgery, small studies targeting euvolemia in lung resection patients have been shown to be safe.14Assaad S Kyriakides T Tellides G et al.Extravascular lung water and tissue perfusion biomarkers after lung resection surgery under a normovolemic fluid protocol.J Cardiothorac Vasc Anesth. 2015; 29: 977-983Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar The ESTS/ERAS Society guidelines have also adopted a recommendation targeting euvolemia, and we will likely see more data concerning the implications of this in the near future. In addition to fluid management, intraoperative management of one-lung ventilation (OLV) has long been an area of intense interest. OLV management has evolved to incorporate principles from critical care literature to reduce pulmonary complications. Specifically, low tidal volume (5-6 mL/kg), minimization of plateau pressures, and application of PEEP have now become common place in thoracic anesthesia. Forster et al. adopted these elements in their described ventilation strategy. More recently, ventilation strategies focused on minimization of “driving pressure” (the difference between plateau end-inspiratory airway pressure and PEEP) have shown promise in reducing pulmonary complications in thoracic surgery. Two recent studies in thoracic surgery have demonstrated intraoperative ventilation aimed at minimizing driving pressure was associated with reduced postoperative pulmonary complications when compared with traditional lung protective strategies.15Park M Ahn HJ Kim JA et al.Driving pressure during thoracic surgery: A randomized clinical trial.Anesthesiology. 2019; 130: 385-393Crossref PubMed Scopus (63) Google Scholar,16Belda J Ferrando C Garutti I The effects of an open-lung approach during one-lung ventilation on postoperative pulmonary complications and driving pressure: A descriptive, multicenter national study.J Cardiothorac Vasc Anesth. 2018; 32: 2665-2672Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar More studies are underway and may trigger further evolution in the management of OLV. The authors believe that Forster et al. are to be commended for clearly demonstrating the effectiveness of an ERAS pathway in reducing complications rates and delays in discharge from hospital in VATS lung resection patients. Their work also highlights the importance of ensuring high compliance to ERAS elements. In the future, the authors believe that ERAS pathways in thoracic surgery will move to focus on better understanding factors influencing compliance and act to optimize them, while adding additional elements that are individualized to patients, improve patient experience, and ultimately further improve patient outcomes. This research did not receive any specific grant from funding agencies in the public, commercial, or not- for-profit sectors. Impact of Compliance With Components of an ERAS Pathway on the Outcomes of Anatomic VATS Pulmonary ResectionsJournal of Cardiothoracic and Vascular AnesthesiaVol. 34Issue 7PreviewImplementation of an Enhanced Recovery After Surgery (ERAS) program is associated with better postoperative outcomes. The aim of this study was to evaluate the impact of ERAS compliance (overall and to specific elements of the program) on them. Full-Text PDF