Enhanced recovery after surgery and chest tube management

Abstract

This review documents the relationships between enhanced recovery after surgery (ERAS) pathways, chest tube management and patient outcomes following lung resection surgery. ERAS pathways have been introduced to mitigate the harmful stress response that occurs following all major surgery, including lung resection. Improvements to the entire patient pathway, from the preoperative admission clinic through to discharge and beyond, can have additive or synergistic effects and result in improved patient outcomes, reduced length of stay and lower costs. At the same time, there are some key care elements that appear to be more important than others. In the postoperative period, early removal of chest tubes, early mobilization, and limited use of opioids are all independently important factors. These elements of care are all intertwined. Therefore, a focus on proactive chest tube management with the abandonment of conservative chest tube strategies should be a focus of postoperative ERAS pathways. This can be achieved with single tubes, no routine suction, the use of digital drainage systems, and removal of tubes even in the presence of relatively high serous pleural fluid outputs. The goals of early mobilization and opioid-sparing analgesia are more readily achieved once a chest tube has been removed. The result is superior patient outcomes with significantly fewer complications.

ERAS-Implementierung in der Thoraxchirurgie

“…"Drain Pain") [39]. Ob überhaupt eine Thoraxdrainage eingelegt werden sollte, bleibt Teil kontroverser Diskussionen, jedoch sollte eine möglichst frühe Entfernung angestrebt werden [40]. Wenn auf eine Sogbehandlung an der Thoraxdrainage nicht verzichtet werden kann, sollte der Sog unter −10 cmH 2 O eingestellt werden [41,42].…”

Get your 7-point golden medal for pain management in video-assisted thoracoscopic surgery

“…Early removal of chest drains, facilitating those ERATS goals should in these cases be considered [29]. An active chest drain management with evidence-based goals for removal should be integrated into the multimodal analgesic strategy [28 ▪▪ ]. Obviously, this requires the close collaboration between surgeon and anesthesiologist.…”

Thinking outside the “Enhanced Recovery After Surgery” box: would a more progressive, patient-tailored approach in chest tube management be next?

“…An interesting, more progressive approach in chest tube management was addressed by Batchelor in his review, namely chest tube omission after lung resection in selected patients (1). Current literature reports contradictory results regarding its safety in terms of the risk of a postoperative pneumothorax requiring a reintervention (18)(19)(20).…”

“…As part of the special series "Prolonged air leak after lung surgery: prediction, prevention and management" published in the Journal of Thoracic Disease, Batchelor (2023) presents a narrative review on enhanced recovery after surgery (ERAS) and chest tube management (1). The author provides a clear overview of the relevance and benefits of the postoperative ERAS pathway after sublobar and lobar resection, focusing on three intertwined "key care elements": chest tube management, pain relief, and early mobilization.…”