Enhanced Recovery after Thoracic Surgery

Abstract

Enhanced recovery programs (ERPs) aim to reduce psychological and physiological stress related to surgery, and minimize opioid use. This article describes the tenets of enhanced recovery, the guidelines for ERP in lung surgery, and the University of Virginia experience with developing and implementing a program. The impact of these strategies on short-term patient outcomes and potential long-term benefits including influence on lung cancer-specific outcomes are reviewed. The opioid crisis is of utmost importance; this article will explore how ERPs may be a mitigating factor.

Enhanced Recovery After Surgery Program and Opioid Consumption in Pulmonary Resection Surgery: A Retrospective Observational Study

“…The total amount of opioid consumption (median [IQR]) after surgery until discharge was lower in the ERAS group than in the conventional group (MME, 44 mg vs 208 [146-294] mg; median difference, −143 mg; 95% CI, −154 to −132; P < .001; Table 3). The daily average opioid consumption was also lower in the ERAS group than in the conventional group (MME, 8 [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19] mg vs 39 [32-45] mg; median difference, −28 mg; 95% CI, −30 to −26; P < .001; Table 3). The number of patients discharged without an opioid prescription was higher in the ERAS group (156/260 [60%] vs 329/1860 [18%]; odds ratio, 7.0; 95% CI, 5.3-9.3; P < .001; Table 3).…”

“…Some previous studies reported decreased analgesic consumption and pain intensity in patients who received ERAS treatment compared to those who received conventional treatment. 6,[12][13][14] They used multidisciplinary analgesic protocols, such as thoracic epidural analgesia, paravertebral block, or postoperative ketamine infusion, to decrease postoperative opioid consumption, 6,[12][13][14] but these analgesic techniques also carry several risks and limitations. Furthermore, epidural and systemic strategies may be less appropriate for the majority of patients who underwent minimally invasive thoracic surgery for whom the pain may be less severe than after a thoracotomy.…”

“…4 Many previous researchers have reported their experience with the implementation of an ERAS program in thoracic practice. 5,6 Based on these studies, the European Society of Thoracic Surgeons (ESTS) published guidelines for ERAS after lung surgery with 45 evidence-based components. 7 However, most previous studies on ERAS after thoracic surgery were performed on patients who underwent invasive open thoracotomy, and their ERAS protocols mainly focused on improving clinical outcomes, such as length of hospital stay, readmission rate, and postoperative complication grade.…”

“…5 Although a few studies have reported the influence of the ERAS program on opioid-sparing, it appears to be linked to other factors such as early chest tube removal. 6 After thoracic surgery, opioids are commonly administered for postoperative analgesia. However, opioids have a range of side effects, including respiratory depression, postoperative nausea and vomiting (PONV), dizziness, constipation, tolerance development, and a possible role in cancer progression, according to laboratory studies.…”

“…5 Although a few studies have reported the influence of the ERAS program on opioid-sparing, it appears to be linked to other factors such as early chest tube removal. 6…”