Enhanced recovery after thoracic surgery: Systematic review and meta-analysis

Abstract

The enhanced recovery after thoracic surgery (ERATS) protocol has been shown to reduce complications and hospital length of stay (LOS). [1][2][3] In thoracic surgery, the prototypical ERATS pathway involves a preoperative phase, which focuses on patient education and smoking cessation; the intraoperative phase incorporates multimodal anesthesia along with minimally invasive surgery (video-assisted thoracoscopic surgery [VATS]); and the postoperative phase emphasizes the use of incentive spirometry, early mobilization, early chest tube and urinary catheter removal. Goal-directed fluid therapy and minimization of opioids is encouraged. [2][3][4] Most of the evidence for ERATS has been published in small, retrospective, single-center studies and case-series reports, all of which are prone to bias. [5][6][7] In 2016, Fiore and colleagues 8 published a systematic review (SR) of 6 studies on ERATS in lung resections; however, the authors determined their results were inconclusive due to high risk of bias. Li and colleagues 9 also published a SR of 7 randomized-controlled trials (RCTs), but all study participants were from China, Europe, and the Middle East. In 2019, Batchelor and colleagues 3 formulated ERATS guidelines for the Enhanced Recovery After Surgery (ERAS) Society and the European Society of Thoracic Surgeons with an SR. Recently, a few retrospective cohort studies of ERATS in lung resections have been conducted in the United States and Canada, demonstrating that ERATS improves patient outcomes after lung resections and provides more cost-effective care. [10][11][12] In this updated SR and metaanalysis, we aimed to synthesize the evidence regarding the effect of ERATS, in comparison to conventional care, on surgical outcomes of adult patients undergoing lung resections. We hypothesized that ERATS would improve surgical outcomes by decreasing hospital LOS, postoperative complications, and readmission rates. METHODS Eligibility CriteriaThis SR was conducted in compliance with the preferred reporting items for systematic reviews and meta-analyses statement. 13 We developed inclusion and exclusion criteria with respect to populations, interventions, comparators, outcomes, timing, setting, and study designs (Table E1). Studies

Enhanced recovery after surgery and chest tube management

“…While fast-track protocols have previously been described in thoracic surgery and appeared to show an improvement in patient outcomes, specific ERAS pathways for lung cancer surgery have now been published (2,4,(14)(15)(16)(17)(18) and consistently demonstrate improvements in complication rates, length of stay, readmission rates and costs. A recent meta-analysis has confirmed the benefits of ERAS pathways in this group of patients (19). There are also demonstrable benefits in other metrics following surgery, including opioid use in hospital and subsequently following discharge (16,18).…”

An innovative oral management procedure to reduce postoperative complications

“…The review studies regarding the effect of Enhanced Recovery After Thoracic Surgery on specific postoperative pulmonary complications, cost, and patient-reported outcomes such as pain scores and patient satisfaction scores are also warranted. 30 In addition, the use of a comprehensive swallowing evaluation to detect aspiration before initiation of oral feedings after esophagectomy significantly reduced the incidence of pneumonia. This routine swallowing evaluation, incorporated into the postoperative care protocol after esophagectomy, demonstrated that postoperative pneumonia strongly predicted mortality.…”

How, when and why to establish preoperative surgical risk in thoracic surgery

“…Although the contents of Enhanced Recovery After Thoracic Surgery (ERATS) protocols may vary, their use has demonstrated the ability to improve patient outcomes via reductions in length of stay, readmission and postoperative complications [38]. These will ultimately lead to cost savings for healthcare institutions, given that ‘an ounce of prevention is worth a pound of cure’.…”