Enhanced recovery pathway versus standard care in patients undergoing video-assisted thoracoscopic lobectomy

Brunelli, Alessandro; Thomas, C.; Dinesh, Padma; Lumb, Andrew B

doi:10.1016/j.jtcvs.2017.06.037

Cited by 130 publications

(142 citation statements)

References 17 publications

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“…In a recent study, we were not able to find any difference in terms of morbidity, mortality and length of stay between patients submitted to VATS lobectomy before and after the introduction of a formal ERP program at our institution (9). The most likely explanation for this rather disappointing finding is that the majority of the key elements, which constitute ERP were already in place before the start of a formal ERP (i.e., use of a single drain, use of a digital drain system, similar pain management, postoperative rehabilitation, early oral feeding, etc.).…”

contrasting

confidence: 60%

Enhanced recovery pathways version 2.0 in thoracic surgery

Brunelli¹,

Imperatori²,

Droghetti³

2018

J. Thorac. Dis.

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Enhanced recovery pathways (ERPs) after surgery is a multimodal plan of care based on the application of multiple standardized evidence-based elements with the aim to improve the perioperative patient experience and surgical outcomes. These standardized elements are not just limited to the postoperative period but refer to the preoperative phase and obviously the surgical procedure. ERP is based on the concept of "marginal gains", well known in sport. Applied in isolation, the individual elements may have not a great effect on the outcome, but when applied together they act synergistically (1).The concept of ERP has been popularized in other specialties, particularly colorectal surgery, in which this practice has shown great benefits compared to standard care (2).However, thoracic surgeons are used to the elements of ERP, even though these were not badged as such. Certain practices, such as fluid balance, pain management, early mobilization, postoperative rehabilitation, are used in many thoracic surgery centers since decades. Several years ago, Cerfolio and colleagues (3,4) for instance identified modifiable and non-modifiable factors, which could contribute to improve fast track rate. Among the modifiable factors, the most relevant were the management of chest tubes, pain control, and social support plans. In spite of the factors contributing to ERP are well embedded in the thoracic surgery practice, the literature on ERP in our specialty is scant (5). Only few studies tried to analyze the effect of a standardized practice on the outcome after lung surgery. These studies were inconsistent in the elements they used to define a fast track protocol. The findings were also inconsistent. In general, the application of standardized elements of care contributed to reduce hospital stay. However, inconsistent findings were reported in terms of morbidity, mortality and re-admission rates (6-8).In all specialties, minimally invasive surgery represents the most important element in an ERP program. Yet so far most of the studies in thoracic surgery failed to include patients submitted to video-assisted thoracoscopic surgery (VATS), mostly because they were conducted prior to the widespread use of this approach.In a recent study, we were not able to find any difference in terms of morbidity, mortality and length of stay between patients submitted to VATS lobectomy before and after the introduction of a formal ERP program at our institution (9). The most likely explanation for this rather disappointing finding is that the majority of the key elements, which constitute ERP were already in place before the start of a formal ERP (i.e., use of a single drain, use of a digital drain system, similar pain management, postoperative rehabilitation, early oral feeding, etc.). The addition of few other elements such as the assumption of energy drinks before surgery to reduce the catabolic response or the use of warming blanket to prevent shivering and hypothermia among the others are unlikely to provide any benefits in a population who...

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confidence: 60%

Enhanced recovery pathways version 2.0 in thoracic surgery

Brunelli¹,

Imperatori²,

Droghetti³

2018

J. Thorac. Dis.

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“…All patients were selected for pulmonary resection according to current functional guidelines and after discussion during a multidisciplinary tumour board meeting [13]. A preoperative symptom-limited CPET on an electronically braked cycle ergometer was performed to detect the deficit in their oxygen transport system when the postoperative predicted (ppo) FEV1 or ppoDLCO (or both) are <30%, or if the distance walked during shuttle walk test was shorter than 400 meters, according to the locally 5 5 accepted guidelines [1,14].…”

Section: Methodsmentioning

confidence: 99%

“…Surgical pain was managed with a combination of intravenous patient controlled and local paravertebral analgesia. The details of this enhanced recovery pathway was previously described elsewhere [13].…”

Section: Methodsmentioning

confidence: 99%

Minute ventilation-to-carbon dioxide slope is associated with postoperative survival after anatomical lung resection

et al. 2018

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Objectives:The aim of the study was to identify whether ventilation-to-carbon dioxide output (VE/V CO2) slope obtained from cardiopulmonary exercise test (CPET) as part of the preoperative functional workup was an independent prognostic factor for short and long-term survival after major lung resection. Patients and Methods: 974 consecutive patients undergoing lobectomy (n=887) or segmentectomy (n=87) between April 2014 to March 2018 were included. 209 (22%) underwent CPET, and pulmonary function tests and several clinical factors including age, sex, performance status and comorbidities were retrospectively investigated to identify the prognostic factors with a multivariable Cox regression analysis.Results: Among the patients with measured VE/V CO2, the incidence of cardiopulmonary complications in patients with high VE/V CO2 slope (>40) was 37% (19 of 51) vs. 27% (33 of 121) in those with lower slope values (p=0.19). The 90-day mortality in patients with high VE/V CO2 slope (n=8) was 16% vs. 5% (n=6) in those with lower slope values (p=0.03). No overall difference in 2-year mortality was identified between the two groups (VE/VCO2 >40: 70% (54-80) vs. VE/VCO2 ≤40: 72% (63-80), log-rank test, p=0.39). In a Cox regression analysis VE/VCO2 values were associated with poorer 2-year survival (HR 1.05, 95% CI 1.01-1.10, p=0.030). Conclusions:We found that VE/V CO2 slope was an independent prognostic factor for the 90-day mortality and 2-year survival after anatomic pulmonary resection. This finding may assist during the multidisciplinary treatment decision-making process in high-risk patients with lung cancer.

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“…The possible explanation for this finding was that the pre-ERAS "standard of care" already included several ERAS components that may have contributed to provide good outcomes to VATS patients (29).…”

Section: Eras and Vats Lobectomy: What Is The Evidence?mentioning

confidence: 99%

A comprehensive protocol for physiokinesis therapy and enhanced recovery after surgery in patients undergoing video-assisted thoracoscopic surgery lobectomy

Bertani¹,

Ferrari²,

Terzo³

et al. 2018

J. Thorac. Dis.

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Background: Video-assisted thoracoscopic surgery (VATS) lobectomy has recently been adopted as the gold standard surgical option for the treatment of early stage non-small cell lung cancer. Enhanced recovery after surgery (ERAS) is being progressively adopted in thoracic surgery to improve the postoperative outcomes. Even if the benefits of ERAS are universally accepted, to date a standardized and uniform approach has not been described in the medical literature. The Italian VATS group has recently proposed to include in the VATS lobectomy database a structured protocol for ERAS. Methods:The ERAS section of the Italian VATS group is proposing a comprehensive ERAS protocol within the VATS lobectomy database, allowing the prospective collection of a dedicated set of data. Separate sections of the protocol are dedicated to different topics of ERAS. This study is specifically dedicated to the section of physiokinesis therapy. The medical literature will be extensively reviewed and a physiotherapy (PT) protocol of ERAS will be presented and discussed. A seta of structured clinical pathways will also be suggested for adoption in the VATS Group database.Discussion: Pre-and post-operative adoption of an ERAS protocol in patients undergoing VATS lobectomy may promote an improved post-operative course, a shorter hospital stay and an overall more comfortable patients' experience. The mainstays of a physiokinesis therapy ERAS protocol are patients' education, constant physical and respiratory therapy sessions, and adoption of adequate devices. Although many studies have investigated the usefulness of physical and respiratory physiokinesis therapy, a comprehensive ERAS protocol for VATS lobectomy patients has not yet been described. The proposed ERAS platform, adopted by the VATS Group database, will contribute to a prospective data collection and allow a scientific analysis of the results.

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Enhanced recovery pathway versus standard care in patients undergoing video-assisted thoracoscopic lobectomy

Cited by 130 publications

References 17 publications

Enhanced recovery pathways version 2.0 in thoracic surgery

Enhanced recovery pathways version 2.0 in thoracic surgery

Minute ventilation-to-carbon dioxide slope is associated with postoperative survival after anatomical lung resection

A comprehensive protocol for physiokinesis therapy and enhanced recovery after surgery in patients undergoing video-assisted thoracoscopic surgery lobectomy

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