Enhanced Recovery After Thoracic Surgery

Introduction

Enhanced recovery after surgery (ERAS) refers to a comprehensive, evidence-based approach to patient-centered care in the perioperative period. The primary goals of enhanced recovery are an efficient return to baseline functional status and an avoidance of complications. Enhanced recovery has demonstrated success in multiple surgical specialties, particularly colorectal surgery. Although ERAS for thoracic surgery (ERATS) still occupies a small portion of the enhanced recovery literature, it is quickly gaining momentum. This uptick in interest has been aided by the recent release of two separate sets of enhanced recovery guidelines: one for lung resection surgery and one for esophagectomy. In this chapter, we will review the core tenets and specific components of the recent guidelines for ERATS in lung resection surgery, although the general principles for both are similar.

Background

Despite experiencing recent popularity and growth, ERAS (also referred to as enhanced recovery programs [ERPs]) is not a novel concept. Originally described in the 1990s by Kehlet et al. enhanced recovery is a multidisciplinary approach to perioperative care of the surgical patient. The goal of ERPs is a smooth, efficient return to baseline functional status. A natural byproduct, therefore is an increase in the value of health care, both by improving the quality of care and at the same time decreasing its cost. An uncomplicated recovery bodes well for the patient experience, healthcare system, and outcomes. In addition, enhanced recovery in the setting of cancer also promotes an earlier return to neoadjuvant treatment.

Despite an initial shortage of evidence-based literature and lack of formal guidelines, ERATS has recently emerged as an expanding field within ERAS. In addition to several metaanalyses and descriptions of institutional experiences, 2018 saw the release of two individual sets of enhanced recovery thoracic guidelines. The combined ERAS/ European Society of Thoracic Surgeons (ESTS) guidelines were the first of their kind, and represent a review of the available literature by a multinational, multidisciplinary group of authors, including surgeons and anesthesiologists and consensus-based recommendations. In this chapter, we will focus on the ERATS guidelines for lung resection surgery, which are summarized in Table 53.1 .

Fast-Track Versus Enhanced Recovery After Surgery

Often, the terms “fast-track” and enhanced recovery are used interchangeably, but an important distinction lies in the principal endpoint. Fast-track extubation and recovery, which was popularized during the 1990s, primarily focused on time to extubation and time to hospital discharge for cardiac surgery and, to a lesser degree, thoracic procedures. However, unlike ERPs, these protocols tended to be surgeon-driven, and less focused on the collective contributions of the multidisciplinary team. In addition, although certain aspects of fast-track protocols were tailored to allow for early extubation, including minimization of opioid medications, they did not typically include sophisticated approaches to multimodal analgesia, as will be discussed in this chapter. As a final distinction, unlike enhanced recovery, the tenets of fast-track protocols did not typically span the entire perioperative period, instead largely focusing on the intraoperative and postoperative components.

Enhanced Recovery After Surgery General Overview

Several common themes and objectives persist in ERPs regardless of surgical specialty. These core components have been specifically outlined by the governing bodies for ERAS: The Enhanced Recovery after Surgery (ERAS) Society and American Society of Enhanced Recovery (ASER). Outlined in Table 53.2 , these components span the entire perioperative timeframe, from the patient’s initial consultation to hospital discharge and potentially beyond. The preoperative components include: patient education and empowerment, intake of carbohydrate beverage up to 2 hours before surgery, optimization of comorbid conditions, and preemptive multimodal analgesia. Intraoperatively, ERAS goals include: continuation of multimodal analgesia, lung-protective ventilation, and avoidance of salt/crystalloid excess. ^, In the postoperative period, regardless of discipline, early enteral nutrition, mobilization, and removal of tubes and drains are essential. For comparison, Fig. 53.1 outlines components of an enhanced recovery protocol after lung resection surgery.

Enhanced Recovery After Surgery Thoracic Surgery: Justification and Applicability

Patients undergoing thoracic surgery tend to carry a substantial burden of comorbidity, in particular pulmonary and cardiovascular disease. In addition, thoracic surgery is associated with a high risk of morbidity and mortality compared with other surgeries. Therefore at an individual patient level, the potential impact of an ERP is significant. From an institutional and even larger healthcare standpoint, improving the quality and efficiency of care allows more patients to traverse through the system in a given time which also has financial implications.

Initially, the data supporting ERATS for lung resection surgery were sparse and stemmed from single institutions. Over the past decade, the literature supporting specific ERP components and overall pathways has become more rigorous, moving from retrospective reviews to meta-analyses and randomized controlled trials for certain components. Whereas colorectal surgery and other subspecialties have clearly and repeatedly demonstrated success with ERAS, it has only been in recent years that enhanced recovery for thoracic surgery has shown promise in decreasing cost, complications, and hospital length of stay.

The ERAS/ESTS guidelines synthesize the available evidence for particular recommendations in ERATS. For each component, the guidelines use the GRADE system ( www.gradeworkinggroup.org ) to: (1) describe the strength of the literature and (2) assign a level of recommendation based upon expert consensus. Although some commonly accepted and often performed portions of ERATS do not have solid objective evidence, they may still be strongly recommended based upon the pooled opinion of the expert group who authored the guidelines.

Enhanced Recovery After Surgery Thoracic Surgery: Preoperative Components