Enhanced Recovery After Thoracic Surgery




Enhanced Recovery After Thoracic Surgery



Emily G. Teeter, Anoushka M. Afonso, Wanda M. Popescu



Abstract


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.


Keywords


enhanced recovery; thoracic surgery; multimodal analgesia



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.1 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.2–4 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.



Table 53.1

















































































Summary of Enhanced Recovery After Thoracic Surgery Components With Accompanying Levels of Evidence and Recommendation
Component Level of Evidence Level of Recommendation
Clear liquids up to 2 h before surgery High Strong
Avoidance of sedatives Moderate Strong
Mechanical and pharmacologic VTE prophylaxis Moderate Strong
Extended VTE prophylaxis in high-risk patients Low Weak
Perioperative antibiotic prophylaxis High Strong
Use of active warning High Strong
Continuous monitoring of core temperature High Strong
Lung-protective ventilation during one lung ventilation Moderate Strong
Combined regional and general anesthesia Low Strong
Short-acting anesthetic agents Low Strong
Nonpharmacologic PONV prophylaxis High Strong
Multimodal pharmacologic PONV approach Moderate Strong
Multimodal analgesia: Combination of acetaminophen and NSAIDs High Strong
Multimodal analgesia: Use of ketamine Moderate Strong
Multimodal analgesia: Use of dexamethasone Low Strong
Euvolemic fluid management Moderate Strong
Balanced crystalloid solutions High Strong
Early enteral route Moderate Strong

NSAIDs, Nonsteroidal antiinflammatory drugs; PONV, postoperative nausea and vomiting; VTE, venous thromboembolism. From Teeter EG, Kolarczyk LM, Popescu WM. Examination of the enhanced recovery guidelines in thoracic surgery. Curr Opin Anesthesiol. 2019. With permission.



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.5–7 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.2,8–10 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.


image
• Fig. 53.1 Enhanced recovery protocol in lung resection surgery.


Table 53.2

































Core Components of an Enhanced Recovery After Surgery Pathway
Preoperative Intraoperative Postoperative
Patient education and active involvement Fluid therapy to avoid salt and crystalloid excess Early removal of tubes and drains
Decrease in NPO interval Minimally invasive surgical approach Early ambulation
Carbohydrate beverage >2 hours before induction Antibiotic and venous thromboembolism prophylaxis Early enteral feeding
Multimodal analgesia Multimodal analgesia Multimodal analgesia
  Active warming  
  Defined blood pressure goals  


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.11 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.12


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



Optimization of Comorbid Conditions


Perioperative care of the patient undergoing thoracic surgery aims to evaluate patient risk factors, stratify patients based on those risk factors, and ameliorate any conditions before surgical intervention. Through a patient-centered approach, many ERPs focus on a multidisciplinary approach, particularly in the preoperative optimization of the thoracic surgical patient.


Patient counseling, targeted education, and individualized care plans play a key role to reduce stress, fear, or anxiety and improve the morbidity of patients, allowing faster functional and psychologic recovery after thoracic surgery. Refai et al.13 describe a patient education and care plan in thoracic surgery, noting the importance of detailed explanations. Preoperative patient counselling, performed using verbal, written, or multimedia materials, is crucial to achieve the goal of the ERAS project: making the patient a potentially active participant and the main character of his recovery, able to positively impact himself throughout the surgical and healing process.


Because thoracic surgical patients have multiple comorbidities, they are at increasing risk for developing complications after thoracic surgery. Stokes et al. systematically reviewed modifiable risk factors before elective thoracic surgery and identified pain control, nutrition, exercise/physical fitness, and smoking cessation as risk factors that can have a substantial impact on the thoracic surgical patients’ perioperative course.14 Standardized preprocedure guidance to promote patient and staff adherence with elements of an ERP will improve compliance. In thoracic surgery, a multidisciplinary team should evaluate the patient’s cardiopulmonary status with stratified risk assessments of cardiac and lung function preoperatively. Models of risk assessment facilitate calculation and assessment of individual outcomes that may be discussed with the patient to make an informed decision. With the right optimization, preoperative management can shift, an otherwise unlikely surgical candidate, into one who may qualify for surgical treatment.




Tobacco and Alcohol Cessation


Smoking is the strongest risk factor for postoperative pulmonary complications (PPCs) following thoracic surgery. Development of PPCs is a leading cause of in-hospital mortality and increased hospital length of stay and cost in thoracic surgical patients.15 Lugg et al.16 investigated over 450 patients following resection for nonsmall cell lung cancer (NSCLC) to observe the impact of preoperative smoking cessation on long-term survival. They evaluated 462 patients which included 111 (24%) current smokers, 55 (12%) ex-smokers less than 6 weeks, 245 (53%) ex-smokers 6 weeks or longer, and 51 (11%) never smokers. PPCs occurred in 60 (13%) patients in total. Compared with never smokers, current smokers had a higher frequency of PPC (22% vs. 2%,), higher frequency of intensive care unit (ICU) admission (14% vs. 0%) and a longer hospital length of stay (LOS) (6 [5] vs. 5 [2]). In the ex-smokers there was a trend for a lower frequency of PPC (<6 weeks, 10.9% vs. ≥6 weeks, 11.8%) and ICU admission (<6 weeks, 5.5% vs. ≥6 weeks, 4.5, but there was no difference between the under 6 weeks or 6 weeks or more ex-smoking groups before surgery. There was no significant difference in long-term survival found between the groups of differing smoking status in follow-up at 29.8 months. They concluded that current smokers have a higher risk of postoperative morbidity than former smokers after lung surgery for NSCLC. Although previous studies demonstrated a further benefit past the 6-week cessation mark, this study did not observe such a difference. In a systematic review evaluating the influence of smoking cessation on prognosis of early stage lung cancer, Parsons et al. estimated that 5-year survival reaches 33% for nonquitters versus 70% for those patients who quit. Using life table modeling, the authors concluded that the mortality gain observed was most likely linked to the effects of quitting smoking on cancer progression.17


Another retrospective study by Fukui et al. conducted on patients undergoing resection for stage I to III primary lung cancer showed a longer period of smoking cessation may be more effective for reducing the risk of pulmonary complications, although cessation at any time is beneficial for lung cancer surgery.18 In contrast, Matsuoka et al. showed no relationship between the length of preoperative smoking cessation period and the frequency of postoperative complications in 1248 patients who underwent lobectomy.19 However, recommendations from the ERAS Society suggest that smoking cessation should be at least 4 weeks before surgery.4


ERPs should integrate a robust preoperative workup with dedicated counseling for patient optimization. Not only do these programs reduce mortality, but they can be cost-effective and improve quality of life in lung cancer surgery.20


Significant alcohol use is a modifiable perioperative risk factor in lung resections. Graf et al. reported in the Veterans Health Administration that 13% of patients undergoing lung resection reported drinking more than two drinks per day in the preoperative period, and have associatedincreased risk of postoperative complications.21 In addition, patients drinking at least five drinks per day experienced an increased 30-day mortality after resection for NSCLC.22 From an oncologic standpoint, alcohol abuse has been shown an independent predictor for decreased disease-specific and progression-free survival among patients with lung cancer.23 Although optimal timing of alcohol cessation is unknown, the ERATS guidelines’ recommendation is to avoid alcohol for at least 4 weeks before surgery.4

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Oct 6, 2021 | Posted by in ANESTHESIA | Comments Off on Enhanced Recovery After Thoracic Surgery
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