Guidelines for enhanced recovery after lung surgery: need for re-analysis

Abstract

Enhanced Recovery after Surgery (ERAS®) programmes were introduced >20 years ago [1] and repeatedly documented to improve outcomes across procedures including lung surgery [1–3]. Consequently, to enhance implementation of available evidence, several ERAS procedure-specific guidelines have been published. The latest and the first in lung surgery is from the ERAS Society and the European Society of Thoracic Surgeons [4]. In this laudable multiauthor effort, the literature was reviewed and summarized in 45 ERAS items, 40 of which received a strong recommendation [4]. Although principles of care of ERAS definitely have been shown to improve outcomes, including reduced length of stay (LOS) and fewer complications after many surgical procedures [2], an important implementation challenge remains to be solved: Recent lung surgery surveys from several European countries have shown only ∼70% compliance with ERAS principles [5–7]. Furthermore, a variable number of ERAS items have been used [5–7]. In this context, it is difficult for the busy clinician to interpret the many different ERAS factors to be considered for improved implementation. For example, some of the ERAS guideline authors [4] previously published a 15-element ERAS programme recommending a median LOS in the hospital of 5 days; about 70% of the patients underwent video-assisted thoracoscopic surgery (VATS) [8] but exact compliance data were not included. To further complicate this issue [9], a study from a well-established ERAS VATS centre showed no difference in LOS or outcomes between an initial cohort receiving 5 ERAS components including multimodal patient-controlled opioid and paravertebral local anaesthetics, early (unspecified) mobilization, optimized chest drain management and avoidance of a fluid overload compared to the same programme to which in a subsequent cohort was added 7 other ERAS components including patient information, incentive spirometry, preoperative carbohydrate loading, preoperative warming, motivational talks, early oral intake and nausea and vomiting prophylaxis. These observations add to the important discussion about the necessity of the different ERAS components, although specific information about compliance with individual components was not provided [9]. One may therefore ask why general implementation is so difficult [5–7] despite so much evidence? This problem is not unique to thoracic surgery. A recent survey of ERAS guidelines for hip and knee replacement showed the same problem and emphasized that inclusion of a large number of interventions with variable procedure-specific evidence may limit the feasibility or even the justification for many of the items in these guidelines [10]. Furthermore, with regard to future improvement, it must be answered in more detail whether guidelines are provided to enhance ‘early’ recovery and reduce LOS or to enhance ‘post-discharge’ recovery and reduce the complication rate, which unfortunately has rarely been done [1]. Importantly, the presented lung ERAS evidence [4] is often based on old data lacking full implementation of ERAS and therefore potentially not applicable to achieving a median LOS ≤4 days, which is common practice in many units where minimally invasive lung surgery (VATS/robot-assisted thoracic surgery) is the standard of care [3]. Furthermore, several ERAS guidelines, including the ERAS guideline for lung surgery [4], use transferable evidence from other fields of surgery and therefore are not necessarily applicable to the specific procedure in question. Consequently, with the trans-European lung surgery experience uniformly showing difficulties with ERAS implementation and often a median LOS >4 days [5–7], the ERAS and ESTS guidelines [4], with as many as 40 ‘firm’ recommendations, may need a more critical reassessment. First, when discussing guidelines to enhance ‘early recovery’, specifically after minimally invasive lung surgery designed to achieve a median LOS ≤4 days and fewer readmissions, a number of items such as preoperative counselling; focus on nutrition (except for patients with a body mass index of <18.5); smoking and alcohol use; fasting guidelines including preoperative carbohydrate drinks (for which there is absolutely no procedure-specific evidence); avoidance of fluid overload and hypothermia; postoperative nausea and vomiting prophylaxis; antibiotic and thromboembolic prophylaxis; urinary bladder catheter management; and anaemia need reconsideration. Thus, they are all either well-established ‘general’ perioperative care principles or, in some cases, lack updated data to be important for ‘early recovery’ with minimally invasive lung surgery leading to LOS ≤4 days. These considerations must be separated from guidelines to improve ‘post-discharge recovery’ where obviously appropriate antibiotic prophylaxis is important, because wound infections usually occur >4 days postoperatively. However, the thromboembolic prophylaxis recommendations require more data because they may not be relevant after early mobilization and discharge in a fully implemented ERAS programme with the goal of a LOS ≤4 days, as demonstrated in the classical thromboembolic surgical model in hip and knee replacement [10]. Finally, a key issue for ‘post-discharge recovery’ is a continuous optimal pain management plan that follows well-established multimodal opioid-sparing principles and that includes a combination of paracetamol and nonsteroidal anti-inflammatory drugs/Cox-2 inhibitors [4]. However, as included in the surveys and guidelines [4–7], the key components for ‘early’ recovery after lung surgery are a minimally invasive approach (VATS/robot-assisted thoracic surgery) [3], opioid-sparing pain management, early postoperative mobilization and, most importantly, modern care principles for drain removal [3, 4], the latter apparently still being debatable and difficult to implement [5–7]. In summary, recommendations for enhanced recovery after lung surgery not only need to be followed by better implementation but also to provide simpler guidelines based on essential perioperative interventions rather than 40 recommendations that may be difficult for busy clinicians to interpret and achieve agreement on with anaesthesiologists, surgeons, nurses and physiotherapists. Also, a better separation between ‘patient-related’ care factors and pure ‘organizational’ care factors is needed. Future perioperative care guidelines need to pay attention to specific levels of risk (e.g. frailty, ‘high-pain’ responders, specific comorbidities) [1] as well as the need for regular updates. Finally, future guidelines should pay increased attention to the role of pre- and postoperative communication to enhance the success of ERAS and to include assessment of patient satisfaction, quality of life and functional recovery. Hopefully, further data and research on the basic pathophysiological mechanisms to enhance recovery [1] may help to provide a second version of ERAS recommendations for lung surgery to enhance recovery and reduce complications and readmissions with a median LOS of ≤4 days, together with a separate discussion on improving recommendations for ‘post-discharge recovery’ issues. Finally, we should not forget the economic aspects of pre- and intraoperative care to improve the cost-effectiveness of enhanced recovery programmes even though the primary aim of ERAS is to enhance recovery [1]. L.H. was financially supported by China Scholarship Council (No. 201908430204). Conflict of interest: R.H.P. has received speaker fee from Medtronic.

Topics & Concepts