Impact of Compliance With Components of an ERAS Pathway on the Outcomes of Anatomic VATS Pulmonary Resections.

OBJECTIVES: Implementation of an Enhanced Recovery After Surgery (ERAS) program is associated with better postoperative outcomes. The aim of this study was to evaluate the impact of ERAS compliance (overall and to specific elements of the program) on them. DESIGN: Retrospective analysis of prospectively collected data. SETTING: University hospital, monocentric. PARTICIPANTS: All adult (≥18 years old) patients undergoing video-assisted thoracic surgery (VATS) anatomic pulmonary resection. INTERVENTIONS: ERAS-governed VATS anatomic pulmonary resection. MEASUREMENTS AND MAIN RESULTS: Demographics, surgical characteristics and pre-, peri-, and postoperative compliance with 16 elements of the ERAS program were assessed. Postoperative outcomes and length of stay were compared between low- (<75% of adherence) and high-compliance (≥75%) groups. From April 2017 to November 2018, 192 ERAS patients (female/male: 98/94) of median age of 66 years (interquartile range 58-71) underwent VATS resection (109 lobectomies, 83 segmentectomies). There was no 30-day mortality and resurgery rate was 5.7%. Overall ERAS compliance was 76%. High compliance was associated with fewer complications (18% v 48%, p < 0.0001) and lower rate of delayed discharge (37% v 60%, p = 0.0013). Early removal of chest tubes (odds ratio [OR]: 0.26, p < 0.002), use of electronic drainage (OR: 0.39, p = 0.036), opioid cessation on day 3 (OR: 0.28, p = 0.016), and early feeding (OR: 0.12, p = 0.014) were associated with reduced rates of postoperative complications. Shorter hospital stay was correlated with early removal of chest tubes (OR: 0.12, p < 0.0001) and opioid cessation on day 3 (OR: 0.23, p = 0.001). CONCLUSIONS: High ERAS compliance is associated with better postoperative outcomes in patients undergoing anatomic pulmonary VATS resections.

Impact of an enhanced recovery after surgery pathway on thoracoscopic lobectomy outcomes in non-small cell lung cancer patients: a propensity score-matched study.

BACKGROUND: This study evaluates the effect of enhanced recovery after surgery (ERAS) pathways on postoperative outcomes of non-small cell lung cancer (NSCLC) patients undergoing video-assisted thoracic surgery (VATS) lobectomy. METHODS: We retrospectively reviewed all consecutive patients undergoing VATS lobectomy for NSCLC between January 2014 and October 2019 and assigned them to the relevant group ("pre-ERAS" or "ERAS"). Length of stay, readmissions and complications within 30 days were compared between both groups. A propensity score-matched analysis was performed based on sex, age, type of operation, comorbidities, American Society of Anesthesiologists (ASA) score and preoperative pulmonary functions. RESULTS: A total of 307 records (164 male/143 female; 140 ERAS/167 pre-ERAS; median age: 67) were reviewed. There was no statistical difference in patient's characteristics. Overall ERAS compliance was 81%. The ERAS group presented significantly shorter length of stay (median 5 vs. 7 days; P=0.004) without significant difference in cardiopulmonary complication rate (27.1% vs. 35.9%; P=0.1). Readmission (3.6% vs. 5.4%; P=0.75) and duration of drainage (median 2 vs. 3 days; P=0.14) were similar between groups. The propensity score-matched analysis showed that the length of hospital stay was reduced by 1.4 days (P=0.034) and the postoperative cardiopulmonary complication rate by 13% (P=0.044) in the ERAS group. CONCLUSIONS: Adoption of an ERAS pathway for VATS lobectomies in NSCLC patients has decreased the length of hospital stay and the cardiopulmonary complication rate without affecting the readmission rate.

An enhanced recovery after surgery program for video-assisted thoracoscopic surgery anatomical lung resections is cost-effective.

BACKGROUND: Enhanced recovery after surgery (ERAS) programs have been reported to decrease complications and shorten hospital stays after lung resections, but their implementation requires time and financial investment with dedicated staff. The aim of this study was to evaluate the clinical and economic outcomes of video-assisted thoracoscopic surgery (VATS) anatomical pulmonary resections before and after implementation of an ERAS program. METHODS: The first 50 consecutive patients undergoing VATS lobectomy or segmentectomy for malignancy after implementation of an ERAS program were compared with 50 consecutive patients treated before its introduction. The ERAS protocol included preoperative counseling, reduced preoperative fasting with concomitant carbohydrate loading, avoidance of premedication, standardized surgery, anesthesia and postoperative analgesia, early removal of chest tube, nutrition and mobilization. Length of stay, readmissions and cardio-pulmonary complications within 30 days were compared. Total costs were collected for each patient and a cost-minimization analysis integrating ERAS-specific costs was performed. RESULTS: Both groups were similar in terms of demographics and surgical characteristics. The ERAS group had significantly shorter postoperative length of stay (median: 4 vs. 7 days, P<0.0001), decreased pulmonary complications (16% vs. 38%; P=0.01) and decreased overall post-operative complications (24% vs. 48%, P=0.03). One patient in each group was readmitted and there was no 30-day mortality. ERAS-specific costs were calculated at €729 per patient including the clinical nurse and database costs. Average total hospitalization costs were significantly lower in ERAS group (€15,945 vs. €20,360, P<0.0001), mainly due to lower costs during the post-operative period (€7,449 vs. €11,454, P<0.0001) in comparison with the intra-operative period (€8,496 vs. €8,906, P=0.303). Cost-minimization analysis showed a mean saving in the ERAS group of €3,686 per patient. CONCLUSIONS: An ERAS program for VATS anatomical lung resection is cost-effective and is associated with a lower complication rate and a shorter postoperative hospitalization.