Lung cancer continues to ranks first among all cancers in terms of incidence and death rates worldwide, including in China. Surgery is deemed the optimal strategy or option for patients with early or resectable tumors. Due to poor lung function and sequential PPCs, patients with lung cancer often require long hospitalizations and high postoperative costs[21-22]. Recently, growing attention has been paid to the implementation of ERAS programs [23-26], which are effective in decreasing postoperative morbidity and mortality and were formerly known as “fast-track surgery” introduced by Kehlet and Mogensen in 1999 . ERAS was first proposed for colorectal surgery and has demonstrated clinical benefits in other surgeries in decreasing morbidity, hospital stay, and costs [23-26].
Some issues should be noted before the implementation of an ERAS protocol in lung cancer surgery. 1) Advances in radiography and prevalent cancer screening programs have considerably increased the probability of early detection and of timely surgical therapy. 2) VATS, which significantly alters thoracic operational steps and brings considerable benefits, such as less wound pain and shorter hospital stay, has become the mainstream approach for lung cancer surgery, especially at early-stages [28-30]. 3) The components of ERAS programs vary among different institutions, and the practice of ERAS elements likely relies on clinical experience. Many elements of ERAS programs have become routine and it is difficult to judge whether temporal changes in practice can improve the outcomes, rather than the use of the ERAS pathway per se.
Our ERAS multidisciplinary and collaborative team was established in 2015 to more professionally and effectively carry out the ERAS pathway. The patients are counselled and supervised by trained nurses to complete the ERAS phases. Breathing exercise and postoperative nutrition procedures are conducted by specialized physical therapists and nutritionists.
We found that the proportion of patients who underwent the ERAS pathway with early-stage (stage 0 or I) cancer were not significantly greater than those of patients who underwent the routine pathway, but the proportion of VATS among ERAS patients increased. The possible reasons were that the wide promotion of minimally invasive surgery and the commonly accepted or recognized advantaged of VATS, especially for young surgeons. From the surgeons’ perspective, the implementation of minimally invasive surgery is also an important element of the ERAS protocol, as it offers patients a shorter surgical time, less intraoperative blood loss, postoperative pain and surgical trauma, and faster sequential recovery after surgery. In the guidelines for ERAS drafted by the ERAS Society and the European Society of Thoracic Surgeons (ESTS), a VATS approach for lung resection is recommended for early-stage lung cancer with a high evidence level and strong recommendation grade . According to the results, lower surgery time and less blood loss were observed in the ERAS group, showing the potential benefits that this minimally invasive approach provided to the patients’ postoperative recovery.
PPCs are considered important negative influences on recovery outcomes, increasing the risk of mortality. Evidence shows that ERAS regimens integrating effective perioperative courses prevent PPCs for patients with lung cancer undergoing lung resection . Controversially, Brunelli et al. reported no significant difference in postoperative morbidity after the use of an ERAS program. Potential reasons include the lack of a washout period, study heterogeneity, the exact structure of the ERAS program, and the quality of implementation or patient selection.. What’s more, their conventional care was very similar to ERAS before they introduced ERAS. We found lower occurrences of PPCs and pneumonia in the ERAS group than in the routine pathway group. Theoretically, elements including the VATS approach, pain, and VTE management may jointly improve postoperative recovery and decrease the PPC rate. Furthermore, the results of multivariable analysis revealed that the ERAS intervention was an independent factor of PPCs as well as of pneumonia and atelectasis, validating its effectiveness in improving postoperative recovery for those patients. Another essential variable was LOS. Proper pain control, chest tube removal and few complications contribute to a shorter LOS, indicating better postoperative recovery. Early mobilization is the most important predictor of reduced morbidity.A recent systematic review summarized RCTs concerning ERAS and reported that four of the five RCTs indicated the mean LOS was significantly shortened by the ERAS . Our study reveals shorter LOS and postoperative LOS in ERAS group, suggesting better recovery in those population. Meanwhile, lower in-hospital expenses including drug costs and a shorter duration for the indwelling chest tube were found in the ERAS group, which also provided evidence of the effectiveness of the ERAS program.
In the present study, we also explored the predictive factors for developing PPCs. In addition to the ERAS intervention, age, COPD, and FEV1 can also significantly and independently predict the risk of developing PPCs.
The study has some limitations that should not be ignored. First, all the patients were selected from a single regional center by a small group of surgeons, and propensity-matching was not analyzed in the control group. As a retrospective study, the lack of randomization limited the control of intergroup bias. We enrolled the patients over a large time span of approximately 5 years. Therefore, better outcome for the ERAS group may be the result of the bias caused by an the increased experience of our team. Second, the effects of the ERAS program, the sole effects of standardization, and whether temporal changes in practice improved the outcomes, rather than the use of the ERAS pathway per se cannot be easily determined. Third, the selection of patients receiving anatomical resection and the exclusion of patients undergoing wedge section and pneumonectomy resulted in a relevant bias and the sequential limitation of generalization of the conclusions. Moreover, we did not detail the in-hospital costs, so we cannot fully explore the economic outcomes of the ERAS program. Finally, we did not assess the pain control and nutrition-related variables between groups, and could not directly assess the role of pain and nutrition management in the ERAS program.