Edited by: Han-Yu Deng, Sichuan University, China
Reviewed by: Massimo Baudo, Lankenau Institute for Medical Research, United States
Jia Huang, Shanghai Jiao Tong University, China
*Correspondence: Yunpeng Zhao,
†These authors have contributed equally to this work
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This study was conducted to evaluate the postoperative short-term outcomes of patients undergoing video-assisted thoracoscopic surgery (VATS) for lung resection with the enhanced recovery after surgery (ERAS) protocol.
A single-institution, prospective randomized controlled study was conducted. The primary outcome measures were postoperative pulmonary complications (PPCs) and postoperative short-term effects.
Among the 611 patients, 305 were assigned to the ERAS group, and 306 were assigned to the routine group. The ERAS group achieved earlier oral feeding, earlier mobilization, a shorter duration of drainage (2.0 vs. 5.0 days, P<0.001), and a shorter hospital stay (3.0 vs. 7.0 days, P<0.001). The biological impacts were confirmed to be significantly better for the ERAS group. Furthermore, the ERAS group also had a lower incidence of PPCs (11.5% vs. 22.9%, P<0.001) than did the routine group. Multivariate logistic regression analysis revealed the following predictors of drainage tube removal on the 1st day after surgery without pneumonia during hospitalization: comorbidity (P=0.029), surgical procedure (P=0.001), and operation time (P=0.039).
Implementation of the ERAS protocol led to a decreased incidence of PPCs, suggesting that the ERAS protocol has a better biological impact on patients undergoing VATS for lung resection. Multigradient individual ERAS protocols are recommended at different institutions according to the individual conditions of patients.
Enhanced recovery after surgery (ERAS) was first reported in the late 1990s (
Thoracic surgery is considered an invasive and traumatic procedure for patients (
The inclusion criteria for patients were as follows (1): had lung lesions suitable for VATS, including benign and malignant lesions diagnosed by CT (enhanced or nonenhanced) or pathological results (2); were aged between 18 and 85 years (3); had a Karnofsky score ≥80 along with cardiopulmonary function, liver function, and renal function indicating the ability to tolerate minimally invasive surgery (4); had normal cognitive function and was able to cooperate with the rehabilitation training (
The exclusion criteria for patients were as follows (1): refused randomization (2); was unable to cooperate with the rehabilitation training or tolerate minimally invasive surgery due to cognitive or physical dysfunctions; and (3) participated in other clinical trials or had received treatment with anticancer drugs in other clinical trials.
The study was approved by the Ethics Committee of the Second Hospital of Shandong University (SDDXDEYY-KYB-2020053). The study’s registration information is as follows: Clinical Trials. Gov ID: NCT04451473 (30/06/2020). Informed consent was obtained from all the patients. Our work was fully compliant with the CONSORT criteria, and this study is reported in line with the CONSORT criteria (
This study was designed as a single-center, randomized, unblinded control trial. Random assignment was performed using the envelope method by a statistician at the Evidence-based Medicine Center of the Second Hospital of Shandong University. Once an informed consent form was signed, the patient was assigned to one group by opening the sequentially numbered envelope (
The patients were randomly assigned to the control group (routine group) and received standard VATS; however, the perioperative management was mainly traditional without systemic ERAS protocol guidance. The traditional management methods were as follows: 1. the patient received no systemic physical pulmonary training before surgery; 2. the patient received sedatives to reduce anxiety preoperatively; 3. the patient fasted from solids for at least 8 hours and from liquids for at least 6 hours; 4. a transurethral catheter was routinely placed and then removed on the second day after surgery; 5. the patient remained completely supine for 6 hours after surgery; 6. the patient fasted from solids and liquids for 6 hours after surgery; 7. the patient achieved ambulation ≥24 hours after surgery; 8. two chest tubes were used when the upper lobe was moved; 9. the chest tube was removed when the highest volume did not exceed 100 ml/24 h; and 10. opioids were the most common drugs in the analgesic regime.
The ERAS protocol was performed mainly according to two guidelines (
1. Dedicated preoperative counseling and education should be given in the preoperative phase. Nutritional status screening and improvement, smoking cessation (2-4 weeks), alcohol dependency management, and even pulmonary prehabilitation (according to the patient’s cognitive ability and compliance) should also be accomplished in this phase.
2. Airway management during the preoperative examination after admission: climbing stairs or power-based cycling, which can enhance cardiopulmonary function, has often been used in the past few years; however, physical pulmonary training in the general ward is strongly recommended (
3. Aspirin withdrawal is not recommended for patients in the ERAS group unless VATS is complicated and accompanied by a high risk of bleeding. Low molecular weight heparin bridging treatment is used during aspirin withdrawal.
4. Sedatives for reducing anxiety preoperatively are prohibited.
5. Clear fluids are allowed up until 2-4 h before the induction of anesthesia, and oral carbohydrate loading can be used routinely.
6. A combination of regional and general anesthetic techniques should be used, and general anesthesia combined with nonintubated spontaneous breathing can be an alternative to double-lumen intubation if the anesthesiologist has mastered the technique.
7. Uniport VATS was routine for patients in the ERAS group. Wedge resection or segmentectomy should be meticulously planned through the scientific reading of thin-slice CT or 3D simulation before surgery. High-quality minimally invasive surgery is the foundation of ERAS protocol implementation.
8. A transurethral catheter is not routinely placed for the sole purpose of monitoring urine output without thoracic epidural anesthesia. Transurethral catheters can be used in one of the following conditions (1): the estimated operation time is more than 150 minutes or even 180 minutes (2); high risk of bleeding; and (3) critical patients with organ dysfunction. If the operation takes a longer time than expected without a urinary catheter, placing a disposable catheter is reasonable. The urinary catheter should be removed immediately after the operation if the patients’ respiratory and circulatory status is stable without prediction advanced life support.
9. The head of bed (by ≥30°) was immediately raised when the patient went back to the general ward. The patient could sit up straight with the help of the charge doctor or charge nurse 2 hours after returning to the ward, and the patient was asked to drink a little water if no postoperative nausea and vomiting (PONV) occurred; otherwise, PONV was treated using nonpharmacological control with or without pharmacological control [16] according to the degrees of discomfort. A small portion of a semifluid diet was encouraged if no PONV occurred. Then, the nutrition procedures could be conducted by specialized nutritionists from the Nutrition Department.
10. Early ambulation evaluation began when the patients could sit up straight 2 hours after returning to the ward. If the patient can keep the straight sitting position without obvious dizziness and weakness, he or she can try to leave the bed and stand beside the sickbed with electrocardiogram monitoring. Marching on the spot can be started if the vital signs and respiratory status remain stable, and then moderate ambulation can be tried with the accompaniment of medical staff and a family member.
11. A single tube was used for the patients in the ERAS group, and the chest tube was removed when the following conditions were met (1): no progressive bleeding or chylothorax (2); no persistent air leakage during continuous cough (3); no obvious atelectasis confirmed by physical examination or imaging examination; and (4) daily serous effusion less than 300 ml/24 h, with the highest volume not exceeding 450 ml/24 h.
12. A multimodal analgesic regimen is recommended for pain relief (
Patients were withdrawn for one of the following reasons: (i) a withdrawal request was made by the patient or the family member; (ii) there was poor compliance with the training protocol; or (iii) severe complications, such as heart disease or stroke, occurred.
Several primary or secondary outcomes have been studied; however, postoperative pulmonary complications (PPCs) are an important and widely used index for evaluating short-term postoperative improvement (
The primary outcome measures were PPCs. The secondary outcome measures were some other postoperative short-term effects, postoperative long-term respiratory function, health-related quality of life (HRQoL), progression-free survival (PFS) and overall survival (OS) for patients who underwent VATS for lung cancer surgery. Continuous variables are expressed herein as means and standard deviations (SDs); data that were not normally distributed are presented as medians and ranges; and binary variables are presented as proportions. The data were evaluated through Student’s t test (data matching a normal distribution), nonparametric statistics, the chi-square test, or Fisher’s exact test, as appropriate. Multivariate logistic regression analysis was used to reveal the predictors of drainage removal on the first day after surgery without pneumonia during hospitalization. Statistical analysis and graph generation were performed with Stata 12.0 (StataCorp LP, College Station, TX, USA) at a significance level of 0.05. Multivariate logistic regression analysis was performed with SPSS statistics software (version 25; SPSS, Inc., Chicago, IL).
From July 2020 to June 2022, 611 patients were enrolled in the study; 305 patients were assigned to the ERAS group, and 306 were assigned to the routine group. The treatment protocol was completed for the enrolled patients. The patient characteristics were balanced between the two groups (
Patients’ characteristics of the study population.
| Characteristics | ERAS group (=305) | Routine group (n=306) | P value |
|---|---|---|---|
| Age, years | 0.671 | ||
| Median | 58 | 59 | |
| Interquartile range | 51-66 | 53-66 | |
| Range | 18-83 | 28-83 | |
| Gender, n (%) | 0.654 | ||
| Male | 140 (45.9%) | 146 (47.7%) | |
| Female | 165 (54.1%) | 160 (52.3%) | |
| Smoking status, n (%) | 0.412 | ||
| Ever | 55 (18.0%) | 64 (21.0%) | |
| Never | 250 (82.0%) | 242 (79.0%) | |
| Comorbidity | 0.913 | ||
| Hypertension | 79 | 79 | |
| Diabetes mellitus | 30 | 36 | |
| Heart disease | 24 | 20 | |
| Brain vascular disease | 20 | 22 | |
| COPD |
10 | 9 | |
| Pathological type | 0.680 | ||
| Malignant tumor | 264 | 269 | |
| Adenocarcinoma | 200 | 210 | |
| Squamous cell |
58 | 51 | |
| Other | 6 | 8 | |
| Benign tumor | 33 | 32 | |
| Hamartoma | 11 | 4 | |
| Granuloma or |
20 | 26 | |
| Sclerosing |
2 | 2 | |
| Pulmonary bulla | 8 | 5 | |
| T stage for Malignant |
0.723 | ||
| Tis | 7 | 9 | |
| T1mi | 31 | 43 | |
| T1 | 152 | 143 | |
| T2 | 51 | 53 | |
| T3 | 20 | 17 | |
| T4 | 3 | 4 | |
| N stage for Malignant |
0.698 | ||
| N0 | 225 | 222 | |
| N1 | 25 | 30 | |
| N2 | 14 | 17 | |
| LNs |
0.201 | ||
| Median | 4 | 5 | |
| Interquartile range | 4-5 | 4-6 | |
| Range | 1-10 | 2-8 | |
| LNs |
0.183 | ||
| Median | 8 | 9 | |
| Interquartile range | 6-13 | 7-13 | |
| Range | 2-32 | 3-36 | |
| Pulmonary function | |||
| FEV1 |
0.210 | ||
| Median | 2.28 | 2.24 | |
| Interquartile range | 1.94-2.73 | 1.88-2.70 | |
| Range | 1.11-4.85 | 1.05-4.78 | |
| MVV |
0.485 | ||
| Median | 91.2 | 89.6 | |
| Interquartile range | 79.4-103.2 | 78.9-103.8 | |
| Range | 63.8-118.5 | 64.6-115.9 | |
| Surgical procedures | 0.061 | ||
| Lobectomy | 163 | 184 | |
| Segmentectomy | 55 | 35 | |
| Wedge resection | 87 | 87 | |
| Operation time (minutes) |
0.150 | ||
| Median | 60 | 60 | |
| Interquartile range | 45-90 | 45-88 | |
| Range | 20-240 | 25-240 | |
| Intraoperative blood loss (mL), mean ± SD | 0.946 | ||
| Median | 50 | 50 | |
| Interquartile range | 40-60 | 40-60 | |
| Range | 20-500 | 20-400 | |
| VATS surgery converted | 0.452 | ||
| to open (%) | 9 (3.0%) | 6 (2.0%) | |
COPD, chronic obstructive pulmonary disease.
LNs, lymph nodes.
FEV1, forced expiratory volume in 1.0 s.
MVV, maximum volume for ventilation.
As shown in
Postoperative recovery of our study population.
| Characteristics | ERAS group (n=305) | Routine group (n=306) | P value |
|---|---|---|---|
| Water feeding 2 hours after RTWa (%) | 210 (68.9%) | 0 (%) | <0.001 |
| Semi- fluid diet within 3 hours after RTWa (%) | 103 (33.8%) | 0 (%) | <0.001 |
| Postoperative moderate ambulation on the surgery day (%) | 114 (37.4%) | 7 (2.3%) | <0.001 |
| Duration of drainage (day) | <0.001 | ||
| Median | 2 | 5 | |
| Interquartile range | 1-2 | 4-6 | |
| Range | 1-8 | 2-11 | |
| Postoperative hospital stay (day) | <0.001 | ||
| Median | 3 | 7 | |
| Interquartile range | 2-4 | 6-8 | |
| Range | 1-13 | 2-15 | |
| Request extension of hospital stay without objective complications (%) | 61 (20.0%) | 32 (10.5%) | 0.001 |
| Readmission rate within 14 days after surgery (%) | 6 (2.0%) | 3 (1.0%) | 0.340 |
aRTW, Return to ward.
Postoperative blood samples were collected and tested two days after surgery (
Blood laboratory examination of our study population.
| Characteristics | ERAS group(n=305) | Routine group (n=306) | P value |
|---|---|---|---|
| Postoperative white blood cell (10^9) | 0.032 | ||
| Median | 11.75 | 12.26 | |
| Interquartile range | 10.2-13.83 | 10.55-14.91 | |
| Range | 7.1-25.82 | 7.01-25.17 | |
| Postoperative NEUT%a | <0.001 | ||
| Median | 82.1 | 84.4 | |
| Interquartile range | 79.8-85.5 | 81.3-86.9 | |
| Range | 58.5-94.9 | 63.3-94.6 | |
| Postoperative CRPb (mg/L) | 0.023 | ||
| Median | 109.0 | 117.1 | |
| Interquartile range | 66.2-149.9 | 86.2-150.0 | |
| Range | 18.1-267.7 | 19.2-263.1 | |
| Postoperative PCTc (ng/ml) | 0.566 | ||
| Median | 0.234 | 0.186 | |
| Interquartile range | 0.10-1.427 | 0.105-0.37 | |
| Range | 0.02-10.16 | 0.02-6.86 | |
| Postoperative ALBd (g/L) | 0.012 | ||
| Median | 38.1 | 37.6 | |
| Interquartile range | 35.4-40.68 | 34.7-39.5 | |
| Range | 21.4-51.4 | 23.9-52.5 | |
| Postoperative PAe(mg/dL) | <0.001 | ||
| Median | 20.5 | 15.5 | |
| Interquartile range | 17.6-23.2 | 13.0-18.7 | |
| Range | 5.7-30.4 | 4.0-27.9 |
aNEUT%, percentage of neutrophile granulocytes.
bCRP, C-reactive protein.
cprocalcitonin.
dalbumin
eprealbumin
The postoperative early complications are shown in
Postoperative early complications of our study population.
| Characteristics | ERAS group (n=305) | Routine group (n=306) | P value |
|---|---|---|---|
| PPCs a (%) | 35 (11.5%) | 70 (22.9%) | <0.001 |
| Pneumonia | 17 (5.6%) | 27 (8.8%) | 0.163 |
| Atelectasis | 13 (4.3%) | 25 (8.2%) | 0.046 |
| Air leak (≥5 days) | 6 (2.0%) | 22 (7.2%) | 0.003 |
| Bronchopleural |
1 (0.3%) | 1 (0.3%) | 1.000 |
| Respiratory failure | 2 (0.7%) | 3 (1.0%) | 1.000 |
| Supraventricular arrhythmia (%) | 7 (2.3%) | 12 (3.9%) | 0.348 |
| Acute myocardial |
0 (0%) | 1 (0.3%) | 1.000 |
| Acute cerebral stroke (%) | 1 (0.3%) | 2 (0.7%) | 1.000 |
| VTEb (%) | 0 (0%) | 2 (0.7%) | 0.497 |
| Urinary irritation (%) | 19 (6.2%) | 78 (25.5%) | <0.001 |
| Acute urinary retention (%) | 2 (0.7%) | 5 (1.6%) | 0.449 |
aPPCs, pulmonary complications. Four patients in ERAS group had ≥ 2 PPCs, eight patient in Routine group had ≥ 2 PPCs.
bvenous thromboembolism, including deep venous thrombosis (DVT) and pulmonary thromboembolism (PTE).
Multivariate logistic regression analysis was used to reveal the predictors of PPCs.
Predictors of PPCs.
| Predictor a | β value | Odds ratio (95% CI) | P value |
|---|---|---|---|
| Gender | 0.634 | 1.884 (1.024- 3.468) | 0.062 |
| Age | 0.039 | 1.040 (1.008- 1.073) | 0.014 |
| Smoking status | 0.124 | 1.132 (0.641- 2.000) | 0.669 |
| Comorbidity | 0.216 | 1.241 (0.893- 1.724) | 0.197 |
| Convert to open | 0.052 | 1.062 (0.317- 3.132) | 0.932 |
| Surgical procedures | 0.358 | 1.430 (0.977- 2.096) | 0.066 |
| Operation time | 0.004 | 1.004 (0.995- 1.012) | 0.397 |
| Intraoperative blood loss | 0.001 | 1.001 (0.996- 1.006) | 0.800 |
| ERAS management | -0.880 | 0.415 (0.229- 0.751) | 0.004 |
aMultivariate logistic regression analysis: gender (female: 0, male: 1), age (numerical variable), smoking status (never: 0, ever: 1), comorbidity (hypertension, diabetes mellitus, heart disease, brain vascular disease, COPD, no comorbidity: 0, one comorbidity: 1, two comorbidities: 2, ≥3 comorbidities: 3), Convert to open (no: 0, yes: 1), surgical procedures (wedge resection: 0, segmentectomy: 1, lobectomy: 2), operation time (minutes, numerical variable), intraoperative blood loss (ml, numerical variable), ERAS management (no: 0, yes: 1), PPCs (no PPCs: 0, PPCs:1).
Multivariate logistic regression analysis was also used to reveal the predictors of drainage tube removal on the 1st day after surgery without causing pneumonia during hospitalization.
Predictors of removal of the drainage the 1st day (without pneumonia) after surgery.
| Predictor a | β value | Odds ratio (95% CI) | P value |
|---|---|---|---|
| Comorbidity | 0.029 | ||
| No comorbidity | Ref. | 1 | |
| One comorbidity | 0.518 | 1.678 (0.905-3.112) | |
| two comorbidities | 0.971 | 2.639 (0.551-12.641) | |
| ≥3 comorbidities | 1.204 | 3.333 (1.346- 8.254) | |
| Surgical procedures | 0.001 | ||
| Wedge resection | Ref. | 1 | |
| Segmentectomy | 0.338 | 1.403 (0.629- 3.126) | |
| Lobectomy | 1.182 | 3.261 (1.706- 6.232) | |
| Operation time | 0.010 | 1.010 (1.000- 1.019) | 0.039 |
aMultivariate logistic regression analysis: gender (female: 0, male: 1), age (numerical variable), smoking status (never: 0, ever: 1), comorbidity (hypertension, diabetes mellitus, heart disease, brain vascular disease, COPD, no comorbidity: 0, one comorbidity: 1, two comorbidities: 2, ≥3 comorbidities: 3), surgical procedures (wedge resection: 0, segmentectomy: 1, lobectomy: 2), operation time (minutes, numerical variable), intraoperative blood loss (ml, numerical variable), removal of the drainage the 1st day (without pneumonia) (satisfied: 0, not satisfied:1).
In recent years, increasing attention has been given to the implementation of ERAS protocols for various tumors (
In the traditional postoperative management mode, patients were asked to stay in the supine posture without drinking or eating for at least 6 hours. Patients were not required to remain in the supine position or fast for a long period when the combination of regional and general anesthetic techniques was used. Patients in the ERAS group were allowed to drink water and have a semifluid diet so that specialized nutritionists could use an earlier intervention. Even more than one-third of the patients in the ERAS group achieved moderate ambulation on the day of surgery, and this approach has been confirmed to be feasible and safe (
The biological impact, which was also investigated in our study, has been investigated in several other organ surgeries within the ERAS program (
In our study, we found lower incidences of PPCs in the ERAS group than in the control group, and the same results were observed for atelectasis and air leakage (≥5 days). We suppose that early mobilization is crucial for reducing morbidity, promoting lung recruitment as soon as possible, promoting quick recovery of gastrointestinal function, and preventing deep venous thrombosis. Rogers LJ (
We recommend that patients with fewer comorbidities, a smaller resection range, or less operation time be candidates for day surgery (from admission to discharge ≤48 hours), although the management details still need exploration and optimization.
The results of this study were similar to some other studies (
Practice elements recommendations of multi- gradient individual ERAS (MGI- ERAS).
| Items | Gradient 1 | Gradient 2 | Gradient 3 |
|---|---|---|---|
| Preadmission information, education and counsellin | Simply completed during simple guidan c | ERAS group makes the simple guidan c | Specialized ERAS group makes systematic guidance on nutrition, smoking cessation, alcohol dependency management, and pulmonary prehabilitation |
| Airway management after admission | Climbing stairs and simple physical pulmonary training guided by surgeons or nurses | ERAS group guided the preoperative airway management | ERAS group including a specialized physiotherapist guided the preoperative airway management |
| Aspirin withdrawal or not (routinr minimally invasive surgery with low bleeding ris) | Aspirin withdrawal for at least one we | Aspirin withdrawal for 3-5 days then LMWHa bringing management | No aspirin withdrawal |
| Preoperative fasting and carbohtdrate treatment | Clear fluids be allowed up until 4 hours before the induction of anaesthesia and soilids until 8 hours before induction | Oral carbohydrate loading be allowed up until 2-4 hours before the induction of anaesthesia and solids until 8 hours before induction | Oral carbohtdrate loading be allowed up until 2 hoursv before the induction of anaesthesia and solids until 6 hours before induction |
| Preventing intraoperative Hypothermi | Temperature control of the operating room during surgery | Convective active warming devices used perioperatively | Continuous measurement of core temperature to guide the temperature control of the patients. |
| Urinary drainage (routine minimally invasive segmentectomy surgery without need for strict fluid management) | The transurethral catheter is moved immediately after the operation | Not routinely placed for patients undergo wedge resection | Not routinely placed for lobectomy, even for sleeve lobectomy or tracheal surgery with low bleeding ris |
| Anaesthetic protoco | A combination of regional and general anaesthetic techniques with lung protective strategies during one-lung ventilation | Completely tubeless protocolb for patients undergo wedge resection. | Completely tubeless protocolb for segmentectomy, lobectomy, even for sleeve lobectomy or tracheal surgery with low bleeding risk. |
| Surgical techniqu | Three- port minimally invasive surgery (including VATS and robotic surgery | Two- port minimally invasive surgery (including VATS and robotic surgery) | Uniport minimally invasive surgery (including VATS and robotic surgery) |
| Postoperative recovery Raising the head of bed (by ≥30°) Sit up straight 4- 6 hours Sit up straight 2 hours after returning to position and mobilization | Raising the head of bed (by ≥30°) immediately back to the general ward, patients should be mobilized within 24 hours of surgery | Sit up straight 4- 6 hours after returning to the general ward, try to leave the sickbed 6- 8 hours after returning to the general ward | Sit up straight 2 hours after returning tothe general ward, moderate ambulationis tried 4 hours after returning to the general ward |
| Postoperative water drinking and diet | Try water drinking 4- 6 hours after returning to the general ward if no PONVc occurs, semi- fluid diet is permitted | Try water drinking 2- 4 hours after returning to the general ward, if no PONVc occurs, semi- fluid diet is permitted. The nutrition procedures is better conducted by specialized nutritionists | Try water drinking ≤2 hours after returning to the general ward, if no PONVc occurs, semi- fluid diet is permitted. The nutrition procedure is better conducted by specialized nutritionists. |
| Removal of the chest Tubes | Thoracic closed drainage with negative pressure can be use for continuous air leak, chest tubes should be removed with the daily serous effusion without progressive bleeding or chylothorax)≤200ml. | Thoracic closed drainage with negative pressure can be used for continuous air leak, chest tubes should be removed with the daily serous effusion (without progressive bleeding or chylothorax)≤300ml. | Thoracic closed drainage with negative pressure can be used for continuous air leak, chest tubes should be removed with the daily serous effusion (without progressive bleeding or chylothorax) ≤450ml. |
| ain relief regim | Multimodal analgesic regime is recommended | Multimodal analgesic regime with the minimized opioids education and pain management consultation is needed sometimes | Multimodal analgesic regime with the minimized opioids dosage, professional psychological counselling for anxious patients and additional techniques such as transcutaneous electrical nerve stimulation carried out by physiotherapist is used. |
aLMWH, low molecular weight heparin.
bCompletely tubeless protocol: VATS surgery with both non-intubated intravenous anesthesia and no urinary catheterization protocol.
cPONV, postoperative nausea and vomiting.
There are several limitations that should not be ignored. First, this was a single-center study. Second, the patients were enrolled more than 2 years previously, and gains in ERAS experience are inevitable, which may have led to bias. Third, a blinded method could not be used in this study, and the timing of return to diet, mobilization, removal of the chest tube, and discharge from the hospital might have been biased or even affected by the patients or their relatives. Moreover, pain control, psychological variables, postoperative functional recovery efficacy and quality of life were not presented. Finally, the economic outcomes of the ERAS program were not explored in this study.
In conclusion, the implementation of the ERAS protocol led to earlier return to diet and mobilization, lower incidences of PPCs and urinary irritation without acute urinary retention, and shorter durations of drainage and postoperative hospital stay, thus providing better biological impacts for patients undergoing VATS lung resection. MGI-ERAS is recommended for the implementation of the ERAS protocol at different institutions with respect to the individual conditions of the patients.
The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding authors.
The studies involving humans were approved by the Ethics Committee of the Second Hospital of Shandong University. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.
YD: Data curation, Formal Analysis, Writing – original draft, Writing – review & editing. LZ: Data curation, Formal Analysis, Writing – review & editing. LS: Data curation, Formal Analysis, Methodology, Supervision, Writing – review & editing. WZ: Data curation, Formal Analysis, Methodology, Writing – review & editing. PL: Data curation, Supervision, Writing – review & editing. BC: Data curation, Supervision, Writing – review & editing. ZT: Data curation, Formal Analysis, Writing – review & editing. YZ: Data curation, Formal Analysis, Funding acquisition, Methodology, Project administration, Software, Supervision, Writing – original draft, Writing – review & editing. XZ: Conceptualization, Formal Analysis, Funding acquisition, Investigation, Project administration, Supervision, Writing – original draft, Writing – review & editing.
The author(s) declare that financial support was received for the research, authorship, and/or publication of this article. The study is funded by Taishan Scholar Project and Key Laboratory of Thoracic Cancer, Shandong University.
We thank doctor Ling Li from Cheeloo Hospital of Shandong University, Ning Li, He Zhang from The Second Hospital of Shandong University, for discussion, guidance or practice of anesthesia and the recovery after that.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.