In parallel with the advancement in surgical techniques that focus on minimally invasive approaches, the Enhanced Recovery After Surgery (ERAS) program has matured in perioperative care.1 Initially developed for colorectal surgery, the ERAS protocols now apply across surgical specialties.
In 2018, ERAS guidelines tailored to thoracic procedures—particularly pulmonary resections—were published.2 These guidelines focus on optimal preoperative preparation and standardized intra- and postoperative protocols.
Key preoperative recommendations include comprehensive patient education about planned treatment, smoking and alcohol cessation support, nutritional assessment with dietary guidance, pulmonary function evaluation, training in respiratory exercises to enhance breathing mechanics, and individualized physical activity programs. Immediately before surgery, prolonged fasting should be avoided. Solid food can be consumed up to 6 hours preoperatively, and fluids can be consumed up to 2 hours before induction.
Perioperative recommendations include optimized thromboprophylaxis, prevention of hypothermia and postoperative nausea/vomiting, lung-protective ventilation strategies during anesthesia, and regional analgesia.
Postoperatively, early mobilization, prompt chest tube removal (with acceptable drainage ≤ 450 mL/day), early transition to oral medications, and optimized pain control with minimized opioid use are advised.
Zhihai Wang et al. conducted a randomized study evaluating ERAS implementation in patients 60 years of age and older undergoing lung cancer surgery. This demographic now constitutes the majority of patients in thoracic oncology. The study participants from this demographic often had multiple comorbid conditions related to smoking (e.g., COPD, atherosclerosis, coronary artery disease, diabetes). COPD, in particular, significantly increases the risk of perioperative pulmonary complications, and reduced spirometric values necessitate careful selection for lung resection.
In the study cohort, emphasis was placed on respiratory mechanics exercises and effective bronchial secretion clearance preoperatively. Crucially, the same regimen was continued postoperatively. Most ERAS protocol elements were implemented per recommendations.
Results demonstrated a clear benefit: a significant reduction in postoperative pulmonary complications, reduced pain severity, shorter duration of chest tube drainage, and improved postoperative lung function. Notably, these positive outcomes were achieved through relatively simple interventions—smoking cessation support and a structured respiratory exercise program.
Isolating the most impactful ERAS component is difficult. However, the consensus is that the more ERAS elements implemented, the better the clinical outcomes. Despite strong guideline recommendations, more high-quality evidence is needed to confirm the effectiveness of many individual components, underscoring the need for iterative guideline updates based on emerging research.3
Evaluating ERAS efficacy is challenging due to limited studies, the protocol’s complexity, and individual patient adherence. Nonetheless, growing literature suggests that optimized preoperative preparation or “prehabilitation” is key. A prehabilitation period of 4 to 6 weeks is considered optimal. Many clinicians worry that such delays could compromise oncological outcomes by postponing definitive treatment. This concern is valid; hence, it is recommended to initiate prehabilitation at the outset of the diagnostic workup. This approach minimizes treatment delay and ensures patients are optimally prepared for surgery. Prehabilitation should also be extended—after adaptation—to patients undergoing chemoradiotherapy or intensive systemic therapy, as these regimens carry significant toxicity, and improving baseline health may enhance treatment tolerance and reduce complications.
In summary, Dr. Wang’s study unequivocally supports the benefits of ERAS in lung cancer. The findings offer clear guidance to thoracic surgeons: Excellent minimally invasive technique alone is not sufficient—optimal preoperative preparation and comprehensive perioperative care are critical to improving early postoperative outcomes.
References
- 1. Kehlet H, Wilmore DW.: Multimodal strategies to improve surgical outcome. Am J Surg. 2002;183(6):630–641
- 2. Batchelor TJP, Rasburn NJ, Abdelnour-Berchtold E, Brunelli A, Cerfolio RJ, Gonzalez M, Ljungqvist O, Petersen RH, Popescu WM, Slinger PD, Naidu B.: Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced Recovery After Surgery (ERAS) Society and the European Society of Thoracic Surgeons (ESTS). Eur J Cardiothorac Surg. 2019 Jan 1;55(1):91-115
- 3. Petersen RH, Huang L, Kehlet H.: Guidelines for enhanced recovery after lung surgery: need for re-analysis. Eur J Cardiothorac Surg. 2021 Jan 29;59(2):291-292.
