Perioperative Lung Resection Outcomes After Implementation of a Multidisciplinary, Evidence-based Thoracic ERAS Program

Objective: This prospective study evaluated perioperative lung resection outcomes after implementation of a multidisciplinary, evidence-based Thoracic Enhanced Recovery After Surgery (ERAS) Program in an academic, quaternary-care center. Background: ERAS programs have the potential to improve outcomes, but have not been widely utilized in thoracic surgery. Methods: In all, 295 patients underwent elective lung resection for pulmonary malignancy from 2015 to 2019 PRE (n = 169) and POST (n = 126) implementation of an ERAS program containing all major ERAS Society guidelines. Propensity score-matched analysis, based upon patient, tumor, and surgical characteristics, was utilized to evaluate outcomes. Results: After ERAS implementation, there was increased minimally invasive surgery (PRE 39.6%-> POST 62.7%), reduced intensive care unit utilization (PRE 70.4%-> POST 21.4%), improved chest tube (PRE 24.3%-> POST 54.8%) and urinary catheter (PRE 20.1%-> POST 65.1%) removal by postoperative day 1, and increased ambulation >= 3x on postoperative day 1 (PRE 46.8%-> POST 54.8%). Propensity score-matched analysis that accounted for minimally invasive surgery demonstrated that program implementation reduced length of stay by 1.2 days [95% confidence interval (CI) 0.3-2.0; PRE 4.4 -> POST 3.2), morbidity by 12.0% (95% CI 1.6%22.5%; PRE 32.0%-> POST 20.0%), opioid use by 19 oral morphine equivalents daily (95% CI 1-36; PRE 101 -> POST 82), and the direct costs of surgery and hospitalization by $3500 (95% CI $1100-5900; PRE $23,000 -> POST $19,500). Despite expedited discharge, readmission remained unchanged (PRE 6.3%-> POST 6.6%; P = 0.94). Conclusions: The Thoracic ERAS Program for lung resection reduced length of stay, morbidity, opioid use, and direct costs without change in readmission. This is the first external validation of the ERAS Society thoracic guidelines; adoption by other centers may show similar benefit.