Enhanced recovery after surgery (ERAS) protocols in thoracic surgery

Enhanced Recovery After Surgery (ERAS) protocols consist of multimodal, evidence-based strategies to decrease surgical-induced stress. They are conceived as pathways that encompass patient care from initial referral to discharge. Usually, they include multiple small improvements incorporated in everyday practice; these elements positively affect patient management. First developed for colorectal surgery, the ERAS approach has now been successfully applied to a wide variety of surgical specialities, resulting in improved postoperative outcomes. Collaterally, reduction of postoperative complication rate, earlier hospital discharge and lower healthcare costs have been reported. Fast-tracking or standardised critical care pathways for thoracic surgery have been known since the late 1990s, but it was not until recently that specific ERAS models have been designed. Notably, there is an increasing interest in ERAS applications to videoassisted thoracic surgery (VATS) and VATS lobectomies. A recent systematic review has warned physicians against the severe methodological limitations of the body of evidence supporting enhancedrecovery pathways; however, a further meta-analysis of randomised controlled trials has demonstrated that ERAS for lung cancer can effectively accelerate postoperative recovery and reduce hospital stay and the related costs without compromising patient safety. The ERAS Guidelines of the European Society of Thoracic Surgery embrace different patient care fields: from preadmission counselling to surgical techniques to early postoperative mobilisation and physiotherapy; most of these recommendations have a strong evidence base. Therefore, they are thought to affect patient outcomes positively. The most shared recommendations include smoking cessation four weeks before surgery, preoperative treatment of malnutrition and anaemia, use of lung-protective strategies during one-lung ventilation, employment of combined regional and general anaesthetic techniques, use of VATS techniques, early oral feeding, removal of chest tube if output ≤450 ml/day.