Retrospective Study Open Access
Copyright ©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Apr 26, 2024; 12(12): 2040-2049
Published online Apr 26, 2024. doi: 10.12998/wjcc.v12.i12.2040
Enhanced recovery after surgery in elderly patients with non-small cell lung cancer who underwent video-assisted thoracic surgery
Mei-Hua Sun, Xiao-Qiang Li, Department of Thoracic Surgery, Peking University Shenzhen Hospital, Shenzhen 518036, Guangdong Province, China
Liu-Sheng Wu, Jun Yan, School of Medicine, Tsinghua University, Beijing 100084, China
Liu-Sheng Wu, Ying-Yang Qiu, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
ORCID number: Liu-Sheng Wu (0000-0001-9580-2257); Xiao-Qiang Li (0000-1122-2124-4156).
Co-first authors: Mei-Hua Sun and Liu-Sheng Wu.
Co-corresponding authors: Xiao-Qiang Li and Jun Yan.
Author contributions: Yan J and Li XQ conceived and designed the study; Qiu YY screened patients to obtain clinical data and data analysis; Wu LS and Sun MH wrote the paper; All authors have read and approved the final draft. Wu LS proposed, designed, and analyzed the data and wrote the first draft of the paper. Sun MH was responsible for patient screening, enrollment, and the collection of clinical data. Both authors have made vital and indispensable contributions to the completion of the project and are therefore qualified to be co-first authors of the paper. As co-corresponding authors, Yan J and Li XQ played an important and indispensable role in project design, data interpretation, and manuscript preparation. Yan J and Li XQ applied for and were successful in obtaining funding for this project. Yan J conceived, designed, and supervised the entire project process. Li XQ assisted and was responsible for data reanalysis and reinterpretation, graphing, comprehensive literature search, preparation, and submission of the current version of the manuscript. The cooperation of Yan J and Li XQ was critical to the publication of this manuscript.
Supported by the Scientific Research Foundation of Peking University Shenzhen Hospital, No. KYQD2021096; the National Natural Science Foundation of China, No. 81972829; and Precision Medicine Research Program of Tsinghua University, No. 2022ZLA006.
Institutional review board statement: The study was approved by the Institutional Review Board of Peking University Shenzhen Hospital, and all patients provided their informed consent before starting the treatment.
Informed consent statement: As it was a retrospective clinical study, all the patients were contacted by telephone to obtain verbal informed consent and it was approved by the ethics committee.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: All data collected and analyzed in this study are included in this article, and technical appendix, statistical code, and dataset available from the corresponding author at dr.lixiaoqiang@gmail.com.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: Https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Xiao-Qiang Li, PhD, Assistant Professor, Department of Thoracic Surgery, Peking University Shenzhen Hospital, No. 1120 Lianhua Road, Futian District, Shenzhen 518036, Guangdong Province, China. dr.lixiaoqiang@gmail.com
Received: November 12, 2023
Peer-review started: November 12, 2023
First decision: January 30, 2024
Revised: February 25, 2024
Accepted: March 15, 2024
Article in press: March 15, 2024
Published online: April 26, 2024

Abstract
BACKGROUND

This study was designed to investigate the clinical outcomes of enhanced recovery after surgery (ERAS) in the perioperative period in elderly patients with non-small cell lung cancer (NSCLC).

AIM

To investigate the potential enhancement of video-assisted thoracic surgery (VATS) in postoperative recovery in elderly patients with NSCLC.

METHODS

We retrospectively analysed the clinical data of 85 elderly NSCLC patients who underwent ERAS (the ERAS group) and 327 elderly NSCLC patients who received routine care (the control group) after VATS at the Department of Thoracic Surgery of Peking University Shenzhen Hospital between May 2015 and April 2017. After propensity score matching of baseline data, we analysed the postoperative stay, total hospital expenses, postoperative 48-h pain score, and postoperative complication rate for the 2 groups of patients who underwent lobectomy or sublobar resection.

RESULTS

After propensity score matching, ERAS significantly reduced the postoperative hospital stay (6.96 ± 4.16 vs 8.48 ± 4.18 d, P = 0.001) and total hospital expenses (48875.27 ± 18437.5 vs 55497.64 ± 21168.63 CNY, P = 0.014) and improved the satisfaction score (79.8 ± 7.55 vs 77.35 ± 7.72, P = 0.029) relative to those for routine care. No significant between-group difference was observed in postoperative 48-h pain score (4.68 ± 1.69 vs 5.28 ± 2.1, P = 0.090) or postoperative complication rate (21.2% vs 27.1%, P = 0.371). Subgroup analysis showed that ERAS significantly reduced the postoperative hospital stay and total hospital expenses and increased the satisfaction score of patients who underwent lobectomy but not of patients who underwent sublobar resection.

CONCLUSION

ERAS effectively reduced the postoperative hospital stay and total hospital expenses and improved the satisfaction score in the perioperative period for elderly NSCLC patients who underwent lobectomy but not for patients who underwent sublobar resection.

Key Words: Enhanced recovery after surgery, Non-small cell lung cancer, Perioperative care, Propensity score, Video-assisted thoracic surgery

Core Tip: This study was designed to investigate the clinical outcomes of enhanced recovery after surgery (ERAS) in the perioperative period in elderly patients with non-small cell lung cancer (NSCLC). ERAS significantly reduced the postoperative hospital stay (6.96 ± 4.16 vs 8.48 ± 4.18 d, P = 0.001) and total hospital expenses (48875.27 ± 18437.5 vs 55497.64 ± 21168.63 CNY, P = 0.014) and improved the satisfaction score (79.8 ± 7.55 vs 77.35 ± 7.72, P = 0.029) relative to those for routine care. ERAS effectively reduced the postoperative hospital stay and total hospital expenses and improved the satisfaction score in the perioperative period for elderly NSCLC patients who underwent lobectomy but not for patients who underwent sublobar resection.



INTRODUCTION

Lung cancer ranks first in all malignant tumours with respect to morbidity and mortality[1]. Surgery is the main treatment for early lung cancer[2], but the complication rate is approximately 30%-50%, resulting in delayed recovery, poor long-term outcomes, and high medical costs[3-5]. Elderly patients with lung cancer often experience a slow recovery and high complication rates after thoracic surgery and thus are a high-risk group for surgical treatment[6-8]. To reduce the postoperative complication rate and accelerate postoperative recovery, many treatment strategies and perioperative management approaches have been incorporated into the surgical field, including infection control, nutritional support, improved fluid management, and comprehensive preoperative assessment. In 2001, Henrik Kehlet, a Danish gastrointestinal surgeon, first proposed the concept of enhanced recovery after surgery (ERAS)[9]. Empirical evidence has demonstrated that effective perioperative management that incorporates ERAS reduces the stress response to surgical trauma and complications and improves surgical safety and patient satisfaction. ERAS has been proven to effectively reduce common complications and general pain in patients. In recent years, the application of ERAS after thoracic surgery has reduced the perioperative complication rate, length of hospital stay, and hospital expenses[10]. However, evidence of the effectiveness of ERAS following video-assisted thoracic surgery (VATS) is still remains uncertain. In particular, no clinical studies have been conducted to investigate ERAS in elderly patients with lung cancer who underwent VATS.

This study was designed to retrospectively analyse the clinical outcomes of ERAS in elderly patients with lung cancer who underwent VATS at Peking University Shenzhen Hospital over a 5-year period and to investigate the role of ERAS (after propensity score matching) in improving postoperative recovery.

MATERIALS AND METHODS
Clinical data

We retrospectively analysed the clinical data of 412 elderly patients with lung cancer who underwent VATS at the Department of Thoracic Surgery of Peking University Shenzhen Hospital between May 2015 and April 2017. Of these patients, 271 were men, and 141 were women; their mean age was 72.41 ± 4.7 years; and 85 patients underwent ERAS (the ERAS group), and 327 patients received routine care (the control group). Moreover, 187 patients underwent sublobar resection, and 225 patients underwent lobectomy; 330 patients were diagnosed with adenocarcinoma, and 82 patients were diagnosed with squamous cell carcinoma; and 235 patients were in tumor-node-metastasis (TNM) stage I, and 92 patients were in TNM stage II.

The inclusion criteria were as follows: (1) Patients who underwent VATS and were pathologically confirmed to have non-small cell lung cancer (NSCLC) after surgery; (2) patients aged 65-80 years old; (3) patients with NSCLC in TNM stage I to II confirmed by postoperative pathology; and (4) patients with complete clinical data. The exclusion criteria were as follows: (1) Patients with pneumonectomy; or (2) patients with pathologically confirmed small cell lung cancer.

Methods

Perioperative management: The patients were divided into the control group and the ERAS group. The control group received routine care, and the ERAS group underwent ERAS (Table 1).

Table 1 Perioperative management.

Measures
Routine care
ERAS
PreoperativeEducationRoutine preoperative educationERAS education
DietFasting for 6 hDrink 1000 mL of 10% glucose the night before surgery; drink 200 mL of 10% glucose 2 h before surgery
Sedatives (to improve sleep)YesYes
IntraoperativeIndwelling catheter after anaesthesiaYesYes
Temperature maintenanceNoYes
PostoperativeAnalgesiaPatient-controlled epidural analgesiaUse of NSAIDs for 48 h
Infusion volumeTotal intravenous infusion during the first 24 h after the operation < 1500 mL, infusion rate 20-30 mL/min; vasoconstrictors may be used in the case of hypotension or urine output < 20 mL/hRapid intravenous drip of 250 mL of saline within 1 h; the remaining parameters were the same as those in the routine care group
Diet during the first 6 hours after the operationA small amount of water400 mL of liquid food
Promote bowel movementsNoChewing gum
Catheter removal24 h after the operation12 h after the operation
Early exercisePatient choiceLower limb movements

Preoperative management: All patients underwent a one-stop preoperative assessment by surgeons, anaesthesiologists, and nurses to facilitate optimal preoperative preparation and were closely monitored during and after the operation for any complications. The ERAS group was given a copy of an ERAS education brochure with detailed descriptions about daily goals and was asked to complete a diary. Intraoperative management: All patients were given prophylactic antibiotics during the induction period. General anaesthesia was administered with double-lumen tracheal intubation and single-lung breathing. Intraoperative rehydration was achieved with intravenous infusion of balanced fluid, and hypertensive or antihypertensive drugs were given based on blood pressure monitoring during the operation. The indications and the feasibility for surgery were determined in accordance with the China Guidelines for the Diagnosis and Treatment of Primary Lung Cancer (2015). The scope of surgical resection was determined by the treating physician based on patient conditions. Effort was taken to make a small incision, and absorbable sutures were used to close the incision. At the end of surgery, a closed thoracic drainage tube was placed according to routine procedures. Postoperative management: Intravenous infusion was minimized, with adequate analgesia. Non-steroidal anti-inflammatory drugs and acetaminophen were used for pain management. Opioids were avoided whenever possible to prevent postoperative nausea and vomiting and other opioid-related adverse reactions. Patients were encouraged to get out of bed as soon as possible. The catheter was removed at 12 h after operation (Table 2).

Table 2 Patient education.
Patient preoperative education
Pre-operativeBe familiar with the environment and hospitalization process
Preoperative nutritional risk screening
Eat a healthy diet & stay active (1-2 wk before surgery)
Normal diet the day before surgery
Drink moderate glucose 2 h before surgery
Preventive use of antibiotics
PostoperativeEating liquid food moderately within six hours after surgery & infusion
Receive any necessary medications
Removed catheter at 12 h after operation
Day after surgeryNormal diet
Use mixture of non-narcotic pain medication to keep comfortable
Get out of bed as soon as possible
Try to cough and expectorate

Criteria for discharge and follow-up: Discharge criteria were as follows: (1) Removal of the closed thoracic drainage tube; physical mobility; (2) no difficulty breathing (no shortness of breath, wheezing or stridor; oxygen saturation > 94%); and (3) no serious complications; complications (if any) were under control.

Calculation of medical expenses: The hospital medical records were used to record and calculate the total medical expenses, including laboratory tests, physical examinations, medications, nursing, surgery, supplies, and postoperative rehabilitation.

Satisfaction: A homemade satisfaction questionnaire was used during the week after discharge to evaluate patient satisfaction. The contents included staff attitude, operating techniques, timeliness of nursing, overall hospital experience, and pain score. Quality of life was analysed, including physical performance, physical pain, mental state, and general health.

Statistical analysis: R language 3.5.3 was used for propensity score matching of pathological classification, TNM stage, and surgical approach at 1:1 between the ERAS group and the control group.

SPSS v25.0 was used for statistical analysis. Measurement data are expressed as the mean value ± SD and analysed with the independent sample t-test or Mann-Whitney U test; count data are expressed as the frequency and were analysed with the chi-square test or Fisher’s exact test. All tests were two-sided, and P < 0.05 was considered statistically significant.

RESULTS
Baseline data

Among the 412 elderly patients with lung cancer who underwent VATS, 327 patients were in the control group and 85 patients were in the ERAS group. No significant between-group differences were observed regarding age (P = 0.220), sex (P = 0.982), body mass index (P = 0.540), or forced expiratory volume in the first second (P = 0.615) (Figure 1). Moreover, 330 patients had adenocarcinoma, and 82 patients had squamous cell carcinoma; 290 patients were in TNM stage I, and 122 patients were in stage II; 187 patients underwent sublobar resection, and 225 patients underwent lobectomy (Table 3). After matching, the control group and the ERAS group each included 85 patients.

Figure 1
Figure 1 Include standard flow chart. ERAS: Enhanced recovery after surgery.
Table 3 Baseline data.
Baseline dataBefore the match (n = 412)
After match (n = 170)
Routine care (n = 327)
ERAS (n = 85)
P value
Routine care (n = 85)
ERAS (n = 85)
P value
Age72.18 ± 4.5372.91 ± 4.940.2272.55 ± 572.91 ± 4.940.643
SexMale215560.98259560.624
Female112292629
BMI (kg/m2)22.54 ± 2.6922.73 ± 2.620.5422.51 ± 2.422.73 ± 2.620.565
FEV1 (L)3.21 ± 0.453.24 ± 0.410.6153.24 ± 0.413.24 ± 0.410.983
Pathological classificationAdenocarcinoma261690.7869691
Squamous cell carcinoma66161616
TNM stageI235550.19855551
II92303030
Surgical approachUniportal VATS282690.24275690.201
Three ports VATS45161016
Scope of resectionPulmonary wedge66140.6414141
Lung segment86212121
Lobectomy175505050

No patient died during the perioperative period or required blood transfusion. At the end of surgery, the tracheal intubation was removed in the operating room, and the patients were able to breathe spontaneously with normal blood gas analysis results. All patients were sent back to the general ward, and no patient required mechanical ventilation in the intensive care unit. Before discharge, any postoperative complications were alleviated and resolved with treatment.

Clinical outcome measures

ERAS significantly improved postoperative hospital stay (6.98 ± 4.3 vs 8.92 ± 4.42 d, P = 0.002), total hospital expenses (52041.86 ± 19062.33 vs 60760.79 ± 20511.58, P = 0.016), and overall satisfaction (79.66 ± 7.5 vs 76.26 ± 7.42, P = 0.013) in the lobectomy subgroup (Table 4). Postoperative hospital stay also improved in the sublobar resection subgroup (6.94 ± 4.03 vs 7.86 ± 3.78 d, P = 0.09), but the differences of total hospital expenses (P = 0.247) and overall satisfaction (P = 0.621) did not reach statistical significance. In the ERAS group (n = 85), 3 patients had atelectasis, 9 had pulmonary infection, 4 had atrial fibrillation, and 2 had arrhythmia; the postoperative complication rate was 21.2%. In the control group (n = 85), 4 patients had atelectasis, 12 had pulmonary infection, 4 had atrial fibrillation, and 3 had arrhythmia; the postoperative complication rate was 27.1%. The difference did not reach statistical significance (Table 5).

Table 4 Clinical outcome measures (scope of resection subgroup analysis).
Outcome Measures
Total (n = 170)
Pulmonary wedge (n = 28)
Segmentectomy (n = 42)
Pulmonary lobe (n = 100)
ERAS (n = 85)
Routine care (n = 85)
P value
ERAS (n = 14)
Routine care (n = 14)
P value
ERAS (n = 21)
Routine care (n = 21)
P value
ERAS (n = 50)
Routine care (n = 50)
P value
Postoperative hospital stay (d)6.06 ± 2.076.61 ± 1.680.0245.43 ± 1.916.14 ± 1.990.3525.9 ± 2.516.29 ± 1.650.3256.3 ± 1.916.88 ± 1.590.040
Total hospital expenses (CNY)42757.63 ± 14963.1653748.72 ± 18356.110.00037812.08 ± 13327.5441836.7 ± 13282.690.45439187.44 ± 18933.8351245.25 ± 16865.50.00745641.86 ± 13016.7558135.55 ± 18757.680.001
Postoperative 48-h pain score2.38 ± 0.912.59 ± 0.880.1092.29 ± 0.832.43 ± 0.760.6672.33 ± 1.112.48 ± 0.870.5602.42 ± 0.862.68 ± 0.910.135
Satisfaction score80.65 ± 7.7476.67 ± 7.10.00180 ± 7.9977 ± 6.860.42780.29 ± 7.1276.9 ± 5.660.13080.98 ± 8.0476.48 ± 7.790.003
Readmission within 30 d011.0000000011.000
Complications (n)14260.030221.0005120.0287120.065
Air leakage7130.153111.000370.277350.712
Atelectasis240.67800121.000121.000
Pulmonary infection360.493111.000111.000140.359
Atrial fibrillation121.00000011.000111.000
Arrhythmia111.00000011.000101.000
Table 5 Clinical outcome measures (age subgroup analysis).
Outcome measures
Total (n = 170)
Age 60-73 (n = 28)
Age 74-80 (n = 42)
ERAS (n = 85)
Routine (n = 85)
P value
ERAS (n = 14)
Routine care (n = 14)
P value
ERAS (n = 21)
Routine care (n = 21)
P value
Postoperative hospital stay (d)6.06 ± 2.076.61 ± 1.680.0245.96 ± 26.57 ± 1.70.0576.18 ± 2.176.67 ± 1.690.188
Total hospital expenses (CNY)42757.63 ± 14963.1653748.72 ± 18356.110.00042122.76 ± 13923.8352334 ± 18206.280.00843471.85 ± 16202.5155417.37 ± 18628.50.001
Postoperative 48-h pain score2.38 ± 0.912.59 ± 0.880.1092.33 ± 0.832.8 ± 0.830.0062.43 ± 1.012.33 ± 0.870.687
Satisfaction score80.65 ± 7.7476.67 ± 7.10.00181.16 ± 7.5276.78 ± 6.310.00480.08 ± 8.0476.54 ± 8.010.055
Readmission within 30 d011.00000011.000
Complications (n)14260.0305110.1098150.071
Air leakage7130.153451.000380.179
Atelectasis240.678121.000120.982
Pulmonary infection360.493130.625230.977
Atrial fibrillation121.000011.000111.000
Arrhythmia111.00000111.000
DISCUSSION

ERAS is a multimodal perioperative protocol based on best medical evidence. In the 1990s, Kehlet et al[11] first used it for patients undergoing colectomy to enhance postoperative recovery[11]. It includes preoperative optimization, intraoperative stress management, and enhanced postoperative recovery, with the goal of accelerating the recovery and resumption of normal activities. It reduces the length of the hospital stay and hospital expenses without increasing the readmission rate. With the gratifying results and low surgical wound, VATS approach is recommended as the standard scheme by several international academic organizations, including the European Society of Thoracic Surgeon, the American College of Chest Physicians and Minimally Invasive Cardiothoracic Surgery[12]. In thoracic surgeries, VATS is a main part of ERAS protocols in the relevant guidelines[13]. At present, class I evidence of the effectiveness of ERAS after thoracic surgery is scarce, especially in elderly patients with lung cancer. This study showed that ERAS improved the clinical efficacy of VATS in elderly patients with lung cancer. At present, data on ERAS in patients undergoing thoracic surgery are limited. Cerfolio et al[14] applied ERAS in patients undergoing open pneumonectomy, with a special focus on preoperative patient education, the use of epidural anaesthesia, active standardized removal of the catheter and drainage tube after surgery, early physical movement, and a daily plan for discharge within 4 days after surgery[14]. The intervention accelerated recovery without increasing the complication or mortality rate. A small randomized controlled study also showed that preoperative food intake (no fasting), conduction anaesthesia, early postoperative food intake, and early physical movement significantly reduced the incidence of postoperative pulmonary complications[15]. Salati et al[16] performed propensity score matching and demonstrated that ERAS effectively reduced the length of the hospital stay. The study focused on preoperative patient education, standardized postoperative care, and active drainage tube management[16]. In recent years, thoracic surgery-specific ERAS has gradually improved. Madani et al[17] described their ERAS procedures for open lobectomy, including standardized care, as well as preoperative, intraoperative, and postoperative management. The study showed that ERAS significantly reduced the length of the hospital stay and complications without increasing the readmission rate. However, their procedures were relatively conservative. Recent studies have shown that paraspinal block (instead of epidural analgesia) and a more aggressive closed thoracic drainage regimen may provide greater benefits to patients[18-20]. This study showed that ERAS significantly reduced postoperative hospital stay, total hospital expenses, and postoperative complications and improved satisfaction. Subgroup analysis per surgical approach (lobectomy vs sublobar resection) showed that ERAS did not significantly reduce postoperative hospital stay, total hospital expenses, and postoperative complications nor significantly improve satisfaction in the sublobar resection subgroup. The scope of sublobar resection was relatively small, with less impact on postoperative recovery, which may explain the lack of a significant difference between patients with sublobar resection in the ERAS group and the control group. On the other hand, lobectomy involves a greater scope of resection and surgical trauma, and thus, ERAS was superior to routine care in postoperative recovery. These data provide a reference for the selection of an appropriate rehabilitation regime. For ERAS, clinicians must pay attention to the readmission rate. Some studies have shown that for patients with lung cancer, readmission is related to shorter survival19. However, it is not clear whether ERAS will increase the readmission rate of lung cancer patients[17]. In this study, the 30-d readmission rate was 1.2% (only 1 patient in the ERAS group; P > 0.05), which was lower than those reported by other studies.

In recent years, a large body of evidence has demonstrated that VATS reduces complications and improves the prognosis of patients with lung cancer[5,21]. At present, however, evidence of the effectiveness of ERAS following VATS is inadequate, especially evidence on the role of ERAS following VATS in elderly patients with lung cancer. This was the first study to investigate the role of ERAS in the perioperative period in elderly patients with lung cancer. We performed propensity score matching to optimize the control group and comprehensively analysed perioperative outcome measures, including postoperative hospital stay, total hospital expenses, postoperative 48-hour pain score, and satisfaction score. This study showed that for elderly patients with lung cancer, ERAS effectively improved postoperative recovery (including hospital stay and hospital expenses) and patient satisfaction and reduced the postoperative complication rates.

CONCLUSION

This is the first study to perform propensity score matching to demonstrate the effectiveness of ERAS for elderly patients with lung cancer. Further subgroup analysis showed that ERAS had significant effects in the lobectomy subgroup. In summary, ERAS may be used as an effective treatment for elderly patients with lung cancer, especially patients undergoing lobectomy.

ARTICLE HIGHLIGHTS
Research background

Lung cancer is the leading cause of death worldwide, and non-small cell lung cancer (NSCLC) in the elderly accounts for a significant proportion. With the significant growth of the aging population, the need for surgical treatment of elderly patients has gradually become more prominent. Video-assisted thoracic surgery (VATS) has become an important choice for the treatment of senile NSCLC due to its characteristics of less trauma and rapid recovery. However, current systematic studies on VATS in postoperative recovery in elderly patients are relatively limited. Therefore, an in-depth understanding of the influence of VATS on elderly patients and revealing its potential role in postoperative rehabilitation are of great significance for guiding the individualized treatment of elderly patients with NSCLC and improving surgical results.

Research motivation

The aim of this study was to investigate the potential enhancement of VATS in postoperative recovery in elderly patients with NSCLC.

Research objectives

This study was designed to investigate the clinical outcomes of enhanced recovery after surgery (ERAS) in the perioperative period in elderly patients with NSCLC.

Research methods

We retrospectively analysed the clinical data of 85 elderly NSCLC patients who underwent ERAS (the ERAS group) and 327 elderly NSCLC patients who received routine care (the control group) after VATS at the Department of Thoracic Surgery of Peking University Shenzhen Hospital between May 2015 and April 2017. After propensity score matching of baseline data, we analysed the postoperative stay, total hospital expenses, postoperative 48-hour pain score, and postoperative complication rate for the 2 groups of patients who underwent lobectomy or sublobar resection.

Research results

After propensity score matching, ERAS significantly reduced the postoperative hospital stay (6.96 ± 4.16 vs 8.48 ± 4.18 d, P = 0.001) and total hospital expenses (48875.27 ± 18437.5 vs 55497.64 ± 21168.63 CNY, P = 0.014) and improved the satisfaction score (79.8 ± 7.55 vs 77.35 ± 7.72, P = 0.029) relative to those for routine care. No significant between-group difference was observed in postoperative 48-h pain score (4.68 ± 1.69 vs 5.28 ± 2.1, P = 0.090) or postoperative complication rate (21.2% vs 27.1%, P = 0.371). Subgroup analysis showed that ERAS significantly reduced the postoperative hospital stay and total hospital expenses and increased the satisfaction score of patients who underwent lobectomy but not of patients who underwent sublobar resection.

Research conclusions

ERAS effectively reduced the postoperative hospital stay and total hospital expenses and improved the satisfaction score in the perioperative period for elderly NSCLC patients who underwent lobectomy but not for patients who underwent sublobar resection.

Research perspectives

We look forward to more large-sample, multicenter studies to validate the recovery benefits of VATS in elderly patients with NSCLC and to further clarify the safety and effectiveness of the surgical technique. At the same time, combined with biological markers and imaging techniques, the specific mechanism of VATS on postoperative inflammatory response, immune function, and quality of life in elderly patients was further studied. With the help of advanced technical means, the individual differences of elderly patients were finely delineated to provide a more accurate basis for personalized surgical treatment. In addition, the long-term efficacy and survival rate of VATS in elderly patients were evaluated through long-term follow-up to comprehensively understand the long-term impact of surgery. These future research directions will provide an in-depth and comprehensive understanding for further promoting the development of surgical treatment for elderly NSCLC.

Footnotes

Provenance and peer review: Unsolicited article; Externally peer reviewed.

Peer-review model: Single blind

Specialty type: Medicine, research and experimental

Country/Territory of origin: China

Peer-review report’s scientific quality classification

Grade A (Excellent): 0

Grade B (Very good): B

Grade C (Good): 0

Grade D (Fair): 0

Grade E (Poor): 0

P-Reviewer: Perez-Holanda S, Spain S-Editor: Li L L-Editor: A P-Editor: Xu ZH

References
1.  Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;68:394-424.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 53206]  [Cited by in F6Publishing: 51140]  [Article Influence: 8523.3]  [Reference Citation Analysis (122)]
2.  Osarogiagbon RU, Veronesi G, Fang W, Ekman S, Suda K, Aerts JG, Donington J. Early-Stage NSCLC: Advances in Thoracic Oncology 2018. J Thorac Oncol. 2019;14:968-978.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 21]  [Cited by in F6Publishing: 32]  [Article Influence: 6.4]  [Reference Citation Analysis (0)]
3.  Chen FF, Zhang D, Wang YL, Xiong B. Video-assisted thoracoscopic surgery lobectomy versus open lobectomy in patients with clinical stage Ⅰ non-small cell lung cancer: a meta-analysis. Eur J Surg Oncol. 2013;39:957-963.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 75]  [Cited by in F6Publishing: 71]  [Article Influence: 6.5]  [Reference Citation Analysis (0)]
4.  Vannucci F, Gonzalez-Rivas D. Is VATS lobectomy standard of care for operable non-small cell lung cancer? Lung Cancer. 2016;100:114-119.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 31]  [Cited by in F6Publishing: 55]  [Article Influence: 6.9]  [Reference Citation Analysis (0)]
5.  Falcoz PE, Puyraveau M, Thomas PA, Decaluwe H, Hürtgen M, Petersen RH, Hansen H, Brunelli A; ESTS Database Committee and ESTS Minimally Invasive Interest Group. Video-assisted thoracoscopic surgery versus open lobectomy for primary non-small-cell lung cancer: a propensity-matched analysis of outcome from the European Society of Thoracic Surgeon database. Eur J Cardiothorac Surg. 2016;49:602-609.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 233]  [Cited by in F6Publishing: 283]  [Article Influence: 31.4]  [Reference Citation Analysis (0)]
6.  Birim O, Zuydendorp HM, Maat AP, Kappetein AP, Eijkemans MJ, Bogers AJ. Lung resection for non-small-cell lung cancer in patients older than 70: mortality, morbidity, and late survival compared with the general population. Ann Thorac Surg. 2003;76:1796-1801.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 88]  [Cited by in F6Publishing: 92]  [Article Influence: 4.4]  [Reference Citation Analysis (0)]
7.  Kawaguchi Y, Hanaoka J, Ohshio Y, Igarashi T, Kataoka Y, Okamoto K, Kaku R, Hayashi K. A risk score to predict postoperative complications after lobectomy in elderly lung cancer patients. Gen Thorac Cardiovasc Surg. 2018;66:537-542.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 8]  [Cited by in F6Publishing: 10]  [Article Influence: 1.7]  [Reference Citation Analysis (0)]
8.  Im Y, Park HY, Shin S, Shin SH, Lee H, Ahn JH, Sohn I, Cho JH, Kim HK, Zo JI, Shim YM, Lee HY, Kim J. Prevalence of and risk factors for pulmonary complications after curative resection in otherwise healthy elderly patients with early stage lung cancer. Respir Res. 2019;20:136.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 36]  [Cited by in F6Publishing: 43]  [Article Influence: 8.6]  [Reference Citation Analysis (0)]
9.  Gonfiotti A, Viggiano D, Bongiolatti S, Bertolaccini L, Solli P, Bertani A, Voltolini L, Crisci R, Droghetti A. Enhanced Recovery After Surgery (ERAS (®)) in thoracic surgical oncology. Future Oncol. 2018;14:33-40.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 7]  [Cited by in F6Publishing: 8]  [Article Influence: 1.3]  [Reference Citation Analysis (0)]
10.  Rogers LJ, Bleetman D, Messenger DE, Joshi NA, Wood L, Rasburn NJ, Batchelor TJP. The impact of enhanced recovery after surgery (ERAS) protocol compliance on morbidity from resection for primary lung cancer. J Thorac Cardiovasc Surg. 2018;155:1843-1852.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 98]  [Cited by in F6Publishing: 89]  [Article Influence: 14.8]  [Reference Citation Analysis (0)]
11.  Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth. 1997;78:606-617.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 1691]  [Cited by in F6Publishing: 1577]  [Article Influence: 58.4]  [Reference Citation Analysis (1)]
12.  Van Haren RM, Mehran RJ, Mena GE, Correa AM, Antonoff MB, Baker CM, Woodard TC, Hofstetter WL, Roth JA, Sepesi B, Swisher SG, Vaporciyan AA, Walsh GL, Rice DC. Enhanced Recovery Decreases Pulmonary and Cardiac Complications After Thoracotomy for Lung Cancer. Ann Thorac Surg. 2018;106:272-279.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 104]  [Cited by in F6Publishing: 125]  [Article Influence: 20.8]  [Reference Citation Analysis (0)]
13.  Nygren J, Thacker J, Carli F, Fearon KC, Norderval S, Lobo DN, Ljungqvist O, Soop M, Ramirez J; Enhanced Recovery After Surgery Society. Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clin Nutr. 2012;31:801-816.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 263]  [Cited by in F6Publishing: 254]  [Article Influence: 21.2]  [Reference Citation Analysis (0)]
14.  Cerfolio RJ, Pickens A, Bass C, Katholi C. Fast-tracking pulmonary resections. J Thorac Cardiovasc Surg. 2001;122:318-324.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 122]  [Cited by in F6Publishing: 146]  [Article Influence: 6.3]  [Reference Citation Analysis (0)]
15.  Muehling BM, Halter GL, Schelzig H, Meierhenrich R, Steffen P, Sunder-Plassmann L, Orend KH. Reduction of postoperative pulmonary complications after lung surgery using a fast track clinical pathway. Eur J Cardiothorac Surg. 2008;34:174-180.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 118]  [Cited by in F6Publishing: 141]  [Article Influence: 8.8]  [Reference Citation Analysis (0)]
16.  Salati M, Brunelli A, Xiumè F, Refai M, Pompili C, Sabbatini A. Does fast-tracking increase the readmission rate after pulmonary resection? A case-matched study. Eur J Cardiothorac Surg. 2012;41:1083-7; discussion 1087.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 41]  [Cited by in F6Publishing: 51]  [Article Influence: 4.3]  [Reference Citation Analysis (0)]
17.  Madani A, Fiore JF Jr, Wang Y, Bejjani J, Sivakumaran L, Mata J, Watson D, Carli F, Mulder DS, Sirois C, Ferri LE, Feldman LS. An enhanced recovery pathway reduces duration of stay and complications after open pulmonary lobectomy. Surgery. 2015;158:899-908; discussion 908.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 89]  [Cited by in F6Publishing: 117]  [Article Influence: 13.0]  [Reference Citation Analysis (0)]
18.  Yeung JH, Gates S, Naidu BV, Wilson MJ, Gao Smith F. Paravertebral block versus thoracic epidural for patients undergoing thoracotomy. Cochrane Database Syst Rev. 2016;2:CD009121.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 99]  [Cited by in F6Publishing: 169]  [Article Influence: 21.1]  [Reference Citation Analysis (0)]
19.  Baidya DK, Khanna P, Maitra S. Analgesic efficacy and safety of thoracic paravertebral and epidural analgesia for thoracic surgery: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg. 2014;18:626-635.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 108]  [Cited by in F6Publishing: 123]  [Article Influence: 12.3]  [Reference Citation Analysis (0)]
20.  Puri V, Patel AP, Crabtree TD, Bell JM, Broderick SR, Kreisel D, Krupnick AS, Patterson GA, Meyers BF. Unexpected readmission after lung cancer surgery: A benign event? J Thorac Cardiovasc Surg. 2015;150:1496-1504, 1505.e1.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 36]  [Cited by in F6Publishing: 40]  [Article Influence: 4.4]  [Reference Citation Analysis (0)]
21.  Bendixen M, Jørgensen OD, Kronborg C, Andersen C, Licht PB. Postoperative pain and quality of life after lobectomy via video-assisted thoracoscopic surgery or anterolateral thoracotomy for early stage lung cancer: a randomised controlled trial. Lancet Oncol. 2016;17:836-844.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 421]  [Cited by in F6Publishing: 536]  [Article Influence: 67.0]  [Reference Citation Analysis (0)]