Successful postoperative recovery management after thoracoscopic lobectomy and segmentectomy using an ERAS-based protocol of immediate ice cream intake and early ambulation: a 3-year study

Figures & data

Table 1 Patient characteristics

Variables	Phase I (n=271)	Phase II (n=229)	p
Age (years)	66 (19–87)	67 (16–88)	0.14
Gender (Male/Female)	133/139	109/119	0.81
Smoke (pack/year)	20.7±29.8	21.7±30.6	0.59
BMI (kg/mm^2)	22.4±3.9	22.1±3.2	0.56
Histology (LC/MT/Benign)	233/37/2	203/21/4	0.29
Operative time (mins)	218.9±66.9	204.3±53.2	<0.01*
Bleeding (mL)	32.2±107.8	23.7±39.0	0.83
Respiratory function
%Vital capacity	101.2±14.3	99.3±13.7	0.12
FEV% in 1 s	79.2±7.6	78.0±8.8	0.10
Procedures
Segmentectomy/lobectomy	89/183	84/144	0.34
Any preoperative Comorbidity
Cardiovascular	17 (6.3)	15 (6.6)	0.88
Pulmonary	25 (9.)	24 (10.5)	0.62
Diabetes	26 (9.6)	30 (13.2)	0.20

Note: *p<0.05.

Abbreviations: BMI, body mass index; LC, lung cancer; MT, metastasized tumor; FEV1, forced expiratory volume in 1 s.

Table 2 ERAS society guidelines

Postoperative elements	Periods
Phase I	Phase II
Early mobilization	1 POD	On the day
Early intake of oral fluids and solids	On the day ±ice cream	On the day +ice cream
Early removal of urinary catheters and intravenous fluids	1 POD	On the day
Use of chewing gums and laxatives and peripheral opioid-blocking agents (when using opioids)	No	No
Intake of protein and energy-rich nutritional supplements	Diet	Diet
Multimodal approach to control opioid-sparing pain control	Yes	Yes
Multimodal approach to control nausea and vomiting	Yes	Yes
Prepare for early discharge	Yes	Yes
Audit of outcomes and process in multiprofessional, multidisciplinary team on a regular basis	Doctor and Nursing staffs	Yes

Abbreviations: ERAS, enhanced recovery after surgery; POD, postoperative day.

Table 3 Short-term (30-day) morbidity of patients

Characteristic	Phase I (n=271)	Phase II (n=229)	p
Any complications (%)	19 (7.0)	11 (4.8)	0.31
Minor (Clavien-Dingo I–II)	16 (5.9)	7 (3.1)	0.08
Tachyarrhythmia	7 (2.6)	0 (0)
Prolonged air leak (>7 days)	4 (1.5)	0 (0)
Atelectasis	1 (0.4)	1 (0.4)
Surgical site infection	0 (0)	2 (0.9)
Clostridium difficile colitis	1 (0.4)	1 (0.4)
Others^a	3 (1.1)	3 (1.3)
Major (Clavien-Dingo III–IV)	3 (1.1)	4 (1.8)	0.33
Pneumothorax requiring drainage	2 (0.7)	3 (1.3)
Chylothorax requiring drainage	1 (0.4)	0 (0)
Pleural effusion requiring drainage	0 (0)	1 (0.4)
Mortality	0 (0)	0 (0)	–
Readmission	4 (1.5)	3 (1.3)	0.88

Notes: ^a Phase I includes delirium, temporary (reversible) paralysis of the recurrent nerve and chest wall bleeding. Phase II includes Clostridium difficile colitis, acute laryngitis, and thrombosis at the stump of the left upper superior vein.

Table 4 Univariate and multivariate analyses for ≤3 days’ hospitalization after surgery

	Univariate analysis	Multivariate analysis
p	p	HR (95% CI)
Age (equal or less than 60 years old)	0.53
Gender (male)	0.20
Smoking (S.I >800)	0.11	0.22	0.76 (0.48–1.19)
BMI (>24)	0.45
Any comorbidity	0.83
Procedures (Segmentectomy)	0.04	0.25	1.28 (0.84–1.94)
Lymphadenectomy (vs Sampling)	0.63
Operative time (equal or less than 180 mins)	<0.01	0.11	1.43 (0.93–2.21)
Bleeding/Weight ×10^3<1	0.04	0.27	1.44 (0.75–2.76)
Ambulation (yes)	<0.01	0.29	0.73 (0.40–1.31)
Ice (more than half)	<0.01	0.03	1.80 (1.07–3.03)
Light pain (NRS <3) on ambulation	0.43
The removal of drainage tube (<1 day)	0.04	<0.01	2.90 (1.68–4.96)

Abbreviations: BMI, body mass index; NRS, numerical rating scale.

Figure 1 Removal of the drainage tube within 4–6 hrs (the black bar area), within 24 hrs (the gray-dotted area), and after two or more postoperative days (the gray area). *A p-value <0.05 was considered significant.