Implementing a thoracic enhanced recovery with ambulation after surgery program: key aspects and challenges

Enhanced recovery after surgery (ERAS) protocols aim to improve operative outcomes through evidence-based perioperative care (1). The ERAS Society has published guidelines for procedure specific recovery including colorectal, gastric, and gynecologic surgeries (2). The common principles include minimization of preoperative risk (smoking cessation, nutritional support, exercise), limitation of narcotics, maintenance of fluid balance, and early mobilization. Additional challenges unique to thoracic surgery include the physiologic insult caused by one lung ventilation intraoperatively and pain from intercostal incisions limiting respiratory effort. There are currently no consensus guidelines from the ERAS group for general thoracic surgery; however, several groups have published their initial experiences with enhanced recovery protocols (3-10). Common elements include preoperative optimization with smoking cessation and preoperative exercise regimens, intraoperative care modifications with a focus on minimally invasive techniques, drain limitation, and long term narcotic avoidance. A systematic meta-analysis of ERAS for lung cancer surgery found that ERAS patients had significantly lower morbidity rates (RR =0.64, P<0.001) than the control patients, although there was no significant difference in the in-hospital mortality (11). While the principles of ERAS for thoracic surgery are consistent with more general ERAS protocols, these reports demonstrate the wide variation in specific management guidelines at each institution. In particular, the post-operative “early mobility” goal is a generalized encouragement of mobility with no report of a quantitative assessment. Some institutions have a goal of mobilization to a chair on the operative or first post-operative day (7,8,10) while others have ambulation as the goal, anywhere from the first post-operative day (4,6,12) to the day of surgery (3,13)