The Application Status and Prospect of ERAS in
Minimally Invasive Thoracic Surgery
Guangxu Tu and Gang Xu*
Department of Thoracic Surgery, Affiliated Hospital of Zunyi Medical College, Zunyi Medical College, Zunyi, China
Gang Xu, Department of Thoracic Surgery, Affiliated Hospital of Zunyi Medical College , Zunyi Medical College, Zunyi, China, Email:
Received: July 10, 2018; Accepted: August 1, 2018; Published: August 3, 2018
ERAS, which is the acronym for Enhanced Recovery After
Surgery, is a multi-mode perioperative treatment scheme for patients
undergoing surgery. Since ERAS is not a fixed pattern, ERAS protocols
are not only prepared for a specific clinical disease setting but also easy
to apply to all kinds of postoperative rehabilitation program. ERAS
society has issued several guidelines on accelerated rehabilitation
surgery for different operations, and accumulated some practical
evidence concerning preoperative, Intraoperative and postoperative
practice. However, ERAS in the thoracic surgery develops slowly
and there is no guideline to direct enhanced recovery of thoracic
surgery up to now, for this reason, a literature search and analysis of
the application of ERAS in thoracic surgery is conducted to explore
feasible ERAS protocols that can adjust to Thoracic Surgery and the
possible development direction in the future.
Key words: ERAS or Enhanced Recovery After Surgery; Thoracic
surgery; VATS or Video-Assisted Thoracoscopic Surgery;
Surgery is an important method to treat thoracic surgery
diseases. However, for the reason of great trauma in surgery
procedure, patients undergoing thoracic surgery usually have
obvious pain and many complications after surgery, which lead
to a delayed discharge of the hospital. Despite great advances in
surgical techniques and anesthesia, postoperative complications
of thoracic surgery remain high, length of stay still long, hospital
cost still expensive, furthermore, quality of patients’ life is
sacrificed [1,2]. Because of the small incision, less Intraoperative
bleeding, less postoperative pain and faster recovery, VATS
(Video-Assisted Thoracoscopic Surgery) has become the main
operation method of thoracic surgery. Application of ERAS on the
base of minimally invasive surgery is a solid integration of new
technology and new conception, by doing so, enhanced recovery
is achieved and postoperative complications can be distinctly
reduced, so does the length of hospital stay and hospital cost.
In other words, ERAS has a profound meaning for patients of
The Conception of ERAS
ERAS is a new treatment concept and rehabilitation model
that subverts the traditional one. It was first proposed by a
Danish surgeon called Kehlet in the year of 1997 . It refers
to a series of perioperative optimization measures based on
evidence-based medical evidence to reduce stress response and
accelerate preoperative body composition and organ function,
and eventually accelerate postoperative rehabilitation of patients
. ERAS and minimally invasive surgery are two major medical
breakthrough of the 21st century . ERAS can significantly
reduce the incidence of postoperative complications, improve
patients’ comfort, shorten hospitalization time and reduce the
cost of hospitalization; therefore it has been widely used in
urology, breast surgery, gastrointestinal surgery and other fields
The Application of ERAS in Thoracic Surgery
The popularization of minimally invasive concept and
extensive application of endoscopic technology have significantly
reduced the trauma and stress respond of surgery, making ERAS
feasible in thoracic surgery . However, the application status of
ERAS in thoracic surgery is not optimistic. At present, there is no
uniform ERAS guideline for thoracic surgery at home and abroad
. China started late in the field of ERAS. This new concept of
surgery was first introduced into China by academician Li Jieshou
in 2007 . The ERAS concept has attracted more and more
attention from doctors and patients in mainland China in recent
years, but only a few state-level grade hospitals are promoting
and applying. Du Na from Sichuan University proposed a
questionnaire survey about the application of ERAS in China, and
the survey result indicated that the concept of ERAS in thoracic
surgery of most China hospitals is still in the stage of theory
rather than practice, and the lack of a unified and mature plan is
the main reason .
Key elements of ERAS
Surgery as a source of press will inevitably lead to the
psychological and physiological responses of patients during
perioperative period, causing anxiety and tension. A preoperative
education can reduce the anxiety and fear of patients, accelerate
postoperative rehabilitation and reduce hospitalization time,
which is an independent predictor of whether ERAS have a good
effect . A good preoperative education can increase patient
compliance, Jurt, et al. confirmed that patients’ well compliance
with ERAS protocols could significantly reduce the incidence of
complications and shorten hospitalization time . In a patientled
quality study, Gillis, et al. concluded that for most patients
they want to get more information about what accelerated
rehabilitation surgery is and what they need to do in the course
of preoperative education . Therefore, a good preoperative
education should include: detailed information about what might
happen during hospitalization, the role of patients themselves
in the process of ERAS, what they need to do and some specific
postoperative tasks for patients to perform . Preoperative
education should be conducted by the doctors and nurses in the
form of oral education and be repeated again and again in the
later contact with patients, because only when patients serve
themselves as the leading role, fully understand the meaning of
different measures and carry out them actively can the surgery
get the best outcome and quick recovery effect .
Forbidden to eat 12 hours and drink 6 hours before
operation which aims to reduce the risk of reverse flow and
pulmonary aspiration in the process of anesthesia induction
aspiration, has long be recognized as the routine of preoperative
preparation, but there is no clear scientific evidence .A
whole night of fasting is extremely uncomfortable for patients,
and often leads to thirst, hunger, and hypoglycemia, which not
only increases the secretion of insulin antagonism hormone
such as catecholamine and glucocorticoids, but also reduce the
concentration of insulin in serum as well as insulin sensitivity,
as a result, increase insulin resistance . In addition, under
the condition of long-term fasting and prohibition of drinking,
the body further loses fluid through various physiological
processes, resulting in relatively insufficient blood volume
. Regardless of the type of anesthesia, different degree of
expansion of blood vessels is an inevitable side effect, causing
blood pressure relatively low. In order to maintain the stability
of hemodynamics anesthesiologists often speed up the infusion
and transfusion volume before surgery, leading to pulmonary
edema and other unwanted consequences. It has been verified by
clinical evidence-based medicine, if the gastrointestinal tract is
free of obstruction, the liquid food can be emptied through the
stomach for 2h, and the solid food can also be emptied within 6h
. Several studies have confirmed that a 6h fast for solid food
and intake of clear fluids until 2h before initiation of anesthesia
(not more than 400 ml) can increase patients’ comfort, reduce
anxiety and preoperative hypotension, reduce insulin resistance,
and did not increase the risk of reverse flow and aspiration [20-
22]. Therefore, fasting for 6h before surgery and prohibition of
drinking for 2h are acceptable, and 10% glucose can be taken
orally for 200ml ~ 400ml at 2h before surgery .
Traditional view of urethral catheter management believed
that indwelling catheter can evaluate the Intraoperative excess
or lack of fluid by observing the urine volume, and can prevent
the postoperative dysuria caused by anesthesia . However,
this view has many drawbacks. First, the postoperative comfort
of patients is significantly reduced. Secondly, indwelling urinary
catheter is not good for patients to get out of bed early. Third,
urinary infection rates increased . Research showed that the
rate of urinary tract infection was 10% after 1 day of indwelling
catheter, 15% for 2 days, and 100% over 14 days . In addition,
restlessness and adverse events during anesthesia awakening
are often caused by indwelling catheters. Research reveals that
only 10 percent had to have a catheter after surgery, while 90%
of patients had increased perioperative complications due to
urinary catheterization . Qiu fang from Hospital of Sichuan
University and other authors indicate that when operation
time is less than 150 min, No indwelling catheter for patients
doesn’t increase the incidence of urinary retention and urinary
incontinence but can reduce the rate of urinary tract infection,
shorten hospitalization time and improve patients’ comfort .
In addition, zhao jinlan pointed out that: 1. Removal of the urinary
catheter before anesthesia was sober in thoracic surgery could
reduce the incidence of restlessness during general anesthesia
. When the duration of thoracic surgery was shorter than 3h
and the Intraoperative transfusion volume was not more than
1500 ml, the Intraoperative average urine volume was 500 ml.
However, the normal storage capacity of bladder is about 500
ml~800 ml . Therefore, for patients whose preoperative
evaluation time is expected to be less than 3h, no catheterization
is allowed, or urine catheterization is conducted after anesthesia
but removed before anesthesia sobriety.
Intraoperative hypothermia refers to the body temperature
lower than 36°C during operation. Low operating room
temperature, temperature regulating function inhibition caused
by the use of anesthetics, massive Intraoperative infusion of
cryogenic liquid, all above can lead to low temperature of body.
Low temperature may lead to the coagulation mechanism and
leukocyte function being affected in the process of rewarming,
leading to increased cardiovascular burden, etc . In addition,
Intraoperative hypothermia may affect pharmacokinetics and
anaesthesia resuscitation . A study by Samsung medical
center in South Korea pointed out that Intraoperative and early
postoperative thermal insulation can reduce Intraoperative
bleeding, reduce the incidence of postoperative infection and
heart complications, and reduce the role of catabolism .
The use of infusion heating device, cover quilt, adjust the
central air conditioner of the operating room to the appropriate
temperature, the preheating of washing salt water, the use of
heating mattresses can all play a good role in keeping warm.
Limited fluid resuscitation
Fluid therapy is an important element in perioperative
treatment. Its’ main purpose is to maintain hemodynamic
stability and ensure adequate tissue perfusion. Traditional fluid
therapy used the open replenishment strategy proposed by
Shires, focusing on correcting low blood volume. However, large
amount of rehydration fluid often leads to pulmonary edema,
which affects patients’ respiratory and circulation function
. In addition, Intraoperative single lung ventilation and lung
tissue traction can cause pulmonary injury, which aggravates
pulmonary tissue edema, and increase the risk of postoperative
pulmonary infection . In addition, gastrointestinal mucosa
often become edematous due to a large amount of fluid infusion,
which results in slow recovery of gastrointestinal function.
Restrictive fluid therapy can not only satisfy the normal tissue
perfusion, but also avoid the bad consequences caused by a large
amount of rehydration, thus the time of gastrointestinal function
recovery and hospitalization are shorten, and the incidence of
pulmonary infection and other complications are decreased .
Research Show that using lactate ringer’s balance solution to
supply the fluid loss in the process of operation at the speed of
1~2 ml/(kg. h) is feasible and safe, a small amount of colloidal
solution can be given if patients’ blood volume is insufficient, and
all intravenous infusion can be ceased when patients begin to
effectively eat through mouth . In recent years, more and more
attention has been paid to Goal Directed Fluid Therapy (GDFT), a
recent meta-analysis pointed out that the individualized target
oriented fluid administration for different patients can maintain
the proper circulation capacity and tissue oxygen supply and
accelerate the postoperative rehabilitation . Patients require
continuous monitoring capacity reactivity index in the process of
implementing GDFT to make sure blood pressure not less than
20% of the normal and heart rate not more than 20% of the
normal, keep the central venous pressure between 4~12 mm H2O
and keep urine output above 0.5 ml/(kg. h).
The management of thoracic drainage tube
To reconstruct the negative pressure of pleural cavity is the
main purpose of thoracic drainage tube. However, postoperative
incision pain is often caused by the stimulation of pleural
membrane and intercostal nerve’s compression or injury by the
chest tube. What’s more, there are many inconveniences with the
tube such as cough limitation, patients’ unwillingness to perform
rehabilitation training [39,40]. For those reasons, it has become
a hot research topic in recent years to indwell less chest drainage
tube, small tube and even no tube. Multiple studies confirmed
that the effect of single drainage tube and double drainage tube
is similar, and the incidence of postoperative complications is out
of significant difference, but the pain caused by single drainage
tube is apparently less, and the total volume of thoracic drainage
is less [41,42]. The traditional thoracic drainage tube is usually
made of PVC material with large diameter and high hardness,
so the postoperative pain is obvious. At present, there are
researches using no.16 gastric tube, 16F urinary tube and 19F
silicone tube to replace the 28F drainage tube the results showed
that the drainage effect of small diameter drainage tube and
28F drainage tube was similar, but it had obvious advantages in
reducing postoperative pain and promoting wound healing [43-
45]. According to the traditional concept, the thoracic drainage
tube can be removed only if the thoracic drainage flow is less
than 100 ml within 24 hours, and the lung on the affected side is
well re-stretched and there is no air leakage. But in physiological
state, 350-400 ml of chest water produced by the pleura each day
can be absorbed by itself . A meta-analysis showed that the
thoracic drainage tube could be removed when the volume of
thoracic drainage was less than 300 ml/24h, and such a standard
did not increase the incidence of pulmonary atelectasis and
pleural effusion . Furthermore, there are also some studies
in recent years reporting that the spontaneous pneumothorax,
mediastinal tumor, lung wedge resection surgery have no need
to dwell chest tubes if patient does not have emphysema, pleural
effusion and coagulant function abnormality before operation,
and pulmonary nodules is less than 2 cm, the nodule’s distance to
pleural is less than 3 cm, and no more than two wedge resection,
there is no dense adhesion in chest and Intraoperative leak test
is negative [48-50].
Multimodal pain relief
Pain is called the fifth vital sign after body temperature,
pulse, respiratory and blood pressure . Most patients
suffer from a heavy incision pain after undergoing thoracic
surgery; the pain makes breath quick and shallow, cough and
expectoration inefficient, leading to complications such as
hypoxemia, hypercapnia, pneumonia, atelectasis, respiratory
failure and cardiac arrhythmia . Despite of the small incision
and deceased trauma benefited from minimally invasive surgery,
most patients still experienced different degree of pain ranging
from moderate to severe after surgery, which requires active
analgesia . Common analgesia patterns include Patient-
Controlled Intravenous Analgesia (PCIA), Patient-Controlled
Epidural Analgesia (PCEA), and oral opiates. Among them, PCIA
is the most commonly used one, but the adverse reaction of
intravenous opiates is often obvious, including slow recovery of
intestinal function, respiratory inhibition, nausea and vomiting
. In recent years, more and more attention has been paid to
multimodal analgesia. Multimodal analgesia refers to using drugs
with different mechanisms and different analgesia methods to
achieve balanced analgesia and reduce adverse effects on the
nervous, endocrine and immune system . According to Wenk
and Schug, regional block (such as paravertebral block) or local
anesthesia (such as intercostal nerve block) combines with
general analgesia is the best choice for postoperative analgesia
in thoracic surgery . In addition, it is an important principle
of multimodal analgesia to use Nonsteroidal Anti-Inflammatory
Analgesics (NSAIDS) as the basic postoperative analgesic drugs to
reduce the use of opioids . Current guidelines for accelerated
rehabilitation surgery in the United States and Europe recommend
early use of oral NSAIDS as sequential analgesics .
Early oral intake
Oral intake can accelerate the recovery of gastrointestinal
peristalsis, reduce incision infection and the incidence of
pulmonary infection, protect the intestinal mucosal barrier,
enhance immune function, shorten hospitalization time and
reduce hospitalization costs . The traditional standard of
postoperative food intake is gastrointestinal exhaust. But most
patients can tolerate food intake before resuming gastrointestinal
motility. According to American society of enteral nutrition,
the treatment of enteral nutrition should not be based on anal
exhaust. Research showed that fluid in the small intestine began
to be reabsorbed in the early postoperative period, and the small
intestine returned to normal peristalsis 6 hours after surgery
[60,61]. In addition, jiang zhiwei et al. proposed that fasting could
inhibit gastrointestinal function, make gastrointestinal peristalsis
slow or even disappear, and gastrointestinal peristalsis increases
after eating . Jin-lan Yang testified the safety of drinking
water and eating within 6 hours after pulmonary surgery by a
series of prospective studies . There is also Research abroad
reporting that after thoracoscopic pulmonary wedge resection or
lobectomy, food intake can be advanced to within 1h . The
stepwise diet which shifts from a small amount of drinking water
and a liquid diet to a normal diet and adjusts according to the
patient’s tolerance is relatively safer.
Early mobilization is an important element of the concept of
ERAS. In the past, patients were told to stay in bed for 24 hours, or
even more after surgery, but long-term of lying in the bed not only
increased the risk of deep vein thrombosis, but also can cause
lung infection, atelectasis, increased insulin resistance, weaken
muscle strength and reduce the adverse consequences such as
tissue oxygenation [65,66]. Therefore, if the patient’s condition
permits, getting out of bed and early mobilization should begin
as early as possible after the operation . The concept of early
mobilization in the concept of ERAS is defined by Gatt as getting out
of bed and walking on the day of surgery . At present, there is
no unified standard for the specific time of early mobilization, and
there are few domestic studies on early bed movement. luo jia, etc
confirmed the safety and feasibility of the patient’s mobilization
6h after thoracoscopic surgery . In abroad, Harada and others
pointed out that 80% of patients can stay upright and walk on
the day of surgery after 4 h of operation in patients undergoing
non-small cell lung cancer [70,71]. Furthermore, an article
published in the European journal of cardiothoracic surgery
recently reported that patients of lung cancer undergoing lung
resection surgery can ambulation within 1h . The influential
factors of postoperative early ambulation are as follow: upright
standing intolerance: preoperative fluid loss as a result of long
term of fasting and the use of Intraoperative anesthetic drugs
reduce arterial blood pressure both lead to the reduction of brain
blood supply, causing side effects such as dizziness, nausea. In
addition, the loss of fluid during operation may further reduce
blood perfusion in the brain when standing up, leading to delayed
early mobilization . Compared with the traditional concept,
ERAS advocates shortening the time of fasting, and giving oral
or intravenous infusion of 10% saccharide liquid 200~400 ml
2 hours before surgery to prevent the loss of excessive liquid
. Operation time gets shorter and intraoperative blood loss
is reduced by the use of video-assisted thoracoscope surgery.
What’s more, early oral feeding is initiated as soon as possible
after the surgery. Measures above, to some extent, can reduce the
incidence of orthostatic intolerance. Pain of surgery incision: due
to postoperative pain, patients are unwilling to move out of bed by
instinct and self-protection. ERAS emphasizes multi-modal pain
relief, so the symptom of pain is reduced and early mobilization is
promoted by timely assessment the time and degree of pain and
early preventive treatment. Patients’ insufficient understanding
of the significance of early mobilization and lack of compliance
are two important factors of delayed mobilization. Strengthening
preoperative health education and repeatedly informing patients
of the importance of early mobilization can improve patients’
compliance and enthusiasm of early mobilization.
The future of ERAS
ERAS is not a single rigid treatment model, but an approach
requiring multidisciplinary teamwork and improving with the
development of knowledge to help patients recover more quickly
after surgery, the core of which is to reduce the psychological and
physiological stress response of the body . Therefore, A series
of optimization measures based on evidence-based medicine
were used to achieve the ultimate goal of “no pain” and “no
risk” . As a new concept which is contradicted to traditional
treatment concept in the end of 20th century, ERAS had brought
an unprecedented impact on clinical practice. After 20 years
of development, the application of ERAS had been extended to
the fields of orthopedics, urology and lacteal surgery, and all
achieved a good clinical result. Although the present situation of
the application of ERAS in the thoracic surgery is still confined to
theory, the available evidence had showed ERAS using in thoracic
surgery can reduce the postoperative complications, shorten the
length of hospital stay, reduce hospitalization costs. With the
progress of human knowledge and the continuous development
of forensic medicine, the traditional perioperative concept of
thoracic surgery must be replaced by the concept of ERAS.
Most thoracic surgery must be performed under double lumen
tracheal intubation and one lung Ventilation. But when used
for treatment, double lumen tracheal intubation and one lung
Ventilation also cause some undesired complications including
acute Lung injury and a series of respiratory complications .
During the single lung ventilation, the mechanical ventilation side
of the lung is often given a high amount of moisture to maintain the
oxygen saturation of the blood, easily leading to airway damage.
In addition, the collapsed lung may suffer reperfusion injury
during the course of pulmonary recruitment, which is mediated
by the releasing of cytokine and can further lead to collateral lung
injury . In recent years, in order to avoid airway complications
caused by endotracheal intubation, it has become a hot research
topic to avoid endotracheal intubation when carrying out
video-assisted thoracoscopic surgery. More and more practical
evidence had testified the safety and feasibility of performing
thoracoscopic pulmonary wedge resection, lung segment
resection, lobectomy and mediastinal tumor without tracheal
intubation . Researchers showed that non endotracheal
intubation was superior to the endotracheal intubation in terms
of the incidence of complications and hospitalization time [78-
80]. Therefore, non tracheal intubation is likely to be one of the
important elements of ERAS in thoracic surgery in the future.
Table 1: Comparison of the perioperative cares between ERAS and traditional concept
Method in traditional care
Method in ERAS
Normal notification of the process and risk of operation before surgery
Strengthened education and councel throughout the hospitalization
Routinely fasting from midnight before the day of surgery
Fasting solids up to 6 hours prior to surgery, and clear liquids permission up to 2 hours before surgery
Remove the catheter after 24 hours at least
No catheter or indwell the catheter after anesthesia but remove it once the surgery is over
Intra operative warming
No warming measures
Apply different methods to keep warm
Open Rehydration Strategy
Restricted fluid resuscitation
The management of thoracic drainage tube
Double drainage tube or even more, with large diameter
No chest tube or reduce the number of tube as much as possible with a small diameter
Strategies for pain relief
Single and fixed analgesia
Multimodal pain relief
The time of oral feeding
Drink water 6 hours after surgery, and initiate oral food intake at the second day
A stepwise diet from water to solid immediately after surgery
At least on the second day
Get out of bed and walk as early as possible if patient’s condition allow
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