From the Journals

Wanted: Better evidence on fast-track lung resection

Publish date: March 21, 2016
By
Richard Mark Kirkner

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Questions surround fast-track lung surgery

The task that Dr. Fiore and colleagues undertook to evaluate and compare disparate studies of fast-track surgery in lung resection is “akin to comparing not just apples and oranges but apples to zucchini,” Dr. Lisa M. Brown of University of California, Davis, Medical Center said in her invited analysis (J. Thorac. Cardiovasc. Surg. 2016 Mar;151:715-16). Without the authors’ “descriptive approach,” Dr. Brown said, “the results of a true meta-analysis would be uninterpretable.”

Dr. Lisa M. Brown

Nonetheless, the systematic review underscores the need for a blinded, randomized trial, Dr. Brown said. “Furthermore, rather than measuring [hospital] stay, subjects should be evaluated for readiness for discharge, because this would reduce the effect of systems-based obstacles to discharge,” she said. Enhanced recovery pathways (ERPs) in colorectal surgery have been used as models for other specialties, but the novelty of these pathways versus traditional care may be difficult to replicate in thoracic surgery, she said. Strategies such as antibiotic prophylaxis and epidural analgesia in thoracic surgery “are not dissimilar enough from standard care to elicit a difference in outcome,” she said.

In thoracic surgery, ERPs must consider the challenges of pain control and chest tube management unique in these patients, Dr. Brown said. For pain control, paravertebral blockade rather than epidural analgesia could lead to earlier hospital discharges. Use of chest tubes is commonly a matter of surgeon preference, she said, but chest tubes without an air leak and with acceptable fluid output can be safely removed, and even patients with an air leak but no pneumothorax on water seal can go home with a chest tube, Dr. Brown said.

Dr. Brown had no financial relationships to disclose.


 

A host of medical specialties have adopted strategies to speed recovery of surgical patients, reduce length of hospital stays, and cut costs, known as fast-track or enhanced-recovery pathways, but when it comes to elective lung resection, the medical evidence has yet to establish if patients in expedited recovery protocols fare any better than do those in a conventional recovery course, a systematic review in the March issue of the Journal of Thoracic and Cardiovascular Surgery reported (2016 Mar;151:708-15).

A team of investigators from McGill University in Montreal performed a systematic review of six studies that evaluated patient outcomes of both traditional and enhanced-recovery pathways (ERPs) in elective lung resection. They concluded that ERPs may reduce the length of hospital stays and hospital costs but that well-designed trials are needed to overcome limitations of existing studies.

“The influence of ERPs on postoperative outcomes after lung resection has not been extensively studied in comparative studies involving a control group receiving traditional care,” lead author Julio F. Fiore Jr., Ph.D., and his colleagues said. One of the six studies they reviewed was a randomized clinical trial. The six studies involved a total of 1,612 participants (821 ERP, 791 control).

The researchers also reported that the studies they analyzed shared a significant limitation. “Risk of bias favoring enhanced-recovery pathways was high,” Dr. Fiore and his colleagues wrote. The studies were unclear if patient selection may have factored into the results.

Five studies reported shorter hospital length of stay (LOS) for the ERP group. “The majority of the studies reported that LOS was significantly shorter when patients undergoing lung resection were treated within an ERP, which corroborates the results observed in other surgical populations,” Dr. Fiore and his colleagues said.

Three nonrandomized studies also evaluated costs per patient. Two reported significantly lower costs for ERP patients: $13,093 vs. $14,439 for controls; and $13,432 vs. $17,103 for controls (Jpn. J. Thorac. Cardiovasc. Surg. 2006 Sep;54:387-90; Ann. Thorac. Surg. 1998 Sep;66:914-9). The third showed what the authors said was no statistically significant cost differential between the two groups: $14,792 for ERP vs. $16,063 for controls (Ann. Thorac. Surg. 1997 Aug;64:299-302).

Three studies evaluated readmission rates, but only one showed measurably lower rates for the ERP group: 3% vs. 10% for controls (Lung Cancer. 2012 Dec;78:270-5). Three studies measured complication rates in both groups. Two reported cardiopulmonary complication rates of 18% and 17% in the ERP group vs. 16% and 14% in the control group, respectively (Eur. J. Cardiothorac. Surg. 2012 May;41:1083-7; Lung Cancer. 2012 Dec;78:270-5). One reported rates of pulmonary complications of 7% for ERP vs. 36% for controls (Eur. J. Cardiothorac. Surg. 2008 Jul;34:174-80).

Dr. Fiore and his colleagues pointed out that some of the studies they reviewed were completed before video-assisted thoracic surgery became routine for lung resection. But they acknowledged that research in other surgical specialties have validated the role of ERP, along with minimally invasive surgery, to improve outcomes. “Future research should investigate whether this holds true for patients undergoing lung resection,” they said.

The study authors had no financial relationships to disclose.

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