ERAS-Implementierung in der Thoraxchirurgie

Zusammenfassung

Zielsetzung

Dieses Manuskript gibt einen Überblick über die Prinzipien und Voraussetzungen zur Implementierung eines ERAS-Programms in der Thoraxchirurgie.

Methoden

Basierend auf den ERAS-Guidelines für Thorachirurgie der ERAS Society wird das ERAS-Programm mit seinen einzelnen Maßnahmen bei elektiven Lungenoperationen dargestellt. Mit besonderem Augenmerk auf das postoperative Outcome werden die klinischen Maßnahmen anhand einer aktuellen Literaturübersicht beschrieben. Das ERAS-Programm zum optimierten perioperativen Management für elektive lungenresezierende Eingriffe besteht derzeit aus 45 Maßnahmen, die sich auf 4 perioperative Phasen verteilen. Diese Maßnahmen umfassen von der Zeit vor der Krankenhausaufnahme (Patientenaufklärung, Screening und Behandlung möglicher Risikofaktoren wie Anämie, Mangelernährung, Beendigung des Nikotin- oder Alkoholmissbrauchs, Prähabilitation, Kohlenhydratbelastung) über die unmittelbare präoperative Phase (verkürzte Nüchternheitsphase, nicht sedative Prämedikation, Prophylaxe von PONV und thromboembolischen Komplikationen), die intraoperativen Maßnahmen (Antibiotikaprophylaxe, standardisierte Anästhesie, Normothermie, zielgerichtete Flüssigkeitstherapie, minimalinvasive Chirurgie, Vermeidung von Kathetern und Sonden) und die postoperativen Maßnahmen (frühzeitige Mobilisierung, frühzeitige Ernährung, Entfernung eines Blasenkatheters, Hyperglykämiekontrolle). Die meisten dieser Maßnahmen beruhen auf wissenschaftlichen Studien mit hohem Evidenzlevel und führen zu einer Reduktion postoperativer allgemeiner Komplikationen.

Schlussfolgerung

Das ERAS-Programm ist ein optimiertes perioperatives Behandlungsverfahren und kann die postoperative Genesung von Patienten bei elektiven Lungenresektionen durch eine Verringerung der allgemeinen Komplikationsrate und der Gesamtmorbidität verbessern.

Abstract

Background

This manuscript provides an overview of the principles and requirements for implementing the ERAS program in thoracic surgery.

Methods

The ERAS program optimises perioperative management of elective lung resection procedures and is based on the ERAS Guidelines for Thoracic Surgery of the ERAS Society. The clinical measures are described as in the current literature, with a focus on postoperative outcome. There are currently 45 enhanced recovery items covering four perioperative phases: from the prehospital admission phase (patient education, screening and treatment of potential risk factors such as anaemia, malnutrition, cessation of nicotine or alcohol abuse, prehabilitation, carbohydrate loading) to the immediate preoperative phase (shortened fasting period, non-sedating premedication, prophylaxis of PONV and thromboembolic complications), the intraoperative measures (antibiotic prophylaxis, standardised anaesthesia, normothermia, targeted fluid therapy, minimally invasive surgery, avoidance of catheters and probes) through to the postoperative measures (early mobilisation, early nutrition, removal of a urinary catheter, hyperglycaemia control). Most of these measures are based on scientific studies, with a high level of evidence and aim to reduce general postoperative complications.

Conclusion

The ERAS program is an optimised perioperative treatment approach aiming to improve the postoperative recovery in patients after elective lung resection by reducing the overall complication rates and overall morbidity.

Schlüsselwörter

perioperatives Management - ERAS - fast-track - Morbidität - postoperative Komplikationen - perioperative Medizin

Keywords

perioperative management - ERAS - enhanced recovery after surgery - fast-track - postoperative complications - perioperative medicine

Publication History

Received: 06 December 2023

Accepted after revision: 18 February 2024

Article published online:
11 April 2024

• Literatur

• 1 Engelman RM, Rousou JA, Flack JE. et al. Fast-track recovery of the coronary bypass patient. Ann Thorac Surg 1994; 58: 1742-1746 DOI: 10.1016/0003-4975(94)91674-8. (PMID: 7979747)
• 2 Bardram L, Funch-Jensen P, Jensen P. et al. Recovery after laparoscopic colonic surgery with epidural analgesia, and early oral nutrition and mobilisation. Lancet 1995; 345: 763-764 DOI: 10.1016/S0140-6736(95)90643-6.
• 3 Gustafsson UO, Hausel J, Thorell A. et al. Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Arch Surg 2011; 146: 571-577 DOI: 10.1001/archsurg.2010.309. (PMID: 21242424)
• 4 Melloul E, Hübner M, Scott M. et al. Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations. World J Surg 2016; 40: 2425-2440 DOI: 10.1007/S00268-016-3700-1. (PMID: 27549599)
• 5 Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 1997; 78: 606-617 DOI: 10.1093/bja/78.5.606. (PMID: 9175983)
• 6 Nelson G, Bakkum-Gamez J, Kalogera E. et al. Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations-2019 update. Int J Gynecol Cancer 2019; 29: 651-668 DOI: 10.1136/IJGC-2019-000356. (PMID: 30877144)
• 7 Melloul E, Lassen K, Roulin D. et al. Guidelines for Perioperative Care for Pancreatoduodenectomy: Enhanced Recovery After Surgery (ERAS) Recommendations 2019. World J Surg 2020; 44: 2056-2084 DOI: 10.1007/S00268-020-05462-W. (PMID: 32161987)
• 8 Batchelor TJP, Rasburn NJ, Abdelnour-Berchtold E. et al. Guidelines for enhanced recovery after lung surgery: Recommendations of the Enhanced Recovery after Surgery (ERAS®) Society and the European Society of Thoracic Surgeons (ESTS). Eur J Cardiothoracic Surg 2019; 55: 91-115 DOI: 10.1093/ejcts/ezy301. (PMID: 30304509)
• 9 Wang C, Lai Y, Li P. et al. Influence of enhanced recovery after surgery (ERAS) on patients receiving lung resection: a retrospective study of 1749 cases. BMC Surg 2021; 21: 1-8 DOI: 10.1186/s12893-020-00960-z. (PMID: 33676488)
• 10 Lee L, Tran T, Mayo NE. et al. What does it really mean to “recover” from an operation?. Surgery 2014; 155: 211-216 DOI: 10.1016/J.SURG.2013.10.002.
• 11 Benker M, Citak N, Neuer T. et al. Impact of preoperative comorbidities on postoperative complication rate and outcome in surgically resected non-small cell lung cancer patients. Gen Thorac Cardiovasc Surg 2022; 70: 248-256 DOI: 10.1007/S11748-021-01710-5. (PMID: 34554366)
• 12 Miralpeix E, Nick AM, Meyer LA. et al. A call for new standard of care in perioperative gynecologic oncology practice: Impact of enhanced recovery after surgery (ERAS) programs. Gynecol Oncol 2016; 141: 371-378 DOI: 10.1016/J.YGYNO.2016.02.019. (PMID: 26906066)
• 13 Kuemmerli C, Balzano G, Bouwense SA. et al. Are enhanced recovery protocols after pancreatoduodenectomy still efficient when applied in elderly patients? A systematic review and individual patient data meta-analysis. J Hepatobiliary Pancreat Sci 2024; DOI: 10.1002/JHBP.1417.
• 14 Qin X, Li H, Long J. et al. A meta-analysis of the implementation of enhanced recovery after surgery pathways in anterior cervical spine surgery for degenerative cervical spine diseases. Eur Spine J 2024; DOI: 10.1007/S00586-023-08105-5. (PMID: 38212410)
• 15 Dahlke PM, Benzing C, Lurje G. et al. Impact of complexity in minimally invasive liver surgery on enhanced recovery measures: prospective study. BJS Open 2024; 8: zrad147 DOI: 10.1093/BJSOPEN/ZRAD147. (PMID: 38242574)
• 16 Cai Y, Cai X, Zhang X. et al. Impact of enhanced recovery after surgery protocols on surgical site wound infection rates in urological procedures. Int Wound J 2024; 21: e14582 DOI: 10.1111/IWJ.14582. (PMID: 38272818)
• 17 Andreas MN, Dziodzio T, Hillebrandt KH. et al. [Current State of ERAS Implementation in Thoracic Surgery in Germany]. Zentralbl Chir 2022; 147 (Suppl. 01) S21-S28 DOI: 10.1055/A-1759-4375. (PMID: 35235992)
• 18 Weimann A, Braga M, Carli F. et al. ESPEN guideline: Clinical nutrition in surgery. Clin Nutr 2017; 36: 623-650 DOI: 10.1016/J.CLNU.2017.02.013. (PMID: 28385477)
• 19 Nakagawa M, Tanaka H, Tsukuma H. et al. Relationship between the duration of the preoperative smoke-free period and the incidence of postoperative pulmonary complications after pulmonary surgery. Chest 2001; 120: 705-710 DOI: 10.1378/CHEST.120.3.705.
• 20 Oppedal K, Møller AM, Pedersen B. et al. Preoperative alcohol cessation prior to elective surgery. Cochrane Database Syst Rev 2012; (07) CD008343 DOI: 10.1002/14651858.CD008343.PUB2.
• 21 Molenaar CJL, Papen-Botterhuis NE, Herrle F. et al. Prehabilitation, making patients fit for surgery – a new frontier in perioperative care. Innov Surg Sci 2019; 4: 132-138 DOI: 10.1515/iss-2019-0017. (PMID: 33977122)
• 22 Gillis C, Ljungqvist O, Carli F. Prehabilitation, enhanced recovery after surgery, or both? A narrative review. Br J Anaesth 2022; 128: 434-448 DOI: 10.1016/j.bja.2021.12.007. (PMID: 35012741)
• 23 Liu Z, Qiu T, Pei L. et al. Two-Week Multimodal Prehabilitation Program Improves Perioperative Functional Capability in Patients Undergoing Thoracoscopic Lobectomy for Lung Cancer: A Randomized Controlled Trial. Anesth Analg 2020; 131: 840-849 DOI: 10.1213/ANE.0000000000004342. (PMID: 31348053)
• 24 Andreas MN, Dziodzio T, Hillebrandt KH. et al. Current State of ERAS Implementation in Thoracic Surgery in Germany. Zentralbl Chir 2022; 147 (01) S21-S28 DOI: 10.1055/a-1759-4375. (PMID: 35235992)
• 25 Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AMWF). S3-Leitlinie Prophylaxe der venösen Thromboembolie (VTE). Stand: 15.10.2015. Accessed October 01, 2021 at: https://www.awmf.org/uploads/tx_szleitlinien/003–001l_S3_VTE-Prophylaxe_2015–10-abgelaufen_01.pdf
• 26 Vandermeulen EP, Van Aken H, Vermylen J. Anticoagulants and spinal-epidural anesthesia. Anesth Analg 1994; 79: 1165-1177 DOI: 10.1213/00000539-199412000-00024. (PMID: 7978443)
• 27 Bucx MJL, Krijtenburg P, Kox M. Preoperative use of anxiolytic-sedative agents; are we on the right track?. J Clin Anesth 2016; 33: 135-140 DOI: 10.1016/J.JCLINANE.2016.03.025. (PMID: 27555147)
• 28 Hawn MT, Richman JS, Vick CC. et al. Timing of surgical antibiotic prophylaxis and the risk of surgical site infection. JAMA Surg 2013; 148: 649-657 DOI: 10.1001/JAMASURG.2013.134. (PMID: 23552769)
• 29 Gan TJ, Belani KG, Bergese S. et al. Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesth Analg 2020; 131: 411-448 DOI: 10.1213/ANE.0000000000004833. (PMID: 32467512)
• 30 Apfel CC, Läärä E, Koivuranta M. et al. A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers. Anesthesiology 1999; 91: 693-700 DOI: 10.1097/00000542-199909000-00022.
• 31 Scarfe AJ, Schuhmann-Hingel S, Duncan JK. et al. Continuous paravertebral block for post-cardiothoracic surgery analgesia: a systematic review and meta-analysis. Eur J Cardiothorac Surg 2016; 50: 1010-1018 DOI: 10.1093/EJCTS/EZW168. (PMID: 27242357)
• 32 Khalil AE, Abdallah NM, Bashandy GM. et al. Ultrasound-Guided Serratus Anterior Plane Block Versus Thoracic Epidural Analgesia for Thoracotomy Pain. J Cardiothorac Vasc Anesth 2017; 31: 152-158 DOI: 10.1053/J.JVCA.2016.08.023. (PMID: 27939192)
• 33 Jacob M, Chappell D, Hofmann-Kiefer K. et al. A rational approach to perioperative fluid management. Anesthesiology 2008; 109: 723-740 DOI: 10.1097/ALN.0B013E3181863117. (PMID: 18813052)
• 34 Gupta R, Gan TJ. Peri-operative fluid management to enhance recovery. Anaesthesia 2016; 71 (Suppl. 1) 40-45 DOI: 10.1111/ANAE.13309. (PMID: 26620145)
• 35 Yan TD, Black D, Bannon PG. et al. Systematic review and meta-analysis of randomized and nonrandomized trials on safety and efficacy of video-assisted thoracic surgery lobectomy for early-stage non-small-cell lung cancer. J Clin Oncol 2009; 27: 2553-2562 DOI: 10.1200/JCO.2008.18.2733. (PMID: 19289625)
• 36 Wei S, Chen M, Chen N. et al. Feasibility and safety of robot-assisted thoracic surgery for lung lobectomy in patients with non-small cell lung cancer: a systematic review and meta-analysis. World J Surg Oncol 2017; 15: 98 DOI: 10.1186/S12957-017-1168-6.
• 37 Perna V, Carvajal AF, Torrecilla JA. et al. Uniportal video-assisted thoracoscopic lobectomy versus other video-assisted thoracoscopic lobectomy techniques: a randomized study. Eur J Cardiothorac Surg 2016; 50: 411-415 DOI: 10.1093/EJCTS/EZW161. (PMID: 27174549)
• 38 Li S, Feng Z, Wu L. et al. Analysis of 11 trials comparing muscle-sparing with posterolateral thoracotomy. Thorac Cardiovasc Surg 2014; 62: 344-352 DOI: 10.1055/S-0033-1337445.
• 39 Rahman NM, Pepperell J, Rehal S. et al. Effect of Opioids vs NSAIDs and Larger vs Smaller Chest Tube Size on Pain Control and Pleurodesis Efficacy Among Patients With Malignant Pleural Effusion: The TIME1 Randomized Clinical Trial. JAMA 2015; 314: 2641-2653 DOI: 10.1001/JAMA.2015.16840.
• 40 Batchelor TJP. Enhanced recovery after surgery and chest tube management. J Thorac Dis 2023; 15: 901-908 DOI: 10.21037/JTD-22-1373/COIF. (PMID: 36910059)
• 41 Holbek BL, Christensen M, Hansen HJ. et al. The effects of low suction on digital drainage devices after lobectomy using video-assisted thoracoscopic surgery: A randomized controlled trial. Eur J Cardiothoracic Surg 2019; 55: 673-681 DOI: 10.1093/ejcts/ezy361. (PMID: 30445572)
• 42 Lijkendijk M, Licht PB, Neckelmann K. The Influence of Suction on Chest Drain Duration After Lobectomy Using Electronic Chest Drainage. Ann Thorac Surg 2019; 107: 1621-1625 DOI: 10.1016/J.ATHORACSUR.2018.12.059. (PMID: 30742815)
• 43 Castelino T, Fiore JF, Niculiseanu P. et al. The effect of early mobilization protocols on postoperative outcomes following abdominal and thoracic surgery: A systematic review. Surgery 2016; 159: 991-1003 DOI: 10.1016/J.SURG.2015.11.029. (PMID: 26804821)
• 44 Koryllos A, Eggeling S, Schega O. et al. [Delphi Expert Consensus of the German Thoracic Surgery Society on the Management of Chest Tube Drainage]. Zentralbl Chir 2020; 145: 99-107 DOI: 10.1055/a-0963-0404. (PMID: 31394582)
• 45 Xu Y, Udumyan R, Fall K. et al. Validity of Routinely Collected Swedish Data in the International Enhanced Recovery After Surgery (ERAS) Database. World J Surg 2021; 45: 1622-1629 DOI: 10.1007/S00268-021-06094-4. (PMID: 33825960)
• 46 Rogers LJ, Bleetman D, Messenger DE. et al. 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 DOI: 10.1016/j.jtcvs.2017.10.151.
• 47 Koch F, Green M, Dietrich M. et al. [Perioperative management-tasks and significance of specially trained nursing staff]. Zentralbl Chir 2021; 146: 260-268 DOI: 10.1055/a-1393-6892. (PMID: 34154006)
• 48 Currie A, Burch J, Jenkins JT. et al. The impact of enhanced recovery protocol compliance on elective colorectal cancer resection: Results from an international registry. Ann Surg 2015; 261: 1153-1159 DOI: 10.1097/SLA.0000000000001029.
• 49 van Beekum C, Stoffels B, von Websky M. et al. Implementierung eines Fast-Track-Programmes. Chirurg 2020; 91: 143-149 DOI: 10.1007/s00104-019-1009-y.
• 50 Roulin D, Donadini A, Gander S. et al. Cost-effectiveness of the implementation of an enhanced recovery protocol for colorectal surgery. Br J Surg 2013; 100: 1108-1114 DOI: 10.1002/bjs.9184. (PMID: 23754650)
• 51 Li L, Wang Z, Ying X. et al. Preoperative carbohydrate loading for elective surgery: A systematic review and meta-analysis. Surg Today 2012; 42: 613-624 DOI: 10.1007/S00595-012-0188-7. (PMID: 22581289)
• 52 Starke H, von Dossow V, Karsten J. Enhanced Recovery after Surgery (ERAS) in der Thoraxchirurgie. Anästhesie Nachr 2023; 5: 50-52 DOI: 10.1007/s44179-022-00062-6.