Brazilian Journal of Anesthesiology
Brazilian Journal of Anesthesiology
Original Investigation

Implementation of an ERAS program in patients undergoing thoracic surgery at a third-level university hospital. An ambispective cohort study

Implementação de um programa ERAS em pacientes submetidos a cirurgia torácica em um hospital universitário de terceiro nível. Um estudo de coorte ambispectivo

Soledad Bellas-Cotán, Rubén Casans-Francés, Cristina Ibáñez, Ignacio Muguruza, Luis E. Muñoz-Alameda

Downloads: 2
Views: 820



To analyze the effects of an ERAS program on complication rates, readmission, and length of stay in patients undergoing pulmonary resection in a tertiary university hospital.


Ambispective cohort study with a prospective arm of 50 patients undergoing thoracic surgery within an ERAS program (ERAS group) versus a retrospective arm of 50 patients undergoing surgery before the protocol was implemented (Standard group). The primary outcome was the number of patients with 30-day surgical complications. Secondary outcomes included ERAS adherence, non-surgical complications, mortality, readmission, reintervention rate, pain, and hospital length of stay. We performed a multivariate logistic analysis to study the correlation between outcomes and ERAS adherence.


In the univariate analysis, we found no difference between the two groups in terms of surgical complications (Standard 18 [36%] vs. ERAS 12 [24%], p = 0.19). In the ERAS group, only the readmission rate was significantly lower (Standard 15 [30%] vs. ERAS 6 [12%], p = 0.03). In the multivariate analysis, ERAS adherence was the only factor associated with a reduction in surgical complications (OR [95% CI] = 0.02 [0.00, 0.59], p = 0.03) and length of stay (HR [95% CI] = 18.5 [4.39, 78.4], p < 0.001).


The ERAS program significantly reduced the readmission rate at our hospital. Adherence to the ERAS protocol reduced surgical complications and length of stay.


Fast-track rehabilitation,  Enhanced recovery after surgery,  VATS



Analisar os efeitos de um programa ERAS nas taxas de complicações, reinternação e tempo de internação em pacientes submetidos à ressecção pulmonar em um hospital universitário terciário.


Estudo de coorte ambispectivo com um braço prospectivo de 50 pacientes submetidos a cirurgia torácica dentro de um programa ERAS (grupo ERAS) versus um braço retrospectivo de 50 pacientes submetidos a cirurgia antes da implementação do protocolo (grupo padrão). O desfecho primário foi o número de pacientes com complicações cirúrgicas em 30 dias. Os desfechos secundários incluíram adesão ao ERAS, complicações não cirúrgicas, mortalidade, reinternação, taxa de reintervenção, dor e tempo de permanência hospitalar. Realizamos uma análise logística multivariada para estudar a correlação entre os resultados e a adesão ao ERAS.


Na análise univariada, não encontramos diferença entre os dois grupos quanto às complicações cirúrgicas (Padrão 18 [36%] vs. ERAS 12 [24%],p = 0,19). No grupo ERAS, apenas a taxa de reinternação foi significativamente menor (Padrão 15 [30%] vs. ERAS 6 [12%], p = 0,03). Na análise multivariada, a adesão ao ERAS foi o único fator associado à redução de complicações cirúrgicas (OR [95% CI] = 0,02 [0,00, 0,59], p = 0,03) e tempo de internação (HR [95% CI] = 18,5 [4,39, 78,4], p < 0,001).


O programa ERAS reduziu significativamente a taxa de reinternação em nosso hospital. A adesão ao protocolo ERAS reduziu as complicações cirúrgicas e o tempo de internação.


1 Sociedad Española de Oncología Médica -SEOM-. Las cifras del cáncer en España, 2020. [accessed 5 August 2020].

2 American Cancer Society. Cancer Facts & Statistics. [accessed 5 August 2020].

3 Royal College of Physicians Lung cancer clinical outcomes publication 2018 (for surgical operations performed in 2016) RCP, London (2018)

4 F.F. Chen, D. Zhang, Y.L. Wang, et al. Video-assisted thoracoscopic surgery lobectomy versus open lobectomy in patients with clinical stage Ⅰ non-small cell lung cancer: a meta-analysis Eur J Surg Oncol., 39 (2013), pp. 957-963

5 H. Kehlet Multimodal approach to control postoperative pathophysiology and rehabilitation Br J Anaesth., 78 (1997), pp. 606-617

6 H Kehlet, DW Wilmore Evidence-based surgical care and the evolution of fast-track surgery Ann Surg., 248 (2008), pp. 189-198

7 A. Nicholson, M.C. Lowe, J. Parker, et al. Systematic review and meta-analysis of enhanced recovery programmes in surgical patients Br J Surg., 101 (2014), pp. 172-188

8 L. Lee, J. Mata, G.A. Ghitulescu, et al. Cost-effectiveness of enhanced recovery versus conventional perioperative management for colorectal surgery Ann Surg., 262 (2015), pp. 1026-1033

9 F. Paton, D. Chambers, P. Wilson, et al. Effectiveness and implementation of enhanced recovery after surgery programmes: a rapid evidence synthesis BMJ Open., 4 (2014), Article e005015

10 A. Madani, J.F. Fiore, Y. Wang, et al. An enhanced recovery pathway reduces duration of stay and complications after open pulmonary lobectomy Surgery., 158 (2015), pp. 899-908 discussion 908-910

11 M. Giménez-Milà, A.A. Klein, G. Martinez Design and implementation of an enhanced recovery program in thoracic surgery J Thorac Dis., 8 (2016), pp. S37-45

12 M. Scarci, P. Solli, B. Bedetti Enhanced recovery pathway for thoracic surgery in the UK J Thorac Dis., 8 (2016), pp. S78-83

13 E. Von Elm, D.G. Altman, M. Egger, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies Int J Surg., 12 (2014), pp. 1495-1499

14 M.E. Charlson, P. Pompei, K.L. Ales, et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation J Chronic Dis., 40 (1987), pp. 373-383

15 JD. Storey A direct approach to false discovery rates J R Statistical Soc B (Statistical Methodol)., 64 (2002), pp. 479-498

16 R. Casans Francés, J. Ripollés Melchor, A. Abad-Gurumeta, et al. The role of the anaesthesiologist in enhanced recovery programs Rev Esp Anestesiol Reanim., 63 (2016), pp. 273-288

17 J. Ripollés-Melchor, J.M. Ramírez-Rodríguez, R. Casans-Francés, et al. Association between use of enhanced recovery after surgery protocol and postoperative complications in colorectal surgery: the postoperative outcomes within enhanced recovery after surgery protocol (POWER) Study JAMA Surg., 154 (2019), pp. 725-736

18 R.J. Cerfolio, A. Pickens, C. Bass, et al. Fast-tracking pulmonary resections J Thorac Cardiovasc Surg., 122 (2001), pp. 318-324

19 B.M. Muehling, G.L. Halter, H. Schelzig, et al. Reduction of postoperative pulmonary complications after lung surgery using a fast track clinical pathway Eur J Cardiothorac Surg., 34 (2008), pp. 174-180

20 U.O. Gustafsson, J. Hausel, A. Thorell, et al. Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery Arch Surg., 146 (2011), pp. 571-577

21 P.J. Agostini, B. Naidu, P. Rajesh, et al. Potentially modifiable factors contribute to limitation in physical activity following thoracotomy and lung resection: a prospective observational study J Cardiothorac Surg., 9 (2014), p. 128

22 JC Das Neves Pereira, P Bagan, AP Coimbra Israel, et al. Fast-track rehabilitation for lung cancer lobectomy: a five-year experience Eur J Cardiothorac Surg., 36 (2009), pp. 383-391

23 L.S. Bjerregaard, K. Jensen, R.H. Petersen, et al. Early chest tube removal after video-assisted thoracic surgery lobectomy with serous fluid production up to 500 ml/day Eur J Cardiothorac Surg., 45 (2014), pp. 241-246

24 RJ Cerfolio, AS Bryant Results of a prospective algorithm to remove chest tubes after pulmonary resection with high output J Thorac Cardiovasc Surg., 135 (2008), pp. 269-273

25 ERAS Compliance Group The Impact of enhanced recovery protocol compliance on elective colorectal cancer resection: results from an international registry Ann Surg., 261 (2015), pp. 1153-1159

26 M. Bendixen, O.D. Jørgensen, C. Kronborg, et al. Postoperative pain and quality of life after lobectomy via video-assisted thoracoscopic surgery or anterolateral thoracotomy for early stage lung cancer: a randomised controlled trial Lancet Oncol., 17 (2016), pp. 836-844

27 P.E. Falcoz, M. Puyraveau, P.A. Thomas, et al. Video-assisted thoracoscopic surgery versus open lobectomy for primary non-small-cell lung cancer: a propensity-matched analysis of outcome from the European Society of Thoracic Surgeon database Eur J Cardiothorac Surg., 49 (2016), pp. 602-609

28 V. Puri, A.P. Patel, T.D. Crabtree, et al. Unexpected readmission after lung cancer surgery: a benign event? J Thorac Cardiovasc Surg., 150 (2015), pp. 1496-1504 1505.e1-1505; discussion 1504-1505

6098278aa95395605f378eb2 rba Articles
Links & Downloads

Braz J Anesthesiol

Share this page
Page Sections