Study shows Enhanced Recovery After Surgery lowers pain and opioid use for lung cancer patients
Kellie Bramlet Blackburn
MD Anderson surgeons have found a way to reduce pain and opioid use for lung cancer patients undergoing a lung resection. A recent study led by David Rice, M.B. BCh, professor of Thoracic and Cardiovascular Surgery, and published in the Annals of Surgery, showed that using an Enhanced Recovery After Surgery (ERAS) pathway employing a long-acting local anesthetic (liposomal bupivacaine) reduced opioid use by 20% and that the majority of patients reported lower pain scores compared to conventional pain management.
“MD Anderson had already changed our standard of care by employing ERAS protocols. What this study has done is shown that not only are better postoperative outcomes achieved with ERAS but that pain management is improved and this is associated with a significant reduction in the amount of opioids consumed by patients recovering from lung cancer surgery,” Rice says.
A ‘game changing’ Enhanced Recovery After Surgery study
Since 2013, MD Anderson’s ERAS program has improved outcomes and quality of life for thousands of cancer patients. The multimodal perioperative care plan is designed to achieve early recovery for patients undergoing major surgery.
In the case of lung cancer resection, establishing an ERAS pathway means addressing preoperative, intraoperative and postoperative aspects of care, including focusing on patient education, optimizing activity before surgery and establishing the need for patients to participate in early ambulation and pulmonary hygiene efforts in the hospital, as well as the management of chest tubes, which can be a significant source of pain for patients.
Understanding the impact ERAS had had on their lung cancer patients, MD Anderson surgeons designed a study that would quantify this.
“We knew this was potentially going to be a game-changer,” Rice says.
Rice and his team compared 123 consecutive patients who had undergone surgery after the ERAS pathway was implemented utilizing liposomal bupivacaine with a group that had undergone lung resection before ERAS.
The results confirmed their initial suspicions. Epidurals had been used to help manage pain in 66% of the control patients, but not a single patient who underwent lung surgery after ERAS was implemented needed one. Additionally, there was a major reduction in morphine use in the ERAS group. And daily pain scores were lower among those ERAS patients who underwent a thoracotomy, a procedure in which an incision is made in the chest wall between the ribs to allow part or all of the lung to be removed. And overall patients’ hospitals stays were shorter by about one day.
“Across the board, whether patients had a minimally invasive surgery or open surgery, we saw a statistically significant reduction in opioid use,” Rice says. “The icing on the cake is our patients are getting out of the hospital sooner with less opioids.”
He adds that ERAS techniques have become even more important because opioid addiction and the potential for a sudden need for hospital beds due to a COVID-19 surge are on many physicians’ minds.
What’s next for Enhanced Recovery After Surgery in thoracic surgery
This study reflects a wider effort across MD Anderson to reduce opioid use and adopt ERAS pathways. The program has been adopted in more than 16 different surgical service lines and is even being used outside of surgery in stem cell transplantation and emergency medicine.
Rice says the next step for ERAS in thoracic surgery will be to establish a real-time electronic dashboard that determines how much pain patients should expect based on demographics and comorbidities. This will help set patient expectations and help care teams make adjustments to reduce pain.
“It’s all about helping us identify things that we can do better,” Rice says.