Author Archives: Najib Safieddine

Authors: Dr. Anne-Sophie Laliberté and Dr. Andrew Seely

Collaborators: Dr. Michaeline Mcguinty and Dr. Bill Cameron, ID specialist, The Ottawa Hospital

Revision: Dr. Sean McFadden


COVID-19 pandemic has brought unprecedent challenges for the health care system. In the last few months, we have been facing a lot of unknown about this virus, its impact and prognosis. The health care system has been put under pressure and health care worker have been infected with COVID. A significant proportion of patients requiring ICU admission require intubation and ventilation. Management of these patients involves the critical decision regarding timing of extubation. Due to prolonged hypoxemia requiring ongoing ventilation associated with COVID-19, due to concerns regarding patient risks and financial costs of failed extubation, and concerns regarding aerosolization during reintubation and with a tracheostomy present, the indications for and timing of tracheostomy remains highly controversial. Last, the act of performing a tracheostomy is an aerosol-generating procedure that can but health care worker at risk. Thus, the aim of these recommendations is to highlight the optimal timing to do tracheostomy and the technical key points on this technic to increase the patient and health care worker safety. Careful team planning for this technic is strangely recommended to avoid unnecessary steps and minimize aerosol exposition.

Key points for tracheostomy in COVID-19 pandemic

 When is the best timing to do tracheostomy?

Based on cases series and international expert opinion, tracheostomy should be delayed until at least 10 days of mechanical ventilation to assess if the patient may be safely extubated, to give time to ensure survivability, and considered only if patient showed sign of clinical improvement.1 The assessment of whether a patient merits a trial of extubation is highly controversial and based on how patients tolerate spontaneous breathing trials (SBTs). A “cuff leak” test should be performed to ensure no laryngeal edema. Best evidence highlights the value of steroids in all COVID-19 patients with severe hypoxemia, however if some time has lapsed while the patient has completed their steroid therapy, a short two day course of steroids may be considered prior to extubation to decrease the risk of extubation failure.10 However, if the patient fails extubation, most would consider that as an indication for tracheostomy. It remains unclear which patients should not undergo a trial of extubation, and proceed to upfront tracheostomy. There is still controversy around the timing of viral load reduction; testing for SARS-CoV-2 using PCR or NAAT does not distinguish between viable and non-viable virus, and virus can be detected using these methods for weeks to months after clinical illness10. The timing of the tracheostomy should be based on the clinical indication, and should not be deferred on the basis of PCR test positivity.

Tracheostomy should be delayed if any of the following are present:
  • FiO2 >50%
  • PEEP>10
  • May need prone position

Health care worker safety strategy

  • Room with negative pressure air flow is recommended, though not required.
  • Enhanced personal protective device with N95, eye protection, surgical gown and gloves
  • The number of persons should be kept at minimum; for example, 3 individuals can safely perform the procedure: one to perform bronchoscopy to guide the removal of the endotracheal tube and placement of the tracheostomy, one to perform the procedure, and one respiratory therapist to manage the ventilator.
  • Favor doing it in ICU.
  • Dedicated team of the most experienced personnel present

Strategy to minimize aerosol generation

  • Sealed ventilator circuit with HEPA filter.
  • Continuous sedation infusion, along with paralyzing agent should be used to avoid coughing.
  • Pre-oxygenation should be done to permit apnea.
  • Ventilation should be held during creation of tracheal window or dilation until the tracheostomy is installed.
  • Avoid cautery

Prefer tracheostomy method

  • Favor the tracheostomy technique that the dedicated team is the most use to do.
  • Percutaneous technique is generally favored to reduce aerolization, reduce the risk of contamination, shorter procedural time and avoid moving patient to the OR.4,6
  • If possible, single-use bronchoscopes with a sealed ventilator circuit are preferred for percutaneous tracheostomy.
  • Upon removal of bronchoscope, gauze should be used to clean the bronchoscope during removal from the endotracheal tube to diminish risk of aerosolization.
  • Suture tracheostomy in place, to avoid decannulation.
  • Careful removal of endotracheal tube with disposal to avoid aerosolization should be considered.

Optimal management after tracheostomy to reduce the risk of aerosol generation

  • Avoid unnecessary care
  • Non fenestrated cuff tracheostomy should be used
  • Reduce the frequency of changing the inner cannula and cuff pressure check
  • Favor moister exchange filter over adjuncts
  • Favor tracheostomy shield over deflating the cuff
General recommendations:
  1. Timing controversial, yet suggest to wait 10 days to ensure it is required
  2. Dedicated team, with minimum personnel present.
  3. Minimize aerosol generation
  4. Optimize health care worker safety
  5. Favor percutaneous tracheostomy in ICU
  6. Avoid unnecessary care


  1. McGrath, B., Brenner, M., Warrillow, S. et al. Tracheostomy in the COVID-19 era: global and multidisciplinary guidance. The Lancet. July 2020: 8;717-725.
  2. David, A., Russel, M., El-Sayed, I. et al. Tracheostomy guidelines deveoped at a large academic medical center during the COVID-19 pandemic. Head & Neck. 2020;42:1291-1296.
  3. Radhakrishnan, S., Perumbally, H., Surya, S. et al. Guidelines for Surgical Tracheostomy and Tracheostomy Tube chang During the COVID-19 Pandemic: A review Article. Indian J Otorhinolaryngology and Head and Neck Surg. 2020;72:398-401.
  4. Schultz, P., Morvan, J-B., Fakhry, N., et al. French consensus regarding precautions during tracheostomy and post-tracheostomy care in the context of COVID pandemic. European Annals of Otorhinolaryngology, Head and Neack Diseases.2020;137:167-169.
  5. Lamb, C., Desai, N., Angel, L., et al. Use of Tracheostomy During the COVID-19 Pandemic. American College of Chest Physicians/American Association for Bronchology and Interventional Pulmonologu\ Association of Interventional Pulmonology Program Directos Extert Panel Report. CHEST 2020;158:1499-1514.
  6. Neilipovitz, D., Kovacs, B. and Pagliarello, G. Percutaneous Tracheostomy in COVID-19 Patients. Anaesth Critic Care Med J.2020;5.
  7. Tay, J., Khoo, M., and Loh, W. Surgical Considerations for tracheostomy During the COVID-19 Pandemic: Lessons Learned From the Severe Acure Respiratory Syndrome Outbreak. JAMA Otolaryngology-Head & Neack. 2020;146 517-519.
  8. Chiesa-Estomba, C., Lechien, J., Calvo-Henriquez, C. et al. Systematic review of international guidelines for tracheostomy in COVID-19 patients. Oral Oncology.2020;108. 104844.
  9. Long, S., Chern, A., Feit, N., et al. Percutaneous and Open Tracheostomy in Patients with COVID-19: Comparison and Outcomes of an Institutional Series in New York City. Annals of Surgery.2020 [Ahead of Printing]
  10. The RECOVERY Collaborative Group. Dexamethasone in Hospitalized Patients with Covid-19 Preliminary Report. N Engl Med. 2020 DOI:10.1056/NEJMoa2021436.
  11. Kwak PE, Connors JR, Benedict PA, et al. Early Outcomes From Early Tracheostomy for Patients With COVID-19. JAMA Otolaryngol Head Neck Surg.Published online December 17, 2020. doi:10.1001/jamaoto.2020.4837 – early tracheostomy not worse than late, no transmissions to HCWs.

Management of Pericardial Effusions – When to Intervene, and How?

  • Dhruvin H. Hirpara
  • Najib Safieddine


Pericardial effusions are often classified based on size, with small effusions (50-100mL) measuring less than 10mm in thickness, moderate effusions (100-500mL) measuring 10-20mm in thickness, and large effusions (>500mL) measuring more than 20mm in thickness on echocardiographic assessment.1 The timing (acute, subacute, chronic when lasting >3 months), distribution (circumferential or loculated), and hemodynamic impact (none, cardiac tamponade, or effusive-constrictive) are other important clinical considerations in the management of pericardial effusions.2-4 Optimal therapy often involves medical treatment of the underlying etiology of the effusion.3 However, pericardial fluid drainage (via pericardiocentesis or surgery) may be required for large, recurrent, loculated, and/ or hemodynamically significant effusions. Effusions with unclear etiology may also mandate pericardial fluid sampling and/or pericardial biopsy for diagnostic purposes.4,5

We review indications for intervention and discuss the role of percutaneous versus surgical drainage. The below recommendations and associated algorithm (Figure 1, Table 1) are derived from a thorough review of the literature, including clinical practice guidelines and expert consensus.1-10


1. Percutaneous pericardiocentesis (echocardiography, fluoroscopy, or CT guided) is recommended in the following cases:

    • Patients with evidence of hemodynamic compromise (i.e. cardiac tamponade)
    • Symptomatic moderate to large pericardial effusions non-responsive to medical therapy
    • Patients suspected to have tuberculous, neoplastic or bacterial pericarditis
    • Patients with large (>20mm on echocardiography in diastole) idiopathic chronic (>3months) pericardial effusions to minimize the risk of overt cardiac tamponade

2. Percutaneous pericardiocentesis (echocardiography, fluoroscopy, or CT guided) with an indwelling pericardial catheter is recommended:

    • In patients with neoplastic pericardial involvement and longer expected survival (>3 months) to minimize the risk of fluid re-accumulation. Duration of catheter drainage should be guided by patient’s clinical condition and prognosis.

3. Pericardiodesis with intra-pericardial instillation of anti-neoplastic and sclerosing agents is NOT recommended due to risk of constrictive pericarditis and paucity of evidence demonstrating benefit over prolonged catheter drainage alone.

4. Percutaneous balloon pericardiotomy (the balloon allows for dilation of the pericardiotomy if needed for rewiring of a larger bore catheter) is recommended as an option in patients with malignant pericardial effusions, reduced life expectancy (<3 months) and/or prohibitive surgical risk

5. Surgical pericardiotomy and drainage is recommended in the following cases:

    • Patients with “surgical tamponade” (i.e. secondary to aortic dissection or post-infarction myocardial rupture) due to risk of exacerbating the dissection or rupture after rapid pericardial decompression and restoration of systemic arterial pressure with percutaneous techniques.
    • Recurrent and/or loculated pericardial effusions
    • If biopsy of the pericardium is required for diagnostic purposes
    • Patients on anticoagulant therapy, or those with uncorrected coagulopathy, and/or thrombocytopenia (platelet count < 50,000/mm3).

6. Surgical approach: both VATS and subxiphoid pericardial window have similar efficacy. Choice of surgical technique may vary based on surgeon experience, and patient factors including hemodynamic status (positioning and need for single-lung ventilation for the VATS approach may impede emergent access), as well as the need to perform concurrent procedures such as lung/pleural biopsies or drainage of concurrent pleural effusions (facilitated by a VATS approach).

Abbreviations: CT, Computed Tomography; VATS, Video-Assisted Thoracic Surgery

Table 1: Indications for Percutaneous Pericardiocentesis and Surgical Pericardiectomy

*secondary to aortic dissection or post-infarction myocardial rupture



  1. Imazio M, Adler Y. Management of pericardial effusion. Eur Heart J. 2012;34(16): 1186-97.
  2. Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC). Eur Heart J. 2015;42(7):2921–64.
  3. Sagrista-Sauleda J, Merce A, Soler-Soler J. Diagnosis and Management of Pericardial Effusion. World J Cardiol. 2011;3(5):135-43.
  4. Soler-Soler J, Sagrista-Sauleda J, Permanyer-Miralda G. Management of Pericardial Effusion. Heart 2001;86: 235-240.
  5. Campione A, Cacchiarelli M, Ghiribelli C, et al. Which treatment in pericardial effusion? J Cardiovasc Surg 2002;43: 735-9.
  6. Imazio M, Mayosi B, Brucato A, et al. Triage and management of pericardial effusion. J Cardiovasc Med 2010;11(12): 928-35.
  7. Vakamudi S, Ho N, Cremer P. Pericardial Effusions: Causes, Diagnosis, and Management. Prog Cardiovasc Dis 2017;59(4): 380-88.
  8. Ristic A, Seferovic P, Maisch B. Management of Pericardial Effusion. Herz 2005;30: 144-50.
  9. Swanson N, Mirza I, Wijesinghe N, et al. Primary percutaneous balloon pericardiotomy for malignant pericardial effusion. Catheter Cardiovasc Interv 2008;71(4): 504-7.
  10. Liberman M, Labos C, Sampalis J, et al. Ten-Year Experience with Non-traumatic Pericardial Effusions. Arch Surg 2005;140(2): 191-5.

Management of Empyema

  • Basil Nasir
  • Najib Safieddine


Empyema, or pus in the pleural space, in its various clinical manifestations and stages is a common occurrence that thoracic surgeons are frequently asked to manage. This set of recommendations aims to provide an approach to the management of empyema based on best current evidence in the literature and established guidelines from other international bodies. The recommendations are limited to cases of acute empyema (not post-operative cases such as post lung resection empyema). Parapneumonic effusion secondary to pneumonia remains the most common precursor to empyema. Empyema remains a significant cause for hospitalization, patient morbidity and resultant health care costs. The recommendations will focus on reaffirming related definitions, necessary investigations, and appropriate interventions, with specific attention paid to the role of fibrinolytics and indications for surgical intervention (minimally invasive or via thoracotomy).


  • Parapneumonic effusion (Stage 1), whereby the fluid is a free-flowing exudate characterized by a low white cell count, an LDH level less than half that in the serum, normal pH and glucose levels and bacterial organisms.
  • Fibrinopurulent stage (Stage 2), whereby there is bacterial translocation across the damaged lung epithelium or direct contamination of the pleural space from an external source. This bacterial infection stimulates an immune response, creating fibrin deposition and loculations in the fluid. At this stage, fluid analysis may identify the characteristic finding of a pH < 7.1, LDH >1000, Glucose < 40 mg/dl, gram stain +/-.
  • Chronic organizing stage (Stage 3), with scar tissue (pleural cortex) formation. In the later stages, a solid fibrous pleural cortex begins to form, which may encase the lung, preventing re-expansion, impairing lung function and creating a persistent pleural space with continuing potential for infection.


There are two primary objectives to treatment of empyema: (1) complete drainage and evacuation of all infected material in the pleural space and (2) liberation of the lung from the exudative peel, therefore allowing full lung expansion. While there are advantages and disadvantages to the different treatment modalities, the main goal is to achieve both objectives, as this will result in the most optimal outcomes for empyema treatment.

  1. Thoracentesis:
    • In the context of pneumonia or unexplained sepsis, investigation of a pleural effusion should start with a diagnostic thoracentesis in order to differentiate between the presence of a complicated parapneumonic effusion requiring chest tube drainage and a simple parapneumonic effusion where the pneumonia may resolve with antibiotics alone.
  2. Tube thoracostomy:
    • Chest tube insertion (image guided or otherwise) is a useful initial treatment for early stage empyema with minimal septations with or without tube flushing and on-going monitoring with CT imaging to ensure resolution of collection. Lack of resolution should prompt consideration of further intervention.
  3. Fibrinolysis:
    • Although the use of intrapleural fibrinolysis remains controversial in terms of clear evidence, for those patients who are at higher surgical risk and relatively earlier (Stage 1 and to some degree stage 2) fibrinolytic therapy (tPA and DNase) has been reported to have very good results in well selected patients.
  4. Surgical intervention:
    • Surgical management with or decortication is the most definitive means of treating empyema of all stages. However, it is also the most invasive approach, and may not be necessary in early stage empyema. If complete evacuation of infected material and lung expansion can not be achieved by less invasive means, then surgical management is indicated.
    • There is a role for thoracoscopy in the management of empyema. Whether performed by thoracoscopy or thoracotomy, the two objectives of empyema treatment should be sought. If this is possible with thoracoscopy, then it is reasonable to perfume the procedure in that fashion. However, if the infected material cannot be removed or the lung can not be re-expanded completely, then conversion to thoracotomy is encouraged in order to achieve these two objectives.
    • Finally, if it is impossible to evacuate the pleural space of all infected material or lung expansion can not be achieved with a decortication, then one must consider prolonged drainage. This can be achieved in a closed (empyema tube) or in an open fashion (open thoracic window).


Guidelines for Enhanced Recovery After Lung Surgery (ERAS)

Armen Parajian1

1 Department of Thoracic Surgery, Lakeridge Health Oshawa and The Durham Regional Cancer Center, Oshawa ON, Canada


Enhanced Recovery After Surgery, or ERAS, can be considered an evidence-based treatment paradigm for all surgical patients. It’s fundamental tenets are the development and systematic implementation of evidence-based perioperative care protocols. The goal of which is to optimize patient outcomes, decreased morbidity and decrease length of stay. There has been considerable interest in the development of these protocols for nearly two decades with Colorectal Surgery being one of the original champions of the paradigm. There is an abundance of data linking ERAS protocols with improved patient outcomes. This is borne out in many meta-analyses albeit with a significant amount of heterogeneity in the data. “Fast Track” protocols in lung surgery have been described by many authors and more recently a large review by the ESTS and ERAS societies synthesized some of this data into a highly-effective and streamlined recommendations. Continued efforts are needed to generate high level data examining each facet of perioperative care, to solidify any lessons derived there-from.


The following are evidence-based perioperative care recommendations endorsed by the CATS best practice committee for an Enhanced Recovery After Surgery (ERAS) pathway in patients undergoing major pulmonary resection. These recommendations are in line with the recommendations described by the ESTS and ERAS societies however recommendations for which data was less clear, or not relevant in the Canadian clinical context, were modified or excluded. Where possible the data were independently reviewed for quality and relevance, particularly in areas known to have a paucity of quality data. As this document in itself is not based on an exhaustive systematic review of the literature therefore the strength of evidence and grades of recommendation will not be mentioned.

Preoperative phase

Perioperative nutrition

  • Patients should be screened preoperatively for nutritional status and weight loss
  • Oral nutritional supplements should be given to malnourished patients

Smoking cessation

  • Smoking cessation should strongly be encouraged including the use of smoking cessation programs
  • Cessation greater than 4 weeks pre-op is associated lower post operative pulmonary complications

Alcohol dependency management

  • Alcohol consumption (in alcohol abusers) should be avoided for at least 4 weeks before surgery

Pulmonary ‘prehabilitation’

  • Patients with COPD should have their pulmonary function medically optimized by a multidisciplinary team that includes a respirologist


Preoperative fasting and carbohydrate treatment

  • Clear fluids should be allowed up until 2 h before the induction of anaesthesia and solids until 6 h before induction of anaesthesia
  • Oral carbohydrate loading reduces postoperative insulin resistance and can be considered (data is extrapolated from abdominal surgery population)

Preanaesthetic medication

  • Routine administration of sedatives to reduce anxiety preoperatively should be avoided

Perioperative phase

Venous thromboembolism prophylaxis

  • Patients undergoing major lung resection should be treated with pharmacological and mechanical VTE prophylaxis
  • Patients at high risk of VTE may be considered for extended prophylaxis with LMWH for up to 4 weeks although data are lacking in the Thoracic patient population and trials are forthcoming

Antibiotic prophylaxis and skin preparation

  • Routine intravenous antibiotics should be administered within 60 min of, but prior to, the skin incision
  • Hair clipping is recommended if hair removal is required
  • Chlorhexidine–alcohol is preferred to povidone-iodine solution for skin preparation

Preventing intraoperative hypothermia

  • Maintenance of normothermia with convective active warming devices should be used perioperatively
  • Continuous measurement of core temperature for efficacy and compliance is recommended

Standard anaesthetic protocol

  • Lung-protective strategies should be used during one-lung ventilation
  • A combination of regional and general anaesthetic techniques should be used
  • Short-acting volatile or intravenous anaesthetics, or their combination, are equivalent choices

PONV control

  • A multimodal pharmacological approach for PONV prophylaxis is indicated in patients at moderate risk or high risk

Regional anaesthesia and pain  relief

  • Regional anaesthesia (ie intercostal nerve block, paravertebral block or pleural catheter) is recommended with the aim of reducing postoperative opioid use
  • Paravertebral blockade provides equivalent analgesia to epidural anaesthesia
  • A combination of acetaminophen and NSAIDs should be administered regularly to all patients unless contraindications exist
  • Ketamine should be considered for patients with pre-existing chronic pain
  • Dexamethasone may be administered to prevent PONV and reduce pain

Perioperative fluid management

  • Very restrictive or liberal fluid regimes should be avoided in favour of euvolemia
  • Balanced crystalloids are the intravenous fluid of choice and are preferred to 0.9% saline High Strong
  • Intravenous fluids should be discontinued as soon as possible and replaced with oral fluids and diet

Atrial fibrillation prevention

  • Patients taking b-blockers preoperatively should continue to take them in the postoperative period
  • Magnesium supplementation may be considered in magnesium deplete patients

Surgical technique: thoracotomy

  • If a thoracotomy is required, a muscle-sparing technique should be performed
  • Intercostal muscle- and nerve-sparing techniques are recommended
  • Reapproximation of the ribs during thoracotomy closure should spare the inferior intercostal nerve

Surgical technique: minimally invasive surgery

  • A VATS approach for lung resection is recommended for early-stage lung cancer
  • Minimally invasive techniques are feasible in more advanced disease (post-neoadjuvant, sleeve resections) but their use should be limited to surgeons with experience in such techniques

Postoperative phase

Chest drain management

  • The routine application of external suction should be avoided Low Strong
  • Chest tubes should be removed even if the daily serous effusion is of high volume (up to 450 ml/24 h)
  • A single tube should be used instead of 2 after anatomical lung resection

Urinary drainage

  • In patients with normal preoperative renal function, a transurethral catheter should not be routinely placed for the sole purpose of monitoring urine output
  • It is reasonable to place a transurethral catheter in patients with thoracic epidural anaesthesia

Early mobilization and adjuncts to physiotherapy

  • Patients should be mobilized within 24 h of surgery Low Strong

Selected References

  • Rogers LJ, Bleetman D, Messenger DE, Joshi NA, Wood L, Rasburn NJ 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;155:1843–52.
  • Cerfolio RJ, Pickens A, Bass C, Katholi C. Fast-tracking pulmonary resec- tions. J Thorac Cardiovasc Surg 2001;122:318–24.
  • Das-Neves-Pereira JC, Bagan P, Coimbra-Israel AP, Grimaillof-Junior A, Cesar-Lopez G, Milanez-de-Campos JR et al. Fast-track rehabilitation for lung cancer lobectomy: a five-year experience. Eur J Cardiothorac Surg 2009;36:383–91; discussion 391.
  • Muehling BM, Halter GL, Schelzig H, Meierhenrich R, Steffen P, Sunder- Plassmann L et al. Reduction of postoperative pulmonary complications after lung surgery using a fast track clinical pathway. Eur J Cardiothorac Surg 2008;34:174–80.
  • Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg 2008;248:189–98
  • Navarro LH, Bloomstone JA, Auler JO, Cannesson M, Rocca GD, Gan TJ et al. Perioperative fluid therapy: a statement from the international Fluid Optimization Group. Perioper Med 2015;4:3.
  • Fiore JF, Bejjani J, Conrad K, Niculiseanu P, Landry T, Lee L et al. Systematic review of the influence of enhanced recovery pathways in elective lung resection. J Thorac Cardiovasc Surg 2016;151:708–15.e6.
  • Bjerregaard LS, Jensen K, Petersen RH, Hansen HJ. Early chest tube re- moval after video-assisted thoracic surgery lobectomy with serous fluid production up to 500 ml/day. Eur J Cardiothorac Surg 2014;45:241–6.
  • Frendl G, Sodickson AC, Chung MK, Waldo AL, Gersh BJ, Tisdale JE et al. 2014 AATS guidelines for the prevention and management of periopera- tive atrial fibrillation and flutter for thoracic surgical procedures. J Thorac Cardiovasc Surg 2014;148:e153–93.
  • Li S, Zhou K, Che G, Yang M, Su J, Shen C et al. Enhanced recovery pro- grams in lung cancer surgery: systematic review and meta-analysis of randomized controlled trials. Cancer Manag Res 2017;9:657–70
  • Zaouter C, Ouattara A. How long is a transurethral catheter necessary in patients undergoing thoracotomy and receiving thoracic epidural analgesia? Literature review. J Cardiothorac Vasc Anesth 2015;29: 496–501.
  • Allen MS, Blackmon SH, Nichols FC, Cassivi SD, Harmsen WS, Lechtenberg B et al. Optimal timing of urinary catheter removal after thoracic operations: a randomized controlled study. Ann Thorac Surg 2016;102:925–30.

Preoperative Physiologic Assessment Prior to Pulmonary Resection

Simon Turner1, Serena Shum2, Tim van Haaften2

1Thoracic Surgery, University of Alberta

2Anesthesiology, University of Alberta


Anatomic lung resection is the gold standard treatment for early stage lung cancer but may be associated with significant risks of postoperative morbidity and mortality. To reduce the incidence of adverse events, patients should be carefully evaluated prior to any anatomic lung resection. This evaluation should take into account the extent of the planned resection, the patient’s baseline pulmonary and cardiac function as well as any other comorbidities, including factors such as frailty and sarcopenia. Modifiable risk factors, such as coronary artery disease, may be amenable to intervention to allow resection with improved outcomes.


  1. All patients prior to anatomic lung resection should undergo pulmonary function testing with spirometry and diffusion capacity.
    • Patients with predicted post-operative FEV1 and/or DLCO below 40% predicted should be considered above average risk for postoperative complications and death. Post-operative FEV1 and/or DLCO below 30% should be considered exceptionally high risk, and either below 20% considered prohibitive risk.
    • High risk patients may still be candidates for resection with acceptable outcomes, but consideration should be given to further stratification of such patients with testing such as low-tech exercise testing (e.g. shuttle walk test, stair climb), cardiopulomary exercise testing (CPET aka VO2 max) and/or quantitative VQ scan (Fig. 1).

    • Low tech exercise testing such as stair climb, shuttle walk test and 6-minute walk test may be useful to supplement clinical decision making, especially in circumstances where CPET is not readily available. Correlation of these tests with more accurate measures of pulmonary function may vary, especially when performed in non-standardized settings.
    • Patients who may require a pneumonectomy are subject to more significant physiologic impacts of surgery and should undergo more thorough testing than other patients. An echocardiogram to rule out pulmonary hypertension and cardiac dysfunction should be considered. A quantitative VQ scan can give a better estimate of post-operative pulmonary function than predictions based on the number of bronchopulmonary segments being resected.

2. All patients prior to anatomic lung resection should be assessed clinically for cardiac risk factors.

    • The use of a standardized risk score such as the Thoracic Revised Cardiac Risk Index is recommended (Table 1). A ThRCRI score of 2 or greater should be considered high risk.
    • ThRCRI Risk Factor Weighted Score
      Renal failure* 1
      Ischemic heart disease 1.5
      Cerebrovascular disease 1.5
      Pneumonectomy 1.5

      Table 1. Thoracic Revised Cardiac Risk Index (ThRCRI). *serum creatinine >177umol/L

    • Patients at high risk for cardiac complications, especially those undergoing major resections such as pneumonectomy, should have more formal cardiac testing, including echocardiography or be referred to a cardiologist for consideration of angiography or cardiac stress testing.
    • Patients should be assessed for their risk of post-operative atrial fibrillation and managed accordingly. The question of atrial fibrillation prophylaxis is beyond the scope of this review.
    • The role of prehabilitation for patients deemed at high risk of post-operative complications is beyond the scope of this review.

3. Age is a marker of potential increased risk but should not be the only reason a patient is denied potentially curative surgery.

    • Healthy patients at advanced age may be candidates for anatomic lung resection.
    • All patients should have their comorbidities assessed, ideally including the use of a standardized scale such as the Charlson Comorbidity Index.
    • Other measures of increased operative risk, such as frailty and sarcopenia should be taken into consideration.

4. Quality of life (current and expected short- and long-term post-operative) should be considered when discussing risks and benefits of surgery compared to other treatment options.

5. The smoking status of all patients undergoing lung surgery should be assessed, and recommendations made to assist patients in smoking cessation. See the CATS recommendation on this topic for more detail.

6. All patients with questionable operability and/or resectability should be reviewed by a dedicated multidisciplinary oncology team.

7. All patients prior to anatomic lung resection should be assessed by an anesthesiologist for further risk stratification and preoperative optimization.

Key References

  1. Physiologic evaluation of the patient with lung cancer being considered for resectional surgery. Diagnosis and Management of Lung Cancer, 3rd Ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest, 2013;143:e166s-e190s.
  2. ERS/ESTS clinical guidelines on fitness for radical therapy in lung cancer patients (surgery and chemo-radiotherapy). European Respiratory Journal, 2009;34:17-41.
  3. British Thoracic Society guidelines on the radical management of patients with lung cancer. Assessment of the risks of surgery. Thorax, 2010;65(Suppl III):iii11-iii15.

ILD: Indications for Surgical Lung Biopsy and Risk Stratification

  • Authors: Laura Donahoe & Sean McFadden
  • Reviewer: Anne-Sophie Laliberte & Andrew Seely


Interstitial Lung Diseases (ILDs) are a group of heterogeneous diseases of the lung, with variable clinical features, treatment and prognosis. The diagnosis of ILD is based on clinical features, temporal behaviour of symptoms and findings on high-resolution computed tomography (HRCT).  In patients with clinical features of idiopathic pulmonary fibrosis (IPF) and findings of usual interstitial pneumonia (UIP) on HRCT, a diagnosis of IPF can be made without histologic confirmation as long as alternative causes of ILD have been ruled out.   These two factors are sometimes not sufficient to make a diagnosis, though, such as in cases with atypical findings on HRCT [1].  Although the list of ILDs is extensive and many specific diagnoses are treated quite similarly, for some ILDs it is very important to establish a diagnosis prior to initiating treatment.  For patients with IPF, the PANTHER trial from 2011 showed increased mortality with prednisone, azathioprine and N-acetylcysteine NAC  [2].  Also, with the introduction of the anti-fibrotic pirfenidone in 2012 came the requirement from Health Canada to show histologic proof of IPF [3].

Technically, a surgical lung biopsy (SLB) is a very straightforward procedure.  The HRCT is reviewed to ensure that biopsies are not taken from the most severely affected areas of the lung, especially areas of honeycombing, as the histology from these areas usually shows end-stage fibrosis and is non-diagnostic.  Two or more biopsies are taken from different lobes of the lung as there can be discordant findings throughout the same lung [1].  The surgery can be performed by VATS or open approach, with VATS preferred when possible.

Although not a particularly technically challenging procedure, the concern about performing SLB comes from the relatively high mortality rates associated with the surgery.  There are varying reports of mortality rates post SLB, with rates as high as 70% in historical reports [1].  A number of recent studies have re-examined mortality rates, and have found large differences based on whether the procedure is elective (1.7%) or emergent (16%)(see Figure 1)[4].  Fisher et al found that hospitals with higher SLB volume had lower mortality rates, but in examining the data they found that the difference was more related to patient factors and not technical factors [3].  Older age, male sex, non-elective procedure, home oxygen use, higher Charlson Comorbidity Index, and open rather than VATS approach have been shown to be associated with higher mortality in a number of studies [3,4].In a review of all SLB performed in the United States over an 11 year period, a complication rate of 30% was found for elective procedures.  Thus, patient selection is key in performing SLB.

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Follow Up and Surveillance of Esophageal Cancer Treated With Curative Intent

  • Authors: Anne-Sophie Laliberté, MD. FRCSC
  • Reviewers : Brian Johnston and Andrew Seely

Society recommendations

Based on society recommendations and expert consensus, there is no high level of evidence to guide in the development of algorithms.

The majority of recurrences (44%)1 occur in the first two years following cancer treatment, but some have been described up to more than 5 years after. (NCCN)

In case of squamous cell carcinoma, we need to consider the possibility of metachronous cancer.

Incidence of esophageal cancer in Canada:

In 2019, Canadian Cancer Society estimate:

  • 2,300 Canadians will receive a diagnosis of esophageal cancer
  • 2,200 Canadians will die of esophageal cancer

Society recommendations reviewed:

Canadian, American, and French guidelines and recommendations were reviewed.

  • National Comprehensive Cancer Network (2019)
  • Canadian Cancer Society (2019)
  • NICE guidelines (2018)
  • Cancer Care Ontario
  • Thesaurus recommendations (2016)
  • ESMO Clinical Practice Guidelines (2013)
  • French guidelines OncoLogik (2019)

Follow up and surveillance of surgical patient by stage and type of resection:

Clinical and Physical examination:

  • Clinical and physical examination is recommended for all stages, the frequency is variable between the different society recommendations.
  • Follow up at 3, 6, 12, 18, 24 months and then annually.
  • Smoking cessation is recommended
  • Unscheduled evaluation if patient become symptomatic


Early Stage – Stage I:


  • EMR: Endoscopic mucosal resection
  • RFA: Radiofrequency ablation
  • ESD: Endoscopic submucosal resection


Advanced Stage – Stage II&III:


Summary of recommendations for endoscopic and radiologic surveillance after esophageal cancer resection
Stage Endoscopic surveillance Radiologic surveillance
Stage I – Recommended for local resection only: every 3months for one year, then every 6 months for the second year and then annually

– Recommended if residual Barrett’s esophagus

– Treatment of persistent Barrett’s esophagus is recommended

– Radiologic surveillance isn’t recommended for Tis and T1a

– Annual CT-scan for 3 years is recommended for pT1b

Stage II & III – No evidence to recommend Endoscopic – CT-scan every 6 months for 2 years then annually


Summary of recommendations for endoscopic and radiologic surveillance after definitive chemoradiation for esophageal cancer
Stage Endoscopic surveillance Radiologic surveillance
Stage I – Endoscopic surveillance every 3-6 months for 2 years then annually – CT-scan every 6-9months if patient candidate for salvage esophagectomy
Stage II & III – Endoscopic surveillance every 3-6 months for 2 years, then every 6 months for the third year then clinically/ annually. – CT-scan every 6 months for the first 2 years if patient candidate for salvage esophagectomy, then clinically/annually.

Lifelong follow up is recommended.



  • National Comprehensive Cancer Network (2019)
  • Canadian Cancer Society (2019)
  • Cancer Care Ontario
  • Thesaurus recommendations – Thésaurus National de Cancérologie Digestive (publish 23/09/2016)
  • French guidelines OncoLogik ( Esophageal adenocarcinoma :publish 14/05/2019 and Squamous cell carcinoma: publish 28/06/2018)


  1. Du Rieu M.C., Filleron T., Beluchon B. et al.Recurrence risk after Ivor Lewis oesophagectomy for cancer. Journal of Cardiothoracic Surgery 2013,8:213
  2. Mariam Naveed and Nisa Kubilium. Endoscopic Treatment of Early-Stage Esophageal Cancer. Curr Oncol Rep (2018) 20:71.
  3. Sharma, D. Katzka, N. Gupta et al. Quality Indicators for the Management of Barrett’sEsophagus, Dysplasia, and Esophageal Adenocarcinoma: Internation Consensus Recommendations from the American Gastroenterological Association Symposium. Gastroenterology. 2015;149(6):1599-1606.
  4. Stahk, C. Mariette, K. Haustermans et al. Oesophageal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow up. Ann Oncol 2016;27 (suppl.5):v50-57

Guideline on the Prescription and Management of Opioids After Elective Ambulatory Thoracic Surgery


Although the extent of contribution of post-surgical opioid prescription to the opioid crisis in Canada (and worldwide) remains a matter of debate, it is well established that opioids are significantly over prescribed. Some studies have shown that more than half of the individuals that misuse narcotics get them from friends or family. Indeed, left over pills are a major source of diversion, use and misuse. Only 5% – 60% of prescribed narcotics post-surgery are actually used. According to Health Canada, more than 9,000 people lost their lives in Canada between January 2016 and June 2018 related to opioids. Many individual institutions in different surgical disciplines have already adopted initiatives to minimize opioid over prescription. The committee therefore felt it is incumbent on CATS to contribute to the national debate and effort to address this tragic epidemic where it can best have an impact: the daily practice of post thoracic surgery narcotic prescription. Although thoracic surgery specific data is lacking, consensus statements and recommendations for procedures with postoperative pain commensurate with that of most common thoracic surgical procedures are available. The committee therefore relied on this data (referenced below) particularly consensus guidelines adopted by the U of T task force on post-surgery opioid use that included province wide input. Specialty specific guidelines utilized at large centres of excellence were also reviewed.

The ultimate goal is good daily function and not a “pain free” postoperative course.

Many studies have shown that patients who have minimally invasive procedures (VATS and laparoscopy) have less pain both early post-operatively and in the long term (1,2).  It is therefore reasonable to manage post-operative pain based on surgical approach.  For surgical approaches that may be more prone to increased acute and chronic post-operative pain (e.g. extra-pleural pneumonectomy, Pancoast tumour resection, clamshell incision), patients may require higher doses of analgesia.  In such patients with more risk of developing post-operative pain, consideration should be given to adding adjuncts such as gabapentin to improve post-operative pain management and (3-6).

Given the gravity of the opioid crisis nationally, and despite the availability of level one evidence, the BP committee believes that sufficient experiential evidence, expert opinion, and guidelines adopted by centres of excellence for the committee to make recommendations.

Target Population

These recommendations apply to adult patients undergoing typical ambulatory elective thoracic surgery, including lung and foregut procedures but not including less common procedures or procedures only performed in specialized centers, such as lung transplantation, pulmonary thromboendarterectomy, en-bloc spinal resection, and extra-pleural pneumonectomy.

Intended Users

This recommendation is intended for use by health care providers involved in the management and care of thoracic surgical patients including surgeons, allied health professionals, anesthesiologists including the pain team, pharmacists and trainees.


1. Opioid-containing tablets to be prescribed at discharge

1.1.  Following thoracic procedures of a minimal nature, often not requiring general anaesthesia, such as thoracentesis, chest tube or Tenchkoff catheter insertion, Patients should be prescribed 10 opioid-containing tablets.

1.2   Following VATS or minimally invasive surgery, patients discharged from hospital less than 7 days following surgery should be prescribed 15 opioid-containing tablets.

1.3   Following open thoracic surgery (thoracotomy/sternotomy/thoracoabdominal), patients discharged from hospital less than 7 days following surgery should be prescribed 30 opioid-containing tablets.

1.4.  For patients who are discharged on POD >7, regardless of the type of operation, the number of opioid-containing tablets prescribed should be based on the number of opioid-containing tablets/medications that were prescribed in hospital in the 24 hours prior to discharge and other patient-specific information about their post-operative course.

1.4.1. Patients who took no tablets/received no opioids should not be prescribed any tablets.

1.4.2. Patients who took 1-3 tablets/24hrs should be prescribed 15 tablets at discharge.

1.4.3. Patients who took 4+ tablets/24 should be prescribed 30 tablets at discharge.

1.5.  Patients should be prescribed the following opioid-containing tablets:

Hydromorphone 2mg, Q4H PRN.

1.6.  In addition to or in the absence of opioid-containing tablets, patients should be discharged with the following adjunct pain medications:

1.6.1. Acetaminophen 1g PO q8hrs around the clock for 5 days and,

1.6.2. Ibuprofen 400 mg q8hrs around the clock for 3 days (with appropriate assessment of risk factors and patient education).  Other NSAID may be substituted.

Suggested prescription sets:

(for opioid naïve patients)

Procedure Minimally Invasive Surgery (MIS) Open procedures*
LOS < 7days (Uncomplicated)  



Hydromorphone 2mg, Q4H PRN (15 tabs)

Acetaminophen 1g PO q8h (not PRN) 5days

Ibuprofen 400 mg q8h for 3 days**






Hydromorphone 2mg, Q4H PRN (30 tabs)

Acetaminophen 1g PO q8hrs (not PRN) 5days

Ibuprofen 400 mg q8hrs for 3 days**


LOS >7 days Use prescription as above BUT number of opioid-containing tablets prescribed should be based on the number of opioid-containing tablets/medications that were prescribed in hospital in the 24 hours prior to discharge and other patient-specific in-hospital course information.

·         If no opioids being given at time of discharge then none should be prescribed

·         If 1-3 tabs are being given per 24hrs then 15 tabs should be prescribed

·         If 4+ tabs are being given per 24hrs then 30 tabs should be prescribed


* Does not include: Pancoast Tumour Resection, Extrapleural pneumonectomies

** Check for increased risk of UGI bleeding (e.g. pts on prednisone, anticoagulate, …)

Ongoing Narcotic Requirements

If the patient has ongoing narcotic requirements that are beyond the initial discharge prescription given, consideration should be given to referring the patient to a local chronic pain management group.

2. Risk factors for chronic opioid use perioperatively

2.1 Preoperatively, amongst the typical thoracic surgery population, the following patients may be at increased risk for postoperative opioid misuse:

  • Patients with a history of, or concurrent anxiety and/or depression
  • Patients with high levels of pain catastrophizing
  • Patients with a chronic pain diagnosis
  • Preoperative history of drug and/or alcohol use disorder
  • Patients using benzodiazepines and selective serotonin reuptake inhibitors

2.2 Patients seeking >1 refill prescription

2.3 For patients above that are linked with a higher risk of opioid abuse/overuse, involvement of a specialized pain service should be considered. Careful communication and involvement of family/referring physicians should be included if a second refill is requested.

3. Safe disposal of unused opioids

3.1  When prescribing medications, patients should be encouraged to store opioid medications safely out of the reach of children and preferably in a locked location.

3.2  Patients and their families should be provided with education about the proper disposal of unused opioid medications prior to discharge. Patients may return unused medications to pharmacies. Patients may also dispose of medications at home by:

3.2.1  Removing the medications from their original containers, scratching out all identifying information on the prescription label to help protect patient’s identity and the privacy of their personal health information.

3.2.2  Mixing the medications in something unappealing, such as used coffee grounds or kitty litter. This makes the drug less attractive to children and pets, and unrecognizable to people who go through the trash seeking drugs. Then place this mixture in a closed bag, empty can or other sealed container to prevent the drug from leaking or breaking out of a garbage bag.

4. Preoperative patient education

4.1  A University of Toronto patient education brochure agreed to by all Divisions covering expectations for post-operative pain, risk of addiction, and proper disposable is in development and will be circulated when completed.

Suggested reading

  1. Ohbuchi T, Morikawa T, Takeuchi E, Kato H. Lobectomy: video-assisted thoracic surgery versus posterolateral thoracotomy. Jpn J Thorac Cardiovasc Surg.1998 Jun;46(6):519-22.
  2. Kwon ST, Zhao L, Reddy RM, Chang AC, Orringer MB, Crummett CM, Lin J. Evaluation of acute and chronic pain outcomes after robotic, video-assisted thoracoscopic surgery, or open anatomic pulmonary resection. J Thorac Cardiovasc Surg.2017 Aug;154(2):652-659.
  3. Hah J, Mackey SC, Schmidt P, McCue R, Humphreys K, Trafton J, Efron B et al. Effect of Perioperative Gabapentin on Postoperative Pain Resolution and Opioid Cessation in a Mixed Surgical Cohort: A Randomized Clinical Trial. JAMA Surg.2018 Apr 1;153(4):303-311.
  4. Ucak AOnan BSen HSelcuk ITuran AYilmaz AT. The effects of gabapentin on acute and chronic postoperative pain after coronary artery bypass graft surgery. J Cardiothorac Vasc Anesth.2011 Oct;25(5):824-9.
  5. Solak OMetin MEsme HSolak OYaman MPekcolaklar AGurses AKavuncu V. Effectiveness of gabapentin in the treatment of chronic post-thoracotomy pain. Eur J Cardiothorac Surg.2007 Jul;32(1):9-12.
  6. Sihoe AD1Lee TWWan IYThung KHYim AP.The use of gabapentin for post-operative and post-traumatic pain in thoracic surgery patients. Eur J Cardiothorac Surg.2006 May;29(5):795-9.
  7. Opioid Use After Discharge in Postoperative Patients A Systematic Review Adina E. Feinberg, MDCM, Tyler R. Chesney, MD, MSc, Sanjho Srikandarajah, MD, FRCPC,y Sergio A. Acuna, MD, PhD,z and Robin S. McLeod, MD, FRCSC, FACS,z on behalf of the Best Practice in Surgery Group

Recommendation for the Management of Malignant Pleural Effusions

 Daniel Jones, Laura Donahoe, Najib Safieddine


Malignant pleural effusions (MPE) is a common diagnosis in patients with late stage cancer. The majority of patients experience some degree of breathlessness, which has profound effects on their remaining quality of life. Indeed, life expectancy is severely reduced with an MPE diagnosis portending a median survival from 3 to 12 months. The optimal management of MPE remains controversial, with various therapeutic options available. For symptomatic patients these include repeat therapeutic thoracentesis, drainage with an indwelling pleural catheter (IPC), placement of chest tube with bedside talc pleurodesis or other sclerosing agent, and VATS pleurodesis. Ultimately, the goal of intervention is palliation of symptoms for best possible quality of life.


The most recent evidence-based guidelines for the management of MPE are the combined results of a collaboration between American Thoracic Society (ATS), Society of Thoracic Surgeons (STS), and Society of Thoracic Radiology (STR). Given the poor prognosis associated with a diagnosis of MPE, management must be guided by a patient-centered approach. This includes intervening only when patients develop symptoms (i.e. breathlessness), and with priority given to minimally invasive interventions and limited number of interventions.

For patients with known/suspected MPE, we recommend following the ATS/STS/STR clinical practice guideline (Figure 1).

Summary of Evidence

In an attempt to summarize the best recommendations for management of MPE, the ATS/STS/STR addressed 7 clinical questions. The PICO format (Population, Intervention, Comparator and Outcomes) was used to develop pertinent questions, while the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) format and Evidence to Decision framework was used to answer each question.

PICO 1: In Patients with Known or Suspected MPE, Should Thoracic Ultrasound Be Used to Guide Pleural Interventions?

Ans: The panel recommends the use of ultrasound imaging to guide pleural interventions. (Conditional recommendation, very low confidence in estimate of effects).

PICO 2: In Patients with Known or Suspected MPE Who Are Asymptomatic, Should Pleural Drainage Be Performed?

Ans: The panel recommends withholding interventions on patients who remain asymptomatic from an MPE. (Conditional recommendation, very low confidence in estimate of effects).

PICO 3: Should the Management of Patients with Symptomatic Known or Suspected MPE Be Guided by Large-Volume Thoracentesis and Pleural Manometry?

Ans: The panel recommends performing large volume thoracentesis for a two-fold benefit: 1) to ascertain if MPE symptoms are related to effusion, and 2) to determine if lung is expandable (with the future possibility of pleurodesis as a treatment option).  (Conditional recommendation, very low confidence in estimate of effects).

PICO 4: In Patients with Symptomatic MPE with Known or Suspected Expandable Lung and No Prior Definitive Therapy, Should IPCs or Chemical Pleurodesis Be Used as First-Line Definitive Pleural Intervention for Management of Dyspnea?

Ans: The panel equally recommends the use of an indwelling pleural catheter (IPC) or chemical pleurodesis as first line for patients with symptomatic dyspnea.  (Conditional recommendation, low confidence in estimate of effects).

PICO 5: In Patients with Symptomatic MPE Undergoing Talc Pleurodesis, Should Talc Poudrage or Talc Slurry Be Used?

Ans: The panel equally recommends both Talc poudrage and Talc slurry as a therapeutic means for pleurodesis in symptomatic patients with expandable lungs. (Conditional recommendation, low confidence in estimate of effects).

PICO 6: In Patients with Symptomatic MPE with Nonexpandable Lung, Failed Pleurodesis, or Loculated Effusion, Should an IPC or Chemical Pleurodesis Be Used?

Ans: The panel recommends the use of an indwelling pleural catheter (IPC) over chemical pleurodesis in symptomatic patients with either a non-expandable lung, previous failed attempts at pleurodesis or a known loculated effusion. (Conditional recommendation, very low confidence in estimate of effects).

PICO 7: In Patients with IPC-associated Infection (Cellulitis, Tunnel Infection, or Pleural Infection), Should Medical Therapy Alone or Medical Therapy and Catheter Removal Be Used?

Ans: The panel recommends an initial trial of medical therapy (antibiotic treatment) in patients who develop IPC-associated infection. Should the initial trial of medical therapy not improve the clinical situation then the panel recommends removal of the IPC. (Conditional recommendation, very low confidence in estimate of effects).


  1. Li X, Ferguson M. (2014). Optimal Management of Symptomatic Malignant Pleural Effusion from: Difficult Decisions in Thoracic Surgery [electronic resource]: An Evidence-Based Approach – 3rd Edition, London
  2. Porcel JM, Gasol A, Bielsa S, Civit C, Light RW, Salud A. (2015). Clinical features and survival of lung cancer patients with pleural effusions. Respirology; 20:654–659.
  3. Clive  AO, Jones  HE, Bhatnagar  R, Preston  NJ, Maskell  N. (2016). Interventions for the management of malignant pleural effusions: a network meta‐analysis. Cochrane Database of Systematic Reviews, Issue 5
  4. Feller-Kopman DJ, Reddy CB, DeCamp MM, Diekemper RL, Gould MK, Henry T, et al. (2018). Management of Malignant Pleural Effusions. An Official ATS/STS/STR Clinical Practice Guideline. Am J Respir Crit Care Med; 198(7):839-849
  5. Guyatt G, Oxman AD, Akl EA, Kunz R, Vist G, Brozek J, et al. (2011). GRADE guidelines: 1. Introduction—GRADE evidence profiles and summary of findings tables. J Clin Epidemiol; 64:383–394.

Best Practice Recommendations on Enhanced Recovery after Thoracic Surgery (ERATS) for Esophagectomy

N Seyednejad, B. Johnson, G. Darling, A. Seely


Enhanced Recovery After Surgery aims to approach the care of surgical patients in a multimodal, multidisciplinary manner to in order to improve surgical outcomes and quality of care. Enhanced Recovery After Surgery (ERAS) programs are becoming the standard of practice in many surgical specialties throughout the world. Data on implementation of ERAS pathways at many centres have demonstrated improvements in clinical outcomes, patient satisfaction, and results in significant cost savings to the health care system. While ERAS has been widely implemented across the country in various oncological specialties, its uptake for ERATS procedures have been slower and extensively documented. Here, we outline the recommendations for ERATS in patients undergoing an esophagectomy.


  1. Nutritional assessment and optimization:
    • Early involvement / consultation of dietician
    • Use of pharmaco-nutrition when necessary: e.g. Ensure, Boost, or Resource TID
  1. Pre-rehabilitation and exercise regimen:
    • Recommendations for daily exercise: i.e. 45 minute walk daily
  1. Complete smoking cessation:
    • Any duration of time prior to surgery; at least 4 weeks prior to surgery highly advised
    • Nicotine replacement as necessary
  1. Discharge planning:
    • Managing postoperative expectations
    • Patient education i.e. information booklets, outlining what patients should expect in the immediate post operative settings (i.e. drains/chest tubes, analgesic management) and upon discharge
    • Early involvement of allied team members i.e. social worker, nurse educator
  1. Timing of Surgery:
    • 3-6 weeks following completion of chemotherapy
    • 6-10 weeks following the completion of radiation after chemoradiation
  1. Bowel Preparation:
    • Routine use of bowel prep not currently recommended
  1. Standardized best practice anesthesia:
    • Maintain euvolemia
    • Low tidal volumes / lung protective ventilation
  1. Minimally invasive techniques:
    • Laparoscopic abdominal approach preferred when possible; currently controversial, no conclusive evidence available
    • Thoracoscopic chest approach if possible
  1. Minimized use of chest tubes, drains:
    • Eg. 1 chest tube in right pleural cavity
  1. Use of enteric feeding tubes (i.e. nasoduodenal or jejunostomy) is generally recommended, especially if pre-operative malnutrition present:
    • Selective avoidance of feeding tubes reasonable (e.g. no pre-operative malnutrition, no anastomotic concerns)
  1. Optimal multimodal analgesia
    • Use of paravertebral analgesia over a thoracic epidural
    • Regular acetaminophen dosing
    • Limited opioid use
    • NSAID use controversial due to concern for increased risk for anastomotic leak (see references 4 & 6)
  1. Optimal Multimodal analgesia:
    • Early transition to oral/enteral analgesics
    • Minimal use of intravenous opioids
  1. Early oral nutrition:
    • Initiate early oral fluids (e.g. 2 days of sips of water, followed by 2 days of clear fluids, followed by 2 days of full fluids based on recent randomized controlled trial demonstrating no increased risk of adverse events) – see reference 1
    • Patients to stay on full fluids on discharge, until POD7, then transition to post esophagectomy diet
  1. Early Mobilization:
    1. Assisted mobilization (i.e. first steps) POD0
    2. Independent mobilization POD1
  1. Early removal of tubes and drains if no clinical contraindications:
    1. Eg. Removal of Foley catheter POD1 if no epidural (D/C foley on day of epidural discontinuation otherwise)
    2. Eg. Chest tube removal POD3 if no evidence of air leak, chyle leak
    3. Eg. JP Drain removal POD6
    4. Eg. Remove NG POD3 ager clamping evening of POD2 and if no evidence of gastric conduit distention
  2. Optimized glycemic control to normalized levels to promote healing (goal <10mmol/L):
  3. Target timeline to discharge (without any):
    • POD6



  1. Berkelmans GH, Fransen LF, Dolmans-Zwartjes AC, Kouwenhoven EA, van Det MJ, Nilsson M, Nieuwenhuijzen GA, Luyer MD. Direct oral feeding following minimally invasive esophagectomy. Annals of Surgery
  2. Chao L, Ferri L, Mulder S, Ncuti A, Neville A, Lee L, Kaneva P, Watson D, Vassiliou M, Carli F, Feldman L. An enhanced recovery pathways decreases duration of stay after esophagectomy. Surgery 2012: 606-616.
  3. Findlay J, Gillies R, Millo J, Sgromo B, Marshall R, Maynard N. Enhanced recovery for esophagectomy: A systematic review and evidence based guidelines. Ann of Surgery 2014; 259:413-431.
  4. Fjederholt KT,Okholm C,  Svendsen LB, Achiam MP, Kirkegård J, Mortensen FV. Ketorolac and Other NSAIDs Increase the Risk of Anastomotic Leakage After Surgery for GEJ Cancers: a Cohort Study of 557 Patients. J Gastrointestinal Surg 2018: 587-594.
  5. Giménez-Milà M, Klein AA, Martinez G. Design and implementation of an enhanced recovery program in thoracic surgery. Journal of thoracic disease 2016 Feb;8(Suppl 1):S37.
  6. Hakkarainen TW, Steele SR, Bastaworous A, Dellinger EP, Farrokhi E, Farjah F, Florence M, Helton S, Horton M,, Pietro M, Varghese TK, Flum DR. Nonsteroidal anti-inflammatory drugs and the risk for anastomotic failure: a report from Washington State’s Surgical Care and Outcomes Assessment Program (SCOAP). JAMA Surg 2018; 223-228.
  7. Ljungqvist O, Scott M, Fearon KC. Enhanced Recovery After Surgery: A review. JAMA Surg 2017; 152:292-298.
  8. Low DE, Allum W, De Mazoni G, Ferri L, Immanuel A, Kuppusamy M, Law S, Lindblad M, Maynard N, Neal J, Pramesh C, Scott M, Smithers B, Addor V, Ljungqvist O. Guidelines for perioparative care in esophagectomy : enhanced recovery after surgery (ERAS) society recommendations. World J of Surgery 2018; 43:299-330.
  9. Markar S, Karthikesaligam A, Low D. Enhanced recovery pathways lead to an improvement in postoperative outcomes following esophagectomy: systematic review and pooled analysis. Disease of the esophagus 2015; 28: 468-475.
  10. Martin LW, Sarosiek BM, Harrison MA, Hedrick T, Isbell JM, Krupnick AS, Lau CL, Mehaffey JH, Thiele RH, Walters DM, Blank RS. Implementing a thoracic enhanced recovery program: lessons learned in the first year. The Annals of thoracic surgery 2018; 105(6):1597-604.
  11. Thiele RH, Rea KM, Turrentine FE, Friel CM, Hassinger TE, Goudreau BJ, et al. Standardization of Care: Impact of an Enhanced Recovery Protocol on Length of Stay, Complications, and Direct Costs after Colorectal Surgery. Journal of the American College of Surgeons 2015; 220:430–43.