Many clichés exist about the size of the surgeon’s ego. It is certainly true that many surgeons take great pride in their skills and techniques. Any perusal of the articles in a surgical journal, or the presentations at a surgical conference will reveal the sheer prevalence of reports that such-and-such a technique or technology has improved patient outcomes. Great though these achievements are, the focus on intra-operative advances alone tends to grossly neglect the impact of something at least as important—if not more so: peri-operative care.
Very early on, the advent of minimally invasive surgery ushered in the concept of ‘fast track’ management with shortened lengths of stay. Over the years, this has evolved from a simple quest for faster discharge to a pursuit of comprehensive peri-operative care to ensure the best recuperation after any operation. Today, “Enhanced Recovery After Surgery” (ERAS) is not a diktat from a surgeon, but a sophisticated clinical pathway designed by a multi-disciplinary team of physicians, nurses and allied health staff. The ERAS team reviews and digests the medical literature to compile a comprehensive clinical pathway for a defined patient population undergoing a specific procedure using the best available clinical evidence. The objective is to integrate pre-, intra- and post-operative care strategies to yield the most optimal outcomes after that procedure.
In thoracic surgery, the benefits of ERAS are very well demonstrated. Shortenings of chest drain durations and lengths of stay are measured in days, complication rates are reduced to fractions of what they were, and assessments of patient functional recovery and satisfaction are significantly improved. The scale of these improvements is invariably much greater than the purported benefits from any new minimally invasive technique of extravagant new technology alone. The benefits of ERAS are also achieved by perfecting clinical management, and hence are potentially much less expensive than investing in such fancy new techniques and technologies.
The success of ERAS without doubt bursts the bubble of the surgeon’s ego. It can be seen that the key to a patient’s well-being after surgery does not rely entirely on the surgeon’s skill alone. Such skill is still critically important, but without a bespoke clinical pathway to complement the surgery, patients cannot reap the full rewards.
Perhaps talking about multi-disciplinary peri-operative care is less ego-boosting than showing video exploits of one’s operative prowess. The reality is that ERAS continues to receive only minimal exposure and discussion amongst surgeons compared to techniques and technologies. The proportion of journal articles and conference research abstracts devoted to ERAS fall far short of what would be expected given its real-world importance for patients. That is why this current special issue is so significant. Leading Thoracic Surgeons from around the world have come together to share experiences and expert viewpoints on ERAS. The comprehensive discussion of ERAS brings readers deeper understandings and new insights into how to create a successful ERAS clinical pathway for thoracic patients. It is a much needed and most timely issue: a re-focusing away from egos and operative skills, and towards what is most crucial for the patient: the best possible overall recovery from surgery.