Despite implementation of enhanced recovery after surgery (ERAS) in lung surgery, potential barriers for improvements should be identified. The aim of this single-centre, prospective ERAS cohort study was to explore reasons for delayed patient discharge after video-assisted thoracoscopic surgery (VATS) lobectomy with a median length of hospital stay (LOS) of 2 days. Consecutive patients referred for VATS lobectomy were consulted twice daily by an investigator for the primary reasons for continued hospitalization. The secondary outcomes were risk factors for delayed recovery using univariate and multivariate regression analyses. A total of 147 patients were included (69 with LOS more than 2 days and 78 with LOS of 2 days or less) from April 2020 to December 2020. Air leak (27.7 per cent), pneumonia (20.2 per cent), pain (15.3 per cent), urinary/renal factors (11.0 per cent), atrial fibrillation (7.0 per cent), respiratory failure (4.5 per cent), cognitive factors/delirium (4.3 per cent), gastrointestinal factors (3.8 per cent), oxygen dependency (2.7 per cent), social factors (2.0 per cent), and pleural effusion (1.4 per cent) were important factors for discharge more than 2 days after surgery. The 30-day readmission rate after discharge was 21 per cent for LOS of 2 days or less and 22 per cent for LOS more than 2 days (P = 0.856). On a multivariate regression model, age (per 5-year increase, odds ratio (OR) 1.29, 95 per cent c.i. 1.01 to 1.66, P = 0.043) and forced expiratory volume in 1 s (FEV₁) per cent (per 5 per cent increase, OR 0.89, 95 per cent c.i. 0.81 to 0.98, P = 0.021) were significantly related to discharge after more than 2 days. Despite a short median LOS of 2 days, air leak, pneumonia, and pain remain the most important challenges for further improvement of the ERAS programme. Age and FEV₁ per cent were statistically significant risk factors for LOS longer than 2 days.

Days alive and out of hospital (DAOH) integrates overall information of hospitalization, readmissions, and mortality that have been applied as a new outcome measure. However, DAOH after video-assisted thoracoscopic surgery (VATS) in an established enhanced recovery after surgery (ERAS) programme has not been reported. Patients aged ≥18 years with non-small-cell lung cancer undergoing VATS lobectomy in an established ERAS programme were eligible. The primary and secondary outcomes were DAOH during the first postoperative 365 days and reasons for reduced DAOH. A total of 316 consecutive patients with well-defined inclusion criteria and complete follow-up were assessed retrospectively. The median length of stay was 3 days (IQR 2–6). The medians (IQR) of postoperative 30, 60, 90, 180 and 365 DAOH were 27 (22–28), 57 (51–58), 86 (80–88), 176 (169–178) and 359 (349–363) days, respectively. Air leak was the dominant factor for reduced DAOH from postoperative day (POD) 0–30 (47.2%) and 0–365 (38.3%). Side effects of adjuvant chemotherapy were dominant from POD 31–60 and 61–90 (23.5% and 47.1%) and recurrence/metastases from POD 91–180 and 181–365 (25.6% and 50.0%). A low diffusing capacity for carbon monoxide (odds ratios 1.28, 95% confidence interval 1.07–1.53; P=0.007) and prior surgical history (odds ratios 1.80, 95% confidence interval 1.08–2.99; P=0.023) were predictors for low DAOH. DAOH after 1 year with an established VATS lobectomy ERAS programme was only reduced with a median of 6 days. The main factors reducing DAOH were air leak, adjuvant chemotherapy and recurrence. DAOH may be an important patient-centred outcome to define future improvement strategies.

Summary: Little is known about functional recovery following patient discharge in an established enhanced recovery programme after video‐assisted thoracoscopic lobectomy. We conducted a single‐centre pilot prospective observational cohort study. We hypothesised that patients achieved early functional recovery after discharge. A total of 32 patients aged ≥ 18 years were enrolled. A digital device was used for objective activity measurements, and patient‐reported outcomes were collected as subjective measurements. Primary outcomes were the difference in physical activity; sleep duration; pain; fatigue; and average quality of life scores between pre‐operative baseline and 7 days following discharge. The secondary outcome was the reason for reduced daily activity during the first 7 days after discharge. Median (IQR [range]) length of stay was 3 (2–5 [1–13]) days. Up to post‐discharge day 7, total, lower intensity and moderate‐to‐vigorous activities were lower than pre‐operative activity (p < 0.001; p = 0.005 and p = 0.027, respectively). Numerical rating scale (0–10) pain scores increased postoperatively at rest (mean difference 1.2, p < 0.001) and during walking (mean difference 1.4, p < 0.001). Fatigue assessed by the Christensen Fatigue Scale (1–10) was also increased postoperatively (mean difference 1.7, p = 0.001). There was a reduction in quality of life scores, while sedentary activity and sleep duration were unchanged postoperatively. Dominant reasons for not recovering daily activity included fatigue in 43% and pain in 33% of patients. Despite compliance with an enhanced recovery programme with a median length of hospital stay of 3 days after video‐assisted thoracoscopic lobectomy, functional recovery was not achieved within 7 days after hospital discharge. Reduction in postoperative pain and fatigue are important factors to enhance functional recovery.

The choice of surgical procedure for early-stage non-small cell lung cancer (NSCLC) with tumour spread through air spaces (STAS) remain debated. This study aimed to analyse the prognostic influence of STAS on thoracoscopic segmentectomy compared to lobectomy for clinical stage I NSCLC. This retrospective study included prospectively collected data of consecutive patients who underwent thoracoscopic segmentectomy or lobectomy for clinical stage I NSCLC from September 2020 to September 2023 at a high-volume hospital. We assessed overall survival (OS) and recurrence-free survival (RFS) using Kaplan-Meier estimator with log-rank test. LASSO-Cox and Cox regression analyses identified independent factors for survivals of STAS presence. Among the 785 patients in the study, 151 (19.2 %) had STAS-positive NSCLC. No significant difference was observed in OS and RFS between patients with the presence and absence of STAS, nor between those undergoing thoracoscopic segmentectomy and lobectomy for NSCLC in the absence of STAS. Whereas worse survivals were found in segmentectomy for patients with STAS when compared to lobectomy (3-year OS: 58.4 % vs 89.0 %, P < 0.001; 3-year RFS: 69.8 % vs 82.7 %, P < 0.001). On multivariable analysis, segmentectomy (vs. lobectomy) and increased maximum standardized uptake value in positron emission tomography were independent prognostic factors of OS (hazard ratio [HR] 5.81, P = 0.010; HR 1.12, P = 0.022) and RFS (HR 5.78, P = 0.004; HR 1.10, P = 0.025) among patients with STAS. In this study, segmentectomy for clinical stage I NSCLC with STAS had inferior RFS and OS when compared to lobectomy.