Perioperative rehabilitation and the impact of multidisciplinary teams following video-assisted thoracoscopic pulmonary resection: a narrative review

Introduction

Background

Lung cancer remains the leading cause of cancer-related mortality in the United States (1). Video-assisted thoracoscopic surgery (VATS) was first performed in the early 1990s and has subsequently grown to become the primary mode of pulmonary resection for early-stage lung cancer (2,3). VATS was initially met with skepticism, and early literature showed no significant benefits when compared to thoracotomy (4). However, following improvements in surgeon expertise and refinements in operative technique, VATS is now known to reduce short-term and long-term morbidity and mortality (5-7). Surgeons have identified additional perioperative interventions that improve outcomes for their patients. Collaborative care models, including pre- and post-operative rehabilitation, have become increasingly common in thoracic surgery. The development of enhanced recovery after surgery (ERAS) protocols has facilitated a multidisciplinary approach to surgical care across surgical specialties and operative approaches, including both open and minimally invasive surgery. In thoracic surgery, the implementation of ERAS practices has been shown to improve perioperative morbidity and mortality, improve patients’ postoperative pain, and facilitate earlier discharge while reducing healthcare costs (8). Combining preoperative interventions and ERAS postoperative practices gives patients the best chances of successful operative outcomes.

Rationale and knowledge gap

Much has been written on the subject of ERAS protocols in thoracic surgery. Many of these publications provide either an exhaustive description of specific ERAS protocols, or focus on one element of ERAS. This narrative review seeks to succinctly summarize highlights from several auxiliary specialties—e.g., physical rehabilitation and nutrition—that have been shown to significantly benefit postoperative outcomes of patients undergoing VATS for lung cancer. This review serves to educate surgeons on elements of ERAS protocols that are most commonly managed by other non-physician specialties.

Objective

The objective of this narrative review is to provide a high-level summary of the current literature regarding the effect of multimodal rehabilitation on perioperative outcomes for patients undergoing VATS pulmonary resection for lung cancer. Data on physical, respiratory, and psychological rehabilitation, as well as the status of ERAS protocolization for VATS, have been compiled and the major findings are discussed in this review. This review serves as a resource primarily for thoracic surgeons to better understand the literature surrounding perioperative best practices that are often managed by non-physician specialties. However, it also helps other members of the multidisciplinary team—nurses, therapists, nutritionists, and other healthcare professionals who care for patients with resected lung cancer—to better understand the rationale guiding the interventions supplied by their fellow multidisciplinary team members. We present this article in accordance with the Narrative Review reporting checklist (available at https://vats.amegroups.com/article/view/10.21037/vats-24-41/rc).

Methods

A narrative review of the literature was conducted on perioperative rehabilitation for VATS pulmonary resection. The search was conducted via PubMed and Google Scholar using a combination of the following search terms: “video-assisted thoracic surgery”, “minimally invasive thoracic surgery”, “physical rehabilitation”, “pulmonary rehabilitation”, “respiratory rehabilitation”, “perioperative oxygenation”, “psychological therapy”, “perioperative anxiety”, and “ERAS”. More specific search terms were used as indicated to elucidate additional literature on topics of importance in each section of this review [i.e., respiratory muscle training (RMT), positive expiratory pressure (PEP) devices, etc.]. Inclusion criteria for this review were articles written in English and published between 1998 and 2024, with select articles from 2025. Selected articles focused on adult patients greater than 18 years of age. When available, high-quality systematic reviews and meta-analyses were selected for inclusion in our review to provide the highest level of evidence for discussion points. See Table 1 for the search strategy summary.

ERAS protocol for VATS

ERAS protocols include a standardized series of preoperative, intraoperative, and postoperative protocols shown to reduce complications, improve postoperative pain, and decrease hospital length of stay (LOS) (8,9). The application of ERAS protocols following VATS has been described at length in the thoracic surgery literature. The Italian ERAS group created one of the first protocols for VATS lobectomy using the VATS Group database, highlighting how ERAS patients had reduced perioperative complications, shorter hospital LOS, and improved levels of patient comfort (10-12). In 2018, the ERAS Society and the European Society for Thoracic Surgery standardized guidelines for perioperative management of VATS patients (13). VATS-specific protocols have found benefits for pulmonary resections for lung cancer, as well as for other thoracic surgeries, like empyema decortication (14-16). These protocols span several multidisciplinary areas, including perioperative nutrition, physical and respiratory rehabilitation, anesthetic techniques, pain control, chest tube management, and more. The following recommendations are known to improve post-operative outcomes and reduce healthcare costs, and their adoption into clinical practice continues to expand as more literature emerges.

Pre-operative interventions

Interventions in the preoperative period can contribute to improved postoperative outcomes. Many patients with lung cancer are older, frail, and have significant medical comorbidities, increasing their postoperative risk of major cardiac and pulmonary events. Thoracic surgeons must evaluate their patients’ preoperative cardiopulmonary risk and refer them to a cardiologist and/or pulmonologist for preoperative medical optimization. The details of this preoperative evaluation are discussed elsewhere. Many ERAS protocols strongly advocate for the preoperative involvement of multidisciplinary staff, including primary care providers, dietitians, and social workers, who can aid in nutritional optimization, smoking cessation, and access to social and psychological support (13).

Physical prehabilitation

Patients with higher functional status and exercise capacity have fewer clinically relevant complications and overall better outcomes after VATS (17). “Prehabilitation” involves enrolling a deconditioned patient in a preoperative exercise program to help improve physical fitness and prevent perioperative complications. Multiple randomized controlled trials have demonstrated that preoperative exercise-based intervention leads to decreased hospital LOS, postoperative morbidity, pulmonary complications, and functional decline, with some studies reporting lower chest tube durations and a lower incidence of prolonged air leaks (18-20). While the benefit of preoperative exercise rehabilitation is evident, the ideal duration and intensity of prehabilitation programs remains unclear. Conventional cardiorespiratory fitness interventions in chronic respiratory conditions last between 8 to 12 weeks. However, patients with rapidly progressive lung cancer can ill afford substantial delays in surgical care (18). Programs lasting as little as 2 weeks have been shown to improve perioperative functional capacity. However, a significant difference in LOS, postoperative complications, or mortality was not appreciated (21). Programs typically involve a combination of aerobic exercise, strength training, and respiratory therapy, but an optimized regimen is yet to be determined. In addition to exercise, preoperative breathing exercises have been shown to reduce hospital LOS, pulmonary complications, and pneumonia in patients undergoing surgical lung cancer resection, and formal incorporation into prehabilitation protocols is recommended (22). Further evidence from high-quality randomized controlled trials on duration, frequency, and composition of prehabilitation programs is needed to elucidate a specific protocol and minimum number of treatments needed to confer a clinical benefit.

Nutritional optimization

Preoperative nutritional status is another important modifiable risk factor that influences postoperative outcomes (23-25). Approximately 70% of patients with lung cancer suffer from malnutrition and muscle-loss related to their cancer (26). In 2001, Jagoe and his colleagues published their findings that poor preoperative nutrition, measured by low body mass index (BMI), was a predictor of death and need for reintubation after open thoracotomy for lung cancer (27). More recent studies have continued to demonstrate the association between preoperative malnutrition and postoperative complications in patients undergoing VATS (28-30). For example, in 2018, Ramos et al. demonstrated that malnourishment, as determined by the Nutritional Risk Index scoring system, was associated with significantly increased postoperative complications and longer hospital LOS, and that underweight patients had decreased progression-free survival (28). Sarcopenia, generally defined as age-related muscle loss, is closely related to and exacerbated by malnutrition and linked to worsened postoperative outcomes in lung cancer (31-33). In a meta-analysis in 2021, Kawaguchi et al. found that sarcopenia, diagnosed by skeletal muscle mass measurement, had significantly worse overall survival compared to non-sarcopenic patients after resection of non-small cell lung cancer (NSCLC) with an odds ratio of 3.07 [95% confidence interval (CI): 2.45–3.85] (32).

Controversy remains about the best way to determine a patient’s preoperative nutritional status (34). A patient is broadly at risk of malnutrition if they are underweight (BMI <18.5 kg/m²), have had weight loss greater than 5–10% of their total body weight in the three months prior to surgery (35,36). Checking a preoperative albumin level is an easy and cost-effective approach. The National Veterans Affairs National Surgical Risk Study in 1999 demonstrated the association between low albumin levels poor surgical outcomes across 44 medical centers and over 50,000 non-cardiac surgeries (37). In 2017, Meyer et al. again validated the association between hypoalbuminemia and post-operative complications across multiple surgical specialties in over 200,000 patients (38). In a cohort of 556 patients undergoing pulmonary resection for NSCLC, Miura et al. demonstrated that a preoperative albumin level below 4.2 g/dL was associated with worse overall survival and progression-free survival (29). Other studies have also advocated for the use of prealbumin (also known as transthyretin) measurement, which has a shorter half-life than albumin and therefore is more responsive to short-term nutritional changes (39,40). However, both albumin and prealbumin are acute-phase reactants, and numerous disease processes and inflammatory conditions (i.e., nephrotic syndrome, liver dysfunction, trauma, or even cancer itself) alter the body’s albumin and prealbumin levels, making them potentially unreliable as sole predictors of malnutrition. Instead, albumin and/or prealbumin may function better as adjuncts to a global nutritional assessment (41).

Several validated clinical scoring systems are available to assist in the diagnosis of malnutrition (42). While the individual nuances of each of these scoring systems are outside of the scope of this review, suffice it to say that in head-to-head comparisons, these multiple validated scoring systems were found to accurately identify malnutrition and predict the associated increased risk of postoperative complications and lower overall survival after NSCLC resection (43). We will highlight one particular scoring system, though: the “perioperative nutrition screen” (PONS). The PONS is a derivative of another well-validated screening tool, the “malnutrition universal screening tool” (MUST), and was developed explicitly for use in the preoperative setting for patients preparing to undergo major surgery. If patients meet any of four criteria for malnutrition, including (I) a BMI <18.5 kg/m² (or <20 kg/m² for patients older than 65 years); (II) unplanned weight loss >10% of their total body weight in the past 6 months; (III) eating less than 50% of their usual food intake for the past week; or (IV) a preoperative albumin level <3.0 g/dL; they get automatically forwarded to a preoperative nutrition clinic or to see a registered dietician (44).

What can be done in the preoperative setting if our patient is determined to be at high risk of malnutrition? Patients should immediately start consuming a high-protein diet, ensuring at least 1.2 to 1.5 g/kg of body weight of protein daily; however, in stressed circumstances, nutritional guidelines suggest that 1.5 to 2.0 g/kg of protein daily may be better (36). Two randomized controlled trials investigated the impact of high-protein nutritional supplementation (one in combination with a preoperative exercise routine) for patients undergoing NSCLC resection (45,46). Kaya et al. found that implementing a high-protein, immune-modulating formula (containing additional arginine, omega-3 fatty acids, and nucleotides) for 10 days preoperatively was associated with a reduction in post-operative complications and an earlier time to chest tube removal (45). Huang et al. found that the implementation of a preoperative regimen including nutritional supplementation and an exercise component led to a myriad of improved postoperative outcomes, including earlier mobilization, earlier chest tube removal, improved pulmonary function tests, and shortened hospital length-of-stay (46). While there is no universally recommended duration of preoperative nutritional supplementation, data extrapolated from patients undergoing gastrointestinal surgery suggest that even 5 to 7 days of high-protein oral nutritional supplementation may reduce postoperative complications (47). While a longer duration of nutritional supplementation likely contributes to improved outcomes, this needs to be balanced with the risk of delaying an oncologic resection. In cases in which patients have difficulty taking in adequate nutrition, the American Society for Enhanced Recovery and Perioperative Quality Initiative recommends placement of an enteral feeding tube for at least 7 days preoperatively (44).

Nutritional interventions on the day of surgery may also help to improve post-operative outcomes. The traditional practice of making patients “nil per os” (NPO) at midnight the evening before surgery and thus inducing a complete fast of 6 or more hours leading up to major surgery has been repeatedly proven to be detrimental to patient outcomes (48). Current anesthesiology guidelines now recommend a 6-hour fast for solid food, with the allowance of clear liquids up until 2 hours before surgery (49). One Danish study has even found minimal detrimental effects of continuing clear liquids until immediately before elective surgery, showing an association with improved comfort and reduced nausea and vomiting post-operatively (50). Nevertheless, despite this evidence, many institutions continue to enforce a prolonged fast of even clear liquids (51). This has been repeatedly linked to a host of negative outcomes, including increased patient thirst and perioperative stress, increased risk of dehydration with associated perioperative renal injury, and also exacerbating a state of postoperative hyperglycemia, insulin resistance, and muscle breakdown (48,52). As such, many thoracic ERAS guidelines recommend carbohydrate loading and continuing clear liquids up to 2 hours pre-operatively, and we tentatively recommend allowing patients limited clear liquids even within the 2 hours before surgery (13,53-55).

Patient-centered care

Pre-VATS anxiety among lung cancer patients has been reported to be as high as 48%. Each patient’s level of insight into their disease and the perception of their illness is associated with the degree of their anxiety. Additionally, strong social support and a trusting relationship with healthcare providers is a protective factor against lung-cancer-associated anxiety and depression (56). Pre-operative counseling by physicians can help set expectations for the perioperative period, and proper education before surgery is associated with decreased anxiety, subjective pain, and analgesic use post-operatively (57,58). No specific educational format has been demonstrated to be superior to another, but ERAS guidelines recommend providing both written and oral information to patients and pre-operative discussions with all members of the surgical team (13). Outside of the healthcare setting, support groups have been shown to improve the quality of life of lung cancer patients, though their overall effectiveness has been difficult to quantify due to the high degree of variability between the social support programs (59-61). Regardless, connecting patients with mental health and social support resources in the pre-operative period may be effective in mitigating perioperative anxiety and depression.

Post-operative interventions

Pain control

In the immediate postoperative period, multidisciplinary pain regimens can significantly reduce suffering and dependence upon opioids. Locoregional anesthesia, using paravertebral, intercostal, or serratus anterior blocks, can be administered by trained anesthesiologists either immediately preoperatively or postoperatively and provide especially effective pain control (62,63). Oral and intravenous pain regimens can be scheduled with predominantly non-opioid agents [i.e., nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, gabapentin], only utilizing opioids for breakthrough pain (62,64). An extensive discussion of perioperative multimodal pain regimens for patients undergoing VATS will be covered in a separate article in this series.

Supplemental oxygen

Appropriate oxygenation is an important consideration immediately following VATS. Following VATS, many patients require supplemental oxygen to maintain adequate arterial oxygenation. However, an extended duration required post-operative oxygen requirement is correlated with higher odds of mortality within 6 months (65). Preoperative oxygen saturation, exercise-induced hypoxemia, history of smoking, chronic obstructive pulmonary disease (COPD), and/or interstitial pneumonia, and the extent of low attenuation areas of lung parenchyma on helical computed tomography (CT) (<−910 Hounsfield units) are all known predictors of postoperative oxygen requirements, which may be useful tools in identifying at-risk patients that may require more post-operative attention (66,67). It has been hypothesized that the prophylactic use of non-invasive ventilation, with either continuous positive airway pressure (CPAP) mask or high-flow nasal cannula (HFNC), may help improve post-operative oxygenation and mitigate postoperative pulmonary complications, including respiratory failure and need for reintubation. This has been repeatedly studied in randomized controlled trials and meta-analyses with conflicting results (68-74). Earlier studies, like by Perrin et al. in 2007, reported that the use of non-invasive ventilation after lung resection resulted in improved pulmonary dynamics, decreased rates of atelectasis, and earlier discharge (68). A meta-analysis performed by Zhu et al. in 2019 concluded that prophylactic HFNC improved postoperative oxygenation and reduced the rate of postextubation respiratory failure with a relative risk of 0.61 (95% CI: 0.41 to 0.92, z=2.38, P=0.02) (73). However, other well-designed randomized controlled trials, and a more recent meta-analysis by Zhang et al. in 2024, reached the opposite conclusion (69-72,74). This meta-analysis found that the use of HFNC postoperatively improved oxygenation in the first 12 hours after surgery, but found no significant difference in the rate of postoperative hypoxemia, unplanned reintubation, escalation of respiratory support, or length of intensive care unit (ICU) stay or overall hospital LOS (74). As a result, we recommend the routine use of supplemental oxygen via either via nasal cannula or non-rebreather mask in the immediate postoperative period, but with a low threshold to upgrade to non-invasive ventilation if the patient demonstrates frequent desaturations despite these measures.

Early initiation of enteral nutrition

Early resumption of enteral nutrition postoperatively is now the well-accepted standard of care across most surgical specialties, including thoracic surgery (23,24,44). Most ERAS guidelines emphasize resumption of both fluids and solids within 24 hours of surgery, and enteral nutrition should be prioritized over parenteral formulations (13,24,75). Delayed initiation of enteral nutrition has been shown to result in significant caloric and protein deficits, which often persist throughout the duration of hospitalization (76). The use of nutritional supplementation, including high-protein shakes, in the postoperative period helps ensure that patients meet their protein and calorie goals. Effective preoperative nutritional optimization, combined with early initiation of postoperative enteral nutrition, significantly mitigates the catabolic effects of surgery (75).

Physical rehabilitation

Physicians should engage respiratory therapists, physical therapists, and occupational therapists to start the postoperative rehabilitation process as early as possible. Early mobilization is a key component of rehabilitation after VATS, which involves sitting up in a chair and/or ambulating within 24 hours of surgery. Early mobilization protocols decrease post-operative complications, including pulmonary complications like atelectasis and pneumonia, venous thromboembolism, and overall functional decline (13). Ambulation within 24 hours after VATS has specifically been shown to decrease hospital LOS, time to chest tube removal, and pain on and after postoperative day 3 (77,78). For example, a study by Kaneda et al. showed that sitting upright in bed within three to 4 hours after VATS, followed by ambulation at hour 4 after surgery, decreased the duration of oxygen requirement and improved the recovery of pulmonary function, as compared only walking by postoperative day 1 (79,80). Mobilization as early as 4 hours after VATS has not been associated with an increased risk of chest tube complications, falls, heart rate, or postoperative pain (77,80).

RMT is a specific component of pulmonary rehabilitation that includes exercises aimed at improving the strength and endurance of the muscles involved in the respiratory cycle. RMT is frequently broken down into inspiratory and expiratory muscle training (IMT and EMT, respectively), and it consists of a series of resistance-based exercises to improve respiratory capacity. These include diaphragmatic breathing, pursed lips breathing, ‘quick sniffs’ (rapid and short inhalations through the nose to stimulate the diaphragm), and several device-based exercises that promote similar resisted breathing. This type of training, particularly for IMT, is thought to be associated with improved respiratory function (better oxygenation, reduced dyspnea), quality of life, and exercise capacity both in the acute and late phases of recovery (19,81-83). A randomized controlled trial conducted in Taiwan compared patients who were randomized to undergo a 6-week IMT and aerobic exercise protocol versus standard care. Postoperatively, the IMT group showed significant improvements in respiratory function, lung expansion volume, and an improved six-minute walk test between weeks 2 and 12 compared to the standard care group (84). Similarly, a group of researchers in Beijing compared conventional pulmonary rehabilitation to physical manipulation pulmonary rehabilitation, which included intercostal muscle and rib mobilization, thoracic induction, and induced abdominal breathing. The group who underwent more intensive physical rehabilitation demonstrated improved respiratory capacity, decreased hospital LOS, and shorter time to chest tube removal. Altogether, this evidence demonstrates that chest mobility and pulmonary rehabilitation programs may help to reduce perioperative pulmonary complications and expedite patient recovery (85).

Post-operative rehabilitation programs that include breathing exercises have demonstrated improved respiratory capacity compared to programs based on exercise alone, evidencing the beneficial collaboration between respiratory therapists, physical therapists, and occupational therapists (86). Educating nursing staff on these exercises can encourage ongoing rehabilitation after designated therapy sessions. The use of incentive spirometry (IS) is common and readily available after thoracic surgery. However, a 2021 meta-analysis investigating the use of post-operative IS in adults after cardiac, thoracic, and upper abdominal surgery showed that IS alone did not significantly reduce 30-day pulmonary complications or mortality and had no impact on hospital LOS compared to other rehabilitation strategies (87). The data on the use of IS alone after VATS is conflicting at best, though there is evidence to suggest a benefit for post-operative patients with COPD (88-90). Although there is a lack of evidence suggesting that IS alone confers clinical benefits, it is an inexpensive, low-risk tool to encourage breathing and remains a part of post-operative rehabilitation pathways. Sputum retention can contribute to morbidity and mortality after lung surgery, and thus airway clearance mechanisms are often discussed in perioperative rehabilitation protocols. Supported coughing, postural drainage, forced expiration techniques, and active cycle of breathing techniques are all non-invasive treatments known to aid in airway clearance after thoracic surgery (79,91). Several PEP devices exist that are thought to improve pulmonary volumes, decrease atelectasis, and promote expectoration of secretions in the postoperative period. PEP therapy has conflicting evidence, with some studies demonstrating lower rates of pulmonary complication in those performing PEP exercises and others reporting no change in outcomes (92-94). While high-quality literature is lacking, these devices are inexpensive, low-risk, and can be used in conjunction with other rehabilitation modalities to promote recovery.

Minitracheostomy

Prophylactic minitracheostomy is a technique that is discussed, albeit rarely utilized, in thoracic surgery. Minitracheostomies are small-diameter (typically 4 mm) percutaneous devices inserted through the cricothyroid membrane through which repeated suctioning can be performed to facilitate sputum clearance (95). Some data suggests that it may have clinical benefits for patients at high risk of excess sputum production and limited ability to clear secretions (13,96). While the placement of a minitracheostomy is often uncomplicated, some instances of major complications including severe hemorrhage, distal device migration, and esophageal perforation have occurred (97). These devices are seldom used in clinical practice given their invasiveness and risk profile. Further evaluation with randomized control trials would be needed to define specific pre- and postoperative protocols for optimal airway sputum clearance before wide acceptance of their usage.

Conclusions

Herein we review evidence supporting multidisciplinary prehabilitation and rehabilitation interventions for patients undergoing VATS pulmonary resection for lung cancer. This review helps to educate surgeons and the rest of the care team about the literature supporting multidisciplinary best practices from specialties that may ordinarily be outside of their realm of expertise. We discuss the role of preoperative interventions, including prehabilitation programs and nutritional optimization and their impact on postoperative outcomes. Additionally, we discuss how early mobilization, RMT, and early resumption of nutrition postoperatively help to reduce pulmonary complications, hospital LOS, and expedite recovery. By instituting collaborative ERAS protocols and engaging multidisciplinary specialists, patients recover from VATS faster with fewer complications. However, further research regarding specific protocols are needed to determine the optimal dose or time period needed for benefit; for example, determining the optimal period of preoperative physical prehabilitation and nutritional supplementation. The literature strongly supports a collaborative care model incorporating a strong multidisciplinary team to expedite patient recovery, reduce morbidity and mortality, and lower overall healthcare costs.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Video-Assisted Thoracic Surgery for the series “Preoperative Planning and Assessment for VATS Lung Cancer Resection”. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://vats.amegroups.com/article/view/10.21037/vats-24-41/rc

Peer Review File: Available at https://vats.amegroups.com/article/view/10.21037/vats-24-41/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://vats.amegroups.com/article/view/10.21037/vats-24-41/coif). The series “Preoperative Planning and Assessment for VATS Lung Cancer Resection” was commissioned by the editorial office without any funding or sponsorship. G.D.T. served as the unpaid Guest Editor of the series and serves as an unpaid editorial board member of Video-Assisted Thoracic Surgery from February 2025 to December 2026. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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