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Enhanced recovery for lung cancer surgery means stopping smoking and getting fitter beforehand, keyhole surgery where possible, a short fast with a sugary drink, nerve blocks for pain, no routine stomach tube and an early catheter removal, drinking a few hours after the operation, getting up within a day, and physiotherapy.
The ERAS Society and ESTS guideline (2019; 45 items) is the specialty standard; only its abstract could be read, which lists key recommendations without grades: counselling, nutritional screening, smoking cessation, prehabilitation for high-risk patients, avoiding fasting, carbohydrate loading, no sedative premedication, VTE prophylaxis, warming, short-acting anaesthetics, regional anaesthesia, nausea control, opioid-sparing analgesia, euvolaemia, minimally invasive surgery, early chest drain removal, avoiding urinary catheters and early mobilisation. The graded detail here is from the Italian PACTS consensus (2020, USPSTF grades), read in full: VATS whenever possible (good, A); smoking cessation ideally 4 weeks before (fair, A); prehabilitation (poor, A); fasting 2 hours for clear fluids and 6 for solids (good, A) and carbohydrate loading (poor, A); no routine benzodiazepines (fair, B); temperature of at least 36 °C (good, A); balanced crystalloid (good, A) and near-zero fluid balance (fair, A); protective one-lung ventilation (fair, A); risk-based nausea prophylaxis (good, A); no routine nasogastric tube and early catheter removal (fair, A); locoregional analgesia with paravertebral block for VATS (good, A) and epidural for thoracotomy or high risk (fair, A); IV NSAIDs (good, A); no suction on drains without complications (good, D); oral intake 4 to 6 hours after surgery (fair, A); mobilisation within 24 hours and physiotherapy (fair, A).
Why: Smoking is a strong predictor of lung complications after the operation.
“Nonetheless, given that smoking status is a strong predictor of postoperative lung complications, we suggest smoking cessation at least 2-3 weeks before surgery (ideally 4 weeks before).”
PACTS group, Italian intersociety consensus (Perioperative Medicine) 2020 · Level of evidence: Fair. Strength of recommendation: A.
Why: Getting fitter beforehand may reduce chest complications and the time in hospital.
“We recommend preoperative exercise rehabilitation (prehabilitation) in candidates for curative surgical intervention for lung cancer as it may reduce postoperative pulmonary complications.”
PACTS group, Italian intersociety consensus (Perioperative Medicine) 2020 · Level of evidence: Poor. Strength of recommendation: A.
Why: A long fast causes thirst and stress without making anaesthesia safer; a sugary drink reduces discomfort and insulin resistance.
“We recommend limiting clear fluid and solid fasting up to 2 and 6 h, respectively, in patients undergoing lung surgery who are not at risk of delayed gastric emptying.”
PACTS group, Italian intersociety consensus (Perioperative Medicine) 2020 · Fasting: Level of evidence Good, Strength A. Carbohydrate loading: Level of evidence Poor, Strength A.
Why: Sedatives before the operation slow waking and getting up, particularly in older people.
“We suggest avoiding the routine use of benzodiazepines before thoracic surgery, especially in elderly people.”
PACTS group, Italian intersociety consensus (Perioperative Medicine) 2020 · Level of evidence: Fair. Strength of recommendation: B.
Why: Keyhole lung surgery causes fewer complications, less pain and a shorter stay than open surgery.
“We recommend the video-assisted thoracoscopic approach for lung surgery whenever possible, because of the lower incidence of postoperative complications, shorter length of hospital stay, and lower levels of postoperative pain associated with this technique.”
PACTS group, Italian intersociety consensus (Perioperative Medicine) 2020 · Level of evidence: Good. Strength of recommendation: A.
Why: Getting cold during surgery raises the risk of infection, bleeding and heart problems.
“We recommend that intraoperative temperature be monitored using an appropriate system in all patients undergoing thoracic surgery lasting more than 30 min. A core temperature of at least 36 °C should be maintained.”
PACTS group, Italian intersociety consensus (Perioperative Medicine) 2020 · Level of evidence: Good. Strength of recommendation: A.
Why: Too much fluid after lung surgery can cause lung injury; too little can harm the kidneys.
“We recommend a near-zero, rather than restricted or permissive, fluid balance to patients undergoing thoracic surgery. In high-risk patients, a goal-directed approach to fluid therapy should be applied.”
PACTS group, Italian intersociety consensus (Perioperative Medicine) 2020 · Near-zero balance: Level of evidence Fair, Strength A. Balanced crystalloid: Level of evidence Good, Strength A.
Why: Protective ventilation reduces injury to the lung that is left.
“We recommend a protective ventilation approach during one-lung ventilation, based on the combination of low tidal volumes (≤ 6 mL/kg ideal body weight) with alveolar recruitment maneuvers, adequately titrated positive end-expiratory pressure (PEEP) and the lowest fraction of inspired oxygen (FiO2) to maintain satisfactory arterial oxygen saturation.”
PACTS group, Italian intersociety consensus (Perioperative Medicine) 2020 · Level of evidence: Fair. Strength of recommendation: A.
Why: Sickness delays drinking, eating and getting up.
“We recommend evaluation of the risk of postoperative nausea and vomiting, and the use of appropriate prophylaxis according to the level of risk, in all patients undergoing lung surgery.”
PACTS group, Italian intersociety consensus (Perioperative Medicine) 2020 · Level of evidence: Good. Strength of recommendation: A.
Why: Nerve blocks control pain while sparing opioids, which helps breathing, coughing and walking.
“We recommend thoracic paravertebral block for VATS, as part of a multimodal approach.”
PACTS group, Italian intersociety consensus (Perioperative Medicine) 2020 · Paravertebral for VATS: Good, A. Epidural for thoracotomy or high risk: Fair, A. IV NSAIDs: Good, A.
Why: Tubes and catheters add discomfort and keep people in bed.
“We recommend the early removal of urinary catheters to promote mobilization in patients undergoing lung surgery, including those receiving thoracic epidural catheters.”
PACTS group, Italian intersociety consensus (Perioperative Medicine) 2020 · Urinary catheter: Fair, A. Nasogastric tube: Fair, A.
Why: Routine suction does not help an uncomplicated recovery and keeps the patient tied to the wall.
“The routine use of drainage with suction is not recommended in the absence of complications, provided there is full re-expansion of the residual parenchyma after lung resection.”
PACTS group, Italian intersociety consensus (Perioperative Medicine) 2020 · Level of evidence: Good. Strength of recommendation: D.
Why: Early drinking, movement and breathing exercises speed recovery and reduce chest complications.
“We recommend early mobilization of patients within the first 24 h after both minor and major thoracic surgery.”
PACTS group, Italian intersociety consensus (Perioperative Medicine) 2020 · Oral intake 4 to 6 h: Fair, A. Mobilisation within 24 h: Fair, A. Physiotherapy: Fair, A.
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
The ERAS Society and ESTS guideline (2019) is the specialty standard; its abstract says most of its 45 recommendations are strong and lists the key elements, but the graded text could not be read. The PACTS consensus (2020) agrees with every element the ERAS abstract names and grades them: the strongest (good evidence, grade A) are VATS whenever possible, 2-hour and 6-hour fasting, warming, balanced crystalloid, risk-based nausea prophylaxis, paravertebral block for VATS and IV NSAIDs. NICE NG180 supports an enhanced recovery programme for elective major surgery.
ERAS Society and ESTS (European Journal of Cardio-Thoracic Surgery) 2019 · PACTS group, Italian intersociety consensus (Perioperative Medicine) 2020 · PACTS group, Italian intersociety consensus (Perioperative Medicine) 2020 · NICE 2020
Where it differs: Removes the chest drain even when the daily serous output is high, up to 450 ml in 24 hours.
Evidence: Listed as a lung-specific ERAS recommendation by a 2025 appraisal of all ERAS Society guidelines; PACTS suggests a lower threshold of 5 ml/kg a day or less (poor evidence, B). The grade in the ERAS guideline itself could not be read.
Perioperative Medicine 2025 · PACTS group, Italian intersociety consensus (Perioperative Medicine) 2020
Where it differs: Uses a thoracic epidural as standard analgesia, including for VATS.
Evidence: PACTS recommends epidural for thoracotomy, chest wall resection or high-risk patients (fair, A) and paravertebral block for VATS (good, A), with paravertebral in preference to epidural where coagulopathy is known or suspected (fair, A).
PACTS group, Italian intersociety consensus (Perioperative Medicine) 2020
Where it differs: Uses a portable digital drainage system that measures air leak, rather than a conventional bottle.
Evidence: Suggested by PACTS to help early mobilisation (fair, B).
PACTS group, Italian intersociety consensus (Perioperative Medicine) 2020
Where it differs: Admits every patient to intensive care after the operation.
Evidence: Not recommended by PACTS (poor evidence, D).
PACTS group, Italian intersociety consensus (Perioperative Medicine) 2020
Enhanced recovery pathways feed people sooner, limit drips and drains and get them walking the day after an operation. Sixteen randomised trials in bowel surgery found 40 per cent fewer complications and stays more than two days shorter, but in 151 American hospitals given a full implementation programme, most failed to improve compliance with its elements.
Anaesthetic guidelines since at least 2011 say adults can drink clear fluids up to two hours before planned surgery and eat up to six hours before. In a study of 50 women having breast cancer surgery published in 2026, the average fast was 15 hours from food and 12 hours from fluids.
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Key ERAS lung recommendations, and the grade of most of them “As the recommendation grade for most of the elements is strong, the use of a systematic perioperative care pathway has the potential to improve outcomes after surgery.” | Not stated item by item in the abstract; 'the recommendation grade for most of the elements is strong' | ERAS Society and ESTS (European Journal of Cardio-Thoracic Surgery) 2019 |
| Carbohydrate loading up to 2 hours before lung surgery “We recommend preoperative carbohydrate loading with clear fluids up to 2 h prior to surgery for patients undergoing lung surgery, especially malnourished patients, in order to reduce perioperative discomfort and insulin resistance.” | Level of evidence: Poor. Strength of recommendation: A. | PACTS group, Italian intersociety consensus (Perioperative Medicine) 2020 |
| Balanced crystalloid rather than saline “We recommend using balanced crystalloid solutions, rather than normal saline (NaCl 0.9%), as standard fluid of choice.” | Level of evidence: Good. Strength of recommendation: A. | PACTS group, Italian intersociety consensus (Perioperative Medicine) 2020 |
| No routine nasogastric tube “We recommend avoiding the routine placement of a nasogastric tube, and early removal in patients in whom a nasogastric tube is used.” | Level of evidence: Fair. Strength of recommendation: A. | PACTS group, Italian intersociety consensus (Perioperative Medicine) 2020 |
| Thoracic epidural for thoracotomy or high-risk patients “We recommend the use of thoracic epidural analgesia in high-risk patients or in major surgical procedures where the parietal pleura (e.g., chest wall resection) is violated (i.e., thoracotomy, thoracosternotomy, chest wall resection).” | Level of evidence: Fair. Strength of recommendation: A. | PACTS group, Italian intersociety consensus (Perioperative Medicine) 2020 |
| IV NSAIDs, with paracetamol “We recommend the use of intravenous nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce peripheral sensitization to inflammation-induced pain in patients undergoing thoracic surgery.” | Level of evidence: Good. Strength of recommendation: A. | PACTS group, Italian intersociety consensus (Perioperative Medicine) 2020 |
| Chest tubes removed at up to 450 ml a day of serous fluid (ERAS lung, as listed by the 2025 appraisal) “Chest tubes should be removed even if the daily serous effusion is of high volume (up to 450 ml/24 h)” | Not stated in the appraisal | Perioperative Medicine 2025 |
| Oral intake 4 to 6 hours after surgery “We recommend that, in adult patients undergoing thoracic surgery, oral intake, including clear liquids, can be initiated 4–6 h after surgery, in the absence of nausea and vomiting.” | Level of evidence: Fair. Strength of recommendation: A. | PACTS group, Italian intersociety consensus (Perioperative Medicine) 2020 |
| Offer an enhanced recovery programme for elective major or complex surgery “Offer an enhanced recovery programme to people having elective major or complex surgery .” | Not graded (NICE NG180 1.2.1) | NICE 2020 |
Shares Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Clear drinks until two hours before an operation, rather than nothing from midnight, Prehabilitation (the pre-treatment window), Blood clot prevention around cancer surgery, including extended prophylaxis after major abdominal and pelvic operations.
Shares Routine tests before planned surgery, by size of operation and fitness, Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Clear drinks until two hours before an operation, rather than nothing from midnight, Blood clot prevention around cancer surgery, including extended prophylaxis after major abdominal and pelvic operations.
Shares Routine tests before planned surgery, by size of operation and fitness, Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Prehabilitation (the pre-treatment window), Blood clot prevention around cancer surgery, including extended prophylaxis after major abdominal and pelvic operations.
Shares Routine tests before planned surgery, by size of operation and fitness, Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Clear drinks until two hours before an operation, rather than nothing from midnight, Prehabilitation (the pre-treatment window).
Shares Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Clear drinks until two hours before an operation, rather than nothing from midnight, Prehabilitation (the pre-treatment window), Blood clot prevention around cancer surgery, including extended prophylaxis after major abdominal and pelvic operations.
Shares Routine tests before planned surgery, by size of operation and fitness, Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Prehabilitation (the pre-treatment window), Blood clot prevention around cancer surgery, including extended prophylaxis after major abdominal and pelvic operations.
Shares Routine tests before planned surgery, by size of operation and fitness, Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Clear drinks until two hours before an operation, rather than nothing from midnight, Prehabilitation (the pre-treatment window).
Shares Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Clear drinks until two hours before an operation, rather than nothing from midnight, Prehabilitation (the pre-treatment window), Blood clot prevention around cancer surgery, including extended prophylaxis after major abdominal and pelvic operations.