What my life will be like after surgery?

What my life will be like after surgery? How many times surgeons have been asked to anticipate the effects of an operation on medium and long-term postoperative daily activities. With more younger patients undergoing screening programmes, more patients are also asking how much time off work they need to envisage. These questions are not easy to answer with simple percentages or number of lung segments removed that for most of our patients will never make a difference during the decision-making and will never help them to plan their next months and arrange social or family support.

Huang et al. [1] provide a valuable new tool in thoracic surgery for summarizing the overall treatment effects into a single measure, which can complement the informed consent process. Days alive and out of hospital (DAOH) is a patient-centered, pragmatic outcome, which tries to overcome many of the disadvantages of the traditional clinical postoperative outcomes, usually difficult for the patients to translate into their real-life scenarios. It approximates time spent in good health without encompassing important clinical end points like mortality and hospitalization. Not surprisingly, they found that in a thoracic unit with an established enhanced recovery after surgery programme (ERAS), air leak and postoperative complications after lobectomy negatively affected the early DAOH, whereas cancer-related factors as adjuvant therapy and recurrences were responsible for shorter mid and long-term DAOH up to 1 year.

The implementation of ERAS [2] has streamlined the definition of the perioperative journey for patients. Patients are counselled and have their keyworker which often represents their main point of contact with their hospital. But equally, at some point, they need to face the rearrangement of their daily life and walk alone. And anticipating what this long-term journey can be is of paramount importance for patients and their carers, to be prepared and organized during their recovery trajectory after VATS lung resections [3]. In the era of telemedicine, DAOH may be further implemented with information about outpatients’ visit and emergency call as measures of effective Health Service utilization and potential cost-effectiveness analysis.

In this regard, systematic collection of perioperative patient-reported outcomes (PROs) will certainly help define the social and psychological status that can interfere with short- and long-term DAOH as demonstrated in other specialities [4].

Lastly, the adoption of ERAS, although focusing on the quality of a patient’s recovery with the explicit aim of improving postoperative outcomes, can be difficult as demonstrated in the UK [5] and readmission rates after lobectomy may be associated with worse survival [6]. Within these programmes, staff shortage is often the main reason why questionnaire-based methods are failing to collect patient-reported outcomes making the evaluation of treatment from the patient’s voice more difficult. Nevertheless, most of the studies available evaluating ERAS programmes on patients submitted to VATS lung resection have mainly reported objective outcomes as the length of stay, overall morbidity and mortality and hospital costs, without focusing on longer effects of these protocols on patients and their carers’ lives [7].

The authors should be commended for championing a patient-centred measure that appears easy to measure using established data linkage methods, without resorting to variably defined morbidity outcomes. DAOH should be regarded as a valid outcome measure that can answer that initial question and encourage an informed patient’s participation in the decision-making process.

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