A Perioperative Multidisciplinary Management Protocol for Patients Undergoing Lung Cancer Resection: Implementation and Outcomes Analysis

Summary

This protocol details a multidisciplinary perioperative care pathway for lung cancer surgery, integrating prehabilitation, lung-protective strategies, and structured rehabilitation to reduce complications, enhance the quality of acute recovery, and significantly improve 90-day survival.

Abstract

Effective perioperative care is critical for optimizing outcomes after lung cancer surgery. This protocol details the implementation of a structured, multidisciplinary perioperative management bundle designed to enhance recovery and reduce complications. The protocol encompasses three phases: preoperative (including risk assessment, pulmonary rehabilitation, psychological support, and nutritional optimization), intraoperative (featuring lung-protective ventilation strategies), and postoperative (emphasizing early mobilization, multimodal analgesia, and continuous multidisciplinary team coordination). To assess the feasibility and potential impact of this protocol, it was applied to a cohort of patients undergoing lung cancer resection. Clinical outcomes, including postoperative complications, length of hospital stay, perioperative recovery quality, and short-term survival, were analyzed and compared with those receiving conventional perioperative care. The results indicated that high adherence to this comprehensive protocol was associated with a significant reduction in overall postoperative complications (10.0% vs. 29.1%, P < 0.001) and postoperative pneumonia (3.3% vs. 11.0%, P = 0.022). Although the hospital length of stay was statistically comparable between the groups (7.16 ± 3.32 days vs. 7.02 ± 3.66 days, P = 0.731), the comprehensive protocol group demonstrated vastly superior recovery efficiency, characterized by a substantial reduction in maximal acute pain scores (3.47 ± 1.01 vs. 5.17 ± 1.45, P < 0.001) and a major increase in patient satisfaction (91.82 ± 3.67 vs. 83.06 ± 6.13, P < 0.001) without compromising 30-day readmission safety. Most importantly, the protocol served as an independent protective factor that markedly improved 90-day survival (10.0% mortality vs. 29.9% in the conventional care group, P < 0.001). This article provides a step-by-step guide for implementing this multidisciplinary management protocol, supported by rigorously audited clinical outcome data, serving as a practical operational framework for other institutions aiming to standardize and improve perioperative care pathways and short-term survival tracking in thoracic surgery.

Introduction

Lung cancer remains one of the most prevalent and deadly malignancies worldwide, with surgical resection constituting a cornerstone of curative treatment for early-stage disease^1,2,3. However, the perioperative period presents significant risks, including functional decline and early mortality, which can undermine surgical success^4,5. Postoperative complications, particularly pulmonary infections, and compromised baseline status are key barriers to this ideal clinical pathway^6,7.

While advancements in minimally invasive techniques, such as thoracoscopic lobectomy and segmentectomy, have improved outcomes by reducing surgical trauma and accelerating initial recovery^8,9, surgical technique is only one determinant of the patient’s longitudinal journey. Achieving an optimal “textbook outcome”, a composite measure encompassing complete resection, absence of major complications, and timely discharge, remains challenging, with real-world achievement rates underscoring the need for systematic care enhancement¹⁰.

Multidisciplinary, protocol-driven perioperative care, exemplified by Enhanced Recovery After Surgery (ERAS) principles, has emerged as a critical strategy to mitigate these risks and standardize high-quality care^11,12. Within this framework, nursing professionals play a pivotal role in ensuring continuity, leading patient education, and coordinating postoperative monitoring and mobilization^13,14. However, the clinical efficacy of such protocols is heavily predicated on implementation fidelity; low compliance with key protocol components often diminishes the intended clinical benefits, a critical implementation gap that is frequently underreported in thoracic surgery literature¹⁵.

Despite these recognized benefits, a significant gap persists in the availability of detailed, standardized, and easily implementable protocols specific to lung cancer surgery, as much of the existing evidence evaluates isolated interventions rather than providing an integrated, step-by-step clinical roadmap^16,17. Furthermore, while most surgical quality audits rely strictly on 30-day mortality, accumulating evidence suggests that 30-day metrics significantly underestimate the true perioperative risk and failure-to-rescue rates in thoracic oncology, highlighting the clinical necessity of extending short-term survival assessments to 90 days¹⁸.

To address these gaps, this methodology article presents a detailed, structured protocol for multidisciplinary perioperative management of lung cancer resection. Rather than reporting a retrospective study outcome, this work aims to provide a replicable operational framework. The protocol synthesizes evidence-based components, including preoperative risk assessment and prehabilitation, intraoperative lung-protective strategies, and postoperative multimodal rehabilitation, into a cohesive clinical pathway. The specific procedures, team roles, and timing necessary for implementation were detailed. Crucially, explicit binary criteria are established to quantify protocol compliance across multiple phases. The accompanying retrospective cohort analysis, cited from prior work¹⁹, demonstrates the potential clinical outcomes and short-term survival benefits up to 90 days associated with the protocol’s application, supporting its validity and motivating formal adoption and prospective evaluation.

Protocol

This study was conducted in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of Affiliated Kunshan Hospital of Jiangsu University and the First People’s Hospital of Taicang (Approval No. 2022-06-031). Written informed consent was obtained from all participants before their inclusion in the study. The overall pathway of the protocol is summarized in Figure 1.

NOTE: This protocol describes the standardized perioperative management bundle. The following steps outline its implementation for a patient scheduled for lung cancer resection.

1. Preoperative phase (initiated at the time of surgical decision, optimized during hospital admission)

1. Comprehensive baseline assessment and MDT planning
   1. Convene the Multidisciplinary Team (MDT)
      1. Convene a structured MDT briefing within 72 h of patient admission. Ensure mandatory attendance of a thoracic surgeon, an anesthesiologist, a clinical nurse specialist, a physiotherapist, and a dietitian.
      2. Utilize a standardized electronic medical record (EMR) MDT documentation template to record baseline evaluations and generate patient-specific management plans based on cross-disciplinary consensus.
   2. Execute standardized risk assessment
      1. Cardiopulmonary evaluation: Record baseline forced expiratory volume in 1 s (FEV₁), diffusing capacity of the lungs for carbon monoxide (DL_CO), and echocardiography parameters. Apply an intervention threshold where any patient presenting with an FEV₁ < 60% or DL_CO < 60% of the predicted value is automatically flagged as high respiratory risk, triggering an intensified prehabilitation sub-pathway. Apply the Thoracoscore or Eurolung risk model for formal risk stratification.
      2. Nutritional screening: Assess nutritional status using the Patient-Generated Subjective Global Assessment (PG-SGA). Enforce a predefined cutoff value where a PG-SGA score 4 or a body mass index (BMI) < 18.5 kg/m² mandates immediate oral nutritional optimization. Record baseline BMI and serum albumin/prealbumin levels.
      3. Psychological screening: Administer the Hospital Anxiety and Depression Scale (HADS) or a 10-point visual analog scale (VAS) for anxiety. Apply a diagnostic cutoff where a subscale score 8 for either anxiety or depression triggers formal psychological support mechanisms.
   3. Implement structured patient education: Provide a standardized education package, including brochures and instructional videos, covering the surgical journey, pain management modalities, incentive spirometry techniques, and early mobilization targets. Perform the “teach-back” method to confirm patient comprehension.
2. Structured prehabilitation program (minimum 2 weeks pre-op, intensive during admission)
   1. Conduct supervised pulmonary rehabilitation: Enforce twice-daily physiotherapist-led sessions lasting 20–30 min. Include diaphragmatic breathing, pursed-lip breathing, and effective coughing techniques. Set the supervised incentive spirometry training target at 50%–70% of the patient’s measured inspiratory capacity.
      ​NOTE: Define prehabilitation compliance as the verified completion of 80% of all scheduled sessions before the morning of surgery.
   2. Standardize physical conditioning: Enforce daily walking sessions with a progressive target of 30 min of continuous ambulation. Instruct the patient to maintain a moderate walking pace corresponding to a score of 3 to 4 (moderate to severe exertion) on the validated Borg CR10 Scale. Record the achieved daily duration and corresponding Borg scores in a structured patient log.
   3. Administer nutritional optimization
      1. Prescribe high-protein oral nutritional supplements providing 400–600 kcal and 30–40 g of protein daily for patients meeting the nutritional risk criteria (PG-SGA score 4). Implement immunonutrition formulas containing arginine and omega-3 fatty acids for 5–7 days preoperatively for severely malnourished patients. Track adherence via daily dietary charts, defining compliance as consuming 85% of the prescribed volume.
      2. Carbohydrate loading: Administer 400 mL of a clear, carbohydrate-rich drink (12.5% concentration containing 50 g of carbohydrates) exactly 2 h before the scheduled induction of anesthesia, adhering strictly to institutional fasting guidelines.
3. Psychological and logistical preparation
   1. Deliver psychological support: Schedule two 45-min cognitive-behavioral therapy (CBT) sessions conducted exclusively by a certified clinical psychologist or an oncology nurse specialist with specialized psychological counseling credentials. Focus sessions on cognitive-behavioral techniques for anxiety management and setting realistic recovery expectations.
   2. Complete preoperative checklist: Verify a standardized checklist 24 h before surgery to confirm smoking cessation >4 weeks, prehabilitation completion, nutritional compliance, and a clear understanding of postoperative recovery targets.

2. Intraoperative phase

1. Implement lung-protective ventilation
   1. Maintain volume-controlled or pressure-controlled ventilation during one-lung ventilation (OLV) with a tidal volume restricted to 6–8 mL/kg of predicted body weight. Apply positive end-expiratory pressure (PEEP) of 5–8 cm H₂O.
   2. Execute manual alveolar recruitment maneuvers (30 cm H₂O for 10 s) immediately following any ventilator circuit disconnection or airway suctioning.
      NOTE: Rigorously audit intraoperative ventilation compliance, defining it as uninterrupted adherence to all lung-protective ventilation settings throughout the entire duration of OLV.
2. Manage intravenous fluids: Execute goal-directed fluid therapy (GDFT) utilizing dynamic hemodynamic monitoring. Maintain target hemodynamic thresholds defined as a Mean Arterial Pressure (MAP) 65 mmHg and a Stroke Volume Variation (SVV) <12%. Prefer continuous vasopressor infusion (norepinephrine 0.02–0.1 µg/kg/min) over large-volume crystalloid boluses to correct transient hypotension and aim for a near-zero fluid balance.
3. Initiate multimodal analgesia
   1. Administer a loading dose of non-opioid intravenous analgesics (paracetamol 1 g) or flurbiprofen axetil 50 mg) before the surgical incision.
   2. Establish regional analgesia selection criteria based on the surgical approach: for multi-port video-assisted thoracic surgery (VATS) or open thoracotomy, insert a thoracic epidural catheter (TEA) at the T5–T7 interspace and initiate a continuous infusion of 0.2% ropivacaine combined with sufentanil 0.5 µg/mL at a rate of 4–6 mL/h; for single-port VATS, perform an ultrasound-guided paravertebral block (PVB) using 20 mL of 0.375% ropivacaine.
4. Surgical principles
   1. Minimally invasive approach: Prioritize video-assisted thoracic surgery (VATS) or robotic-assisted surgery when oncologically appropriate.
   2. Avoidance of routine drainage: Consider the use of a single small-bore (20–24 F) chest tube or digital drainage system with early ambulation protocols.

3. Postoperative phase (protocol-driven recovery on the ward)

1. Structured early recovery pathway (post-anesthesia care unit to ward)
   1. Respiratory care and mobilization procedure
      1. Immediate post-op: Resume incentive spirometry every 1–2 h while awake. Nurse-assisted coughing and breathing exercises.
      2. Mobilization: With assistance from a physiotherapist or nurse, ensure that patients sit out of bed on the evening of surgery and ambulate 20 m by postoperative day 1.
         ​NOTE: Target is walking 3 times daily, increasing distance progressively. Compliance with early mobilization on Day 1 was achieved only if the patient successfully met both requirements (sitting out of bed on the evening of surgery and completing a minimum of 20 m of walking on postoperative day 1).
   2. Multimodal analgesia regimen
      1. Scheduled medications: Enforce regular, scheduled administration of paracetamol (1 g intravenously or orally every 6 h) combined with a selective COX-2 inhibitor (celecoxib 200 mg orally every 12 h) unless contraindicated.
      2. Analgesia titration: Maintain the regional TEA or PVB catheter infusion. Transition to oral opioids (tramadol 50 mg or oxycodone 5 mg) only when the pain score is consistently controlled (VAS < 4).
      3. Pain monitoring: Assess pain severity using a 10-point Numeric Rating Scale (NRS) at rest and during movement every 4 h. Maintain an active intervention threshold where an NRS score 4 prompts immediate administration of rescue analgesia (e.g., intravenous sufentanil 5 µg) to facilitate active mobilization.
         ​NOTE: Systematically evaluate global patient satisfaction at discharge utilizing a standardized 100-point visual analog scale (VAS).
2. Multidisciplinary monitoring and discharge planning
   1. Daily MDT “Huddle”: Ensure a 15-min daily bedside round involving the surgeon, nurse, physiotherapist, and pain team to review progress, address barriers to mobilization, and adjust the daily plan.
   2. Standardized discharge criteria: Ensure that the patient meets all of the following: adequate analgesia with oral medications, independent ambulation to the bathroom, afebrile with stable vital signs, chest tube removed (if applicable) with no significant air leak/drainage, and patient/caregiver confident with discharge instructions.
   3. Follow-up coordination: Schedule a telephone follow-up at 48–72 h post-discharge by a clinical nurse specialist to assess recovery and a clinic visit at 30 days. Provide a clear contact pathway for concerns.

4. Data collection for outcome validation (retrospective analysis framework)

1. To validate protocol effectiveness, systematically collect data from electronic medical records for both the intervention cohort and historical reference cohorts across primary outcomes (14-day complications using standardized definitions, length of stay), secondary outcomes (30-day and 90-day all-cause mortality, unplanned 30-day readmissions, maximal acute NRS pain scores, discharge global satisfaction), and process metrics (compliance rates calculated per the binary criteria defined in preceding steps).

Results

To evaluate the application effects of this comprehensive management protocol, this study collected and analyzed clinical data from patients undergoing lung cancer resection. The cohort consisted of patients managed according to this protocol, along with a comparable control group receiving conventional perioperative care.

Protocol implementation and baseline characteristics

The baseline clinical, demographic, and surgical characteristics of the study population are summarized in Table 1. Among the 277 patients who underwent anatomical thoracic surgery at the institution between January 2021 and December 2022, 150 were managed under the comprehensive management protocol (intervention group), and 127 received conventional care (control group). The implementation fidelity and compliance metrics audited across the treatment continuum are detailed in Table 2. Key process metrics indicated highly successful protocol execution: prehabilitation completion was achieved in 90.7% of patients in the intervention group (vs. 29.9% in the control group), structured nutritional support was successfully provided to 46.0% (vs. 15.0%), lung-protective ventilation compliance reached 92.7% (vs. 52.0%), and early ambulation on Day 1 was implemented in 88.7% (vs. 37.0%), with all process metrics demonstrating a highly significant improvement (all P < 0.001) in the intervention cohort.

The baseline characteristics of both groups were well-balanced, with no statistically significant differences in mean age (56.04 ± 12.80 vs. 54.06 ± 13.60 years, P = 0.214), female gender distribution (62.0% vs. 66.9%, P = 0.467), body mass index thresholds, smoking history, prevalence of major comorbidities including chronic obstructive pulmonary disease (COPD, 19.3% vs. 18.1%, P = 0.916) and cardiovascular disease, tumor stage, or surgical approach (all P > 0.05, Table 1). This statistical comparability effectively rules out historical selection bias and validates subsequent outcome comparisons between the two groups.

Postoperative complications

The clinical application of the comprehensive care protocol was associated with a significant reduction in short-term postoperative morbidity, as extensively compiled in Table 2.

Pulmonary complications

The incidence of overall postoperative complications was significantly lower in the intervention group (10.0% vs. 29.1%, P < 0.001). This protective effect was most pronounced for pneumonia (3.3% vs. 11.0%, P = 0.022). Favorable, though non-significant, trends were observed for atelectasis (2.0% vs. 1.6%, P = 1.000) and respiratory failure (0.7% vs. 2.4%, P = 0.501).

Non-pulmonary complications

Rates of wound infection (0.0% vs. 3.1%, P = 0.092) and deep vein thrombosis (1.3% vs. 1.6%, P = 1.000) were also lower in the intervention group, although these differences did not reach statistical significance. No significant differences were found in the rates of prolonged air leak (1.3% vs. 4.7%, P = 0.187), pleural effusion requiring drainage, or urinary/gastrointestinal complications (2.0% vs. 0.8%, P = 0.736) between the groups. The comprehensive comparative profile of postoperative complications is illustrated in Figure 2.

Hospital stay and recovery efficiency

A principal benefit of the standardized protocol was a marked improvement in acute recovery efficiency and patient-reported experience. The postoperative hospital length of stay was statistically comparable between the comprehensive management group and the conventional care group (7.16 ± 3.32 days vs. 7.02 ± 3.66 days, P = 0.731, Table 2). Analysis of the hospital length of stay distribution, visually compared via the box plot in Figure 3, demonstrated a distinctly right-skewed profile in both cohorts, with a comprehensive range extending from a minimum of 4 days to a maximum of 24 days. High variability was driven by individual recovery dynamics, and statistical outliers extending beyond the 14-day threshold were observed in both groups using Tukey’s boxplot criteria, corresponding directly to individuals suffering from delayed resolution of low-grade air leaks. However, the intervention group demonstrated substantially superior quality-of-recovery metrics: the maximal numeric rating scale (NRS) pain score on postoperative days 1–3 was significantly reduced in the comprehensive management cohort (3.47 ± 1.01 vs. 5.17 ± 1.45, P < 0.001), representing improved clinical pain control efficiency. Furthermore, global patient satisfaction scores evaluated at discharge were markedly higher in the protocol cohort (91.82 ± 3.67 vs. 83.06 ± 6.13, P < 0.001, Table 2), with the data distribution patterns illustrated in Figure 3.

Survival outcomes and risk factor analysis

The multidisciplinary protocol demonstrated a substantial protective impact on short-term survival outcomes.

Risk factors

To construct a robust prognostic model and prevent the omission of vital confounding parameters, baseline clinical variables were systematically screened using univariate logistic regression. Variables demonstrating a baseline significance threshold of P < 0.10 in univariate screening, specifically advanced age, impaired baseline pulmonary function, preoperative COPD, and cardiovascular disease, along with the primary exposure variable (Comprehensive Management Protocol), were advanced into the final multivariable logistic regression model to control for confounding variables. Multivariable analysis identified the comprehensive perioperative management protocol as a powerful independent protective factor against mortality (Odds Ratio [OR] = 0.36, 95% Confidence Interval [CI]: 0.18–0.74, P = 0.005). Other independent risk predictors identified in the final model included advanced age (≥70 years, OR = 1.98, 95% CI: 1.13–3.48, P = 0.019), impaired pulmonary function (preoperative FEV₁ <60%, OR = 1.62, 95% CI: 1.01–2.60, P = 0.048), preoperative COPD (OR = 1.62, 95% CI: 1.02–2.60, P = 0.044), and cardiovascular disease (OR = 1.68, 95% CI: 1.02–2.78, P = 0.041). The detailed univariate and multivariable regression parameters are presented in Table 3, and the final odds ratios with exact 95% CIs are graphically displayed inline within the forest plot in Figure 4.

Mortality

The 90-day mortality rate was significantly lower in the intervention group (10.0% vs. 29.9%, P < 0.001), representing a profound clinical survival benefit. A lower 30-day mortality rate was also observed (4.0% vs. 10.2%), though this difference approached but did not reach full statistical significance (P = 0.071, Table 2). The Kaplan-Meier survival analysis, stratified into 30-day survival (Figure 5A) and 90-day survival (Figure 5B), showed a clear separation of curves in favor of the comprehensive protocol. This longitudinal survival advantage is fully supported by the inline shaded 95% confidence intervals and the corresponding number-at-risk tracking tables grid positioned below the time axis; specifically, the intervention group maintained a risk pool of 150, 144, and 135 surviving individuals at Days 0, 30, and 90, compared to 127, 114, and 89 individuals in the conventional care cohort, respectively.

Readmission

The unplanned 30-day readmission rate was numerically lower in the intervention group (13.3% vs. 15.7%), but this difference was not statistically significant (P = 0.691, Table 2).

Figure 1: Schematic overview of the perioperative multidisciplinary management protocol. The diagram illustrates the three-phase pathway (preoperative, intraoperative, postoperative) with key interventions and responsible team roles. Please click here to view a larger version of this figure.

Figure 2: Comparison of postoperative complications between groups. Bar graph demonstrating the incidence of major postoperative complications in comprehensive management versus conventional care groups. Each complication category is annotated with its respective statistical significance (P-value or 'ns' for non-significant comparisons) derived from the final audited dataset. Please click here to view a larger version of this figure.

Figure 3: Distribution of postoperative hospital stay duration. Box plot illustrating the comparable postoperative hospital stay duration between the comprehensive management group (7.16 3.32 days) and the conventional care group (7.02 3.66 days, P = 0.731, marked as 'ns'). Red circular markers indicate statistical outliers extending beyond the interquartile range (IQR). Please click here to view a larger version of this figure.

Figure 4: Multivariate analysis of factors associated with 90-day mortality. Forest plot displaying odds ratios (OR) and 95% confidence intervals (CI) from multivariate logistic regression analysis for 90-day mortality. The vertical line at OR = 1.0 indicates no effect, and exact independent risk/protective estimates are displayed inline next to each significant predictor. Please click here to view a larger version of this figure.

Figure 5: Kaplan-Meier overall survival analysis over short-term follow-up timelines. (A) 30-day overall survival curves comparing postoperative survival probabilities between the comprehensive management and conventional care groups. (B) 90-day overall survival curves comparing longitudinal survival between the two cohorts. Both panels are enhanced with shaded 95% confidence interval bands and corresponding number-at-risk tracking tables aligned below the time axis. Please click here to view a larger version of this figure.

Variable	Conventional (n=127)	Comprehensive (n=150)	P-value
Age (mean ± SD)	54.06 ± 13.60	56.04 ± 12.80	0.214
Gender, n (%)			0.467
Female	85 (66.9)	93 (62.0)
Male	42 (33.1)	57 (38.0)
BMI, n (%)			0.381
< 25 kg/m²	87 (68.5)	111 (74.0)
≥ 25 kg/m²	40 (31.5)	39 (26.0)
Smoking history, n (%)			0.237
No	52 (40.9)	50 (33.3)
Yes	75 (59.1)	100 (66.7)
Comorbidity: COPD, n (%)			0.916
No	104 (81.9)	121 (80.7)
Yes	23 (18.1)	29 (19.3)
Comorbidity: CVD, n (%)			0.69
No	100 (78.7)	114 (76.0)
Yes	27 (21.3)	36 (24.0)
Tumor stage, n (%)			0.346
Stage I–II	63 (49.6)	84 (56.0)
Stage III–IV	64 (50.4)	66 (44.0)
Surgical approach, n (%)			0.552
CT-guided biopsy	0 (0.0)	1 (0.7)
VATS Lobectomy	31 (24.4)	35 (23.3)
VATS Segmentectomy	94 (74.0)	112 (74.7)
EBUS-TBNA	0 (0.0)	1 (0.7)
Bronchoscopy	0 (0.0)	1 (0.7)
Thoracoscopic lesion resection	1 (0.8)	0 (0.0)
Thoracoscopic wedge resection	1 (0.8)	0 (0.0)
ASA Score, n (%)			0.135
I	20 (15.7)	32 (21.3)
II	82 (64.6)	79 (52.7)
III	25 (19.7)	39 (26.0)
FEV₁% (mean ± SD)	70.23 ± 15.11	73.11 ± 13.65	0.097

Table 1: Baseline characteristics of patients with lung cancer at admission (n = 277). Values are presented as mean ± standard deviation, median (interquartile range), or number (%). P-values derived from χ² test or the t-test, as appropriate. Abbreviations: VATS = Video-assisted thoracoscopic surgery; COPD = Chronic obstructive pulmonary disease; FEV₁ = Forced expiratory volume in 1 s; ASA = American Society of Anesthesiologists; BMI = Body Mass Index; CVD = Cardiovascular Disease.

Outcome variable	Conventional (n=127)	Comprehensive (n=150)	P-value
Protocol Compliance
Prehabilitation completion, n (%)	38 (29.9)	136 (90.7)	<0.001
Structured nutritional support, n (%)	19 (15.0)	69 (46.0)	<0.001
Lung-protective ventilation, n (%)	66 (52.0)	139 (92.7)	<0.001
Early ambulation on Day 1, n (%)	47 (37.0)	133 (88.7)	<0.001
Postoperative Complications
Overall complications, n (%)	37 (29.1)	15 (10.0)	<0.001
Pneumonia	14 (11.0)	5 (3.3)	0.022
Atelectasis	2 (1.6)	3 (2.0)	1
Respiratory failure	3 (2.4)	1 (0.7)	0.501
Wound infection	4 (3.1)	0 (0.0)	0.092
Deep vein thrombosis	2 (1.6)	2 (1.3)	1
Prolonged air leak	6 (4.7)	2 (1.3)	0.187
Urinary or gastrointestinal	1 (0.8)	3 (2.0)	0.736
Recovery Metrics
Hospital length of stay (days), mean ± SD	7.02 ± 3.66	7.16 ± 3.32	0.731
Maximal NRS pain score (0–10)	5.17 ± 1.45	3.47 ± 1.01	<0.001
Patient satisfaction score	83.06 ± 6.13	91.82 ± 3.67	<0.001
Follow-up Outcomes
30-day readmission rate, n (%)	20 (15.7)	20 (13.3)	0.691
30-day mortality, n (%)	13 (10.2)	6 (4.0)	0.071
90-day mortality, n (%)	38 (29.9)	15 (10.0)	<0.001

Table 2: Comparison of postoperative complications, recovery efficiency, and protocol compliance between the comprehensive management group and conventional care group (n = 277). Values are expressed as a number (%), except for continuous recovery and quality metrics (mean ± SD). The table systematically compiles both implementation process metrics (compliance rates for prehabilitation, nutrition, ventilation, and early mobilization) and comprehensive clinical outcomes. P-values are from chi-square or Fisher’s exact test for categorical variables, and t-test for continuous variables. Complications were assessed within 14 days postoperatively. Pain metrics represent the maximal numeric rating scale (NRS) scores recorded across postoperative days 1–3, and global patient satisfaction was measured via a structured 100-point visual analog scale (VAS) survey at discharge.

Variable	Univariate OR (95% CI)	P-value	Multivariate OR (95% CI)	P-value
COPD	1.66 (1.06–2.59)	0.026	1.62 (1.02–2.60)	0.044
Cardiovascular disease	1.74 (1.08–2.80)	0.023	1.68 (1.02–2.78)	0.041
Preoperative FEV₁ < 60%	1.62 (1.01–2.60)	0.045	1.62 (1.01–2.60)	0.048
Comprehensive Management	0.45 (0.28–0.72)	<0.001	0.36 (0.18–0.74)	0.005
Age ≥ 70 years	1.79 (1.03–3.10)	0.039	1.98 (1.13–3.48)	0.019
Gender (Male)	1.11 (0.59–2.05)	0.736	--	--
BMI ≥ 25 kg/m²	1.53 (0.80–2.86)	0.191	--	--
Smoking history	0.78 (0.43–1.45)	0.432	--	--
Tumor Stage (III–IV)	1.47 (0.81–2.70)	0.208	--	--

Table 3: Univariate and multivariate logistic regression analysis of risk factors associated with 90-day mortality in all lung cancer patients. OR = Odds Ratio; CI = Confidence Interval; VATS = Video-Assisted Thoracoscopic Surgery; COPD = Chronic Obstructive Pulmonary Disease; FEV₁ = Forced Expiratory Volume in 1 s; CVD = Cardiovascular Disease. Variables with P < 0.10 in univariate analysis were included in multivariate modeling. Outcome = 90-day all-cause mortality. "--" indicates variables excluded from the final multivariable model due to a lack of independent statistical significance (P ≥  0.05) during stepwise backward elimination.

Discussion

This methodology article presents a structured, multidisciplinary perioperative management protocol for lung cancer resection, detailing its components and implementation workflow. Representative results from applying this protocol in a clinical cohort demonstrate its association with improved postoperative outcomes, including reduced complications, reduced pain, higher patient satisfaction, and improved short-term survival. This discussion interprets these findings within the context of existing evidence, elucidates the protocol's mechanistic rationale, acknowledges its limitations, and outlines directions for future application and research.

Interpretation and integration with existing evidence

The observed reduction in pulmonary complications aligns robustly with literature advocating for integrated care pathways²⁰. The significant decrease in pneumonia incidence (3.3% vs. 11.0%) corroborates established evidence that structured preoperative breathing exercises and physical prehabilitation improve postoperative pulmonary function^21,22. The mechanism is multifactorial, involving enhanced respiratory muscle strength, improved bronchial hygiene, and reduced atelectasis, all actively promoted by the respiratory care and early mobilization steps within our protocol²³. Crucially, the exceptionally high protocol fidelity documented in our cohort, such as the 90.7% compliance rate in prehabilitation, underscores that the clinical benefits of the bundle are tightly bound to systematic execution rather than isolated interventions, addressing the patient's physiologic and psychologic readiness holistically.

Regarding recovery efficiency, the postoperative hospital length of stay was statistically comparable between the two groups (7.16 ± 3.32 days vs. 7.02 ± 3.66 days, P = 0.731). While a primary objective of conventional Enhanced Recovery After Surgery (ERAS) principles is the reduction of hospital stay²⁴, the current findings reveal a critical paradigm shift toward the "quality of recovery." Despite an identical duration of hospitalization, patients in the comprehensive management group experienced a profound clinical advantage, characterized by a substantial reduction in maximal postoperative pain scores (3.47 ± 1.01 vs. 5.17 ± 1.45, P < 0.001) and a significant increase in global satisfaction scores (91.82 ± 3.67 vs. 83.06 ± 6.13, P < 0.001). Importantly, this optimized quality of in-hospital convalescence was achieved without compromising safety, as evidenced by the statistically equivalent 30-day readmission rates between the cohorts (13.3% vs. 15.7%, P = 0.691). This suggests that the standardized, proactive interventions enhance the patient experience and clinical safety during the acute recovery window²⁵.

Most notably, the protocol was identified as an independent protective factor against postoperative mortality (Multivariate OR = 0.36, 95% CI: 0.18–0.74, P = 0.005). The survival advantage was uniquely apparent when extended to the 90-day follow-up period (10.0% vs. 29.9%, P < 0.001), whereas the 30-day mortality difference did not achieve full statistical significance (4.0% vs. 10.2%, P = 0.071). This disparity strongly validates our methodology of incorporating a 90-day survival horizon, demonstrating that traditional 30-day audits overlook late-onset perioperative failures and failure-to-rescue events in thoracic oncology²⁶. The long-term advantage is potentially mediated by reduced initial complication severity, better preserved functional status, and sustained multidisciplinary support during the critical transitional phase.

The success of the protocol can be attributed to the synergistic action of its core components, as detailed in the methodology. Preoperative prehabilitation (steps 1.2–1.4) directly targets modifiable risk factors: pulmonary training optimizes respiratory reserve, nutritional intervention supports immune function and tissue repair²⁷, and psychological preparation improves compliance and reduces stress. Intraoperative lung-protective strategies (step 2.1) mitigate iatrogenic injury. Postoperative structured recovery (steps 3.1–3.2), including proactive pain management and enforced early mobilization, prevents complications like atelectasis and venous thromboembolism^28,29,30. Crucially, the protocol's design mandates continuous multidisciplinary coordination (steps 1.1 and step 3.2.1), with nursing professionals playing a pivotal role in execution, monitoring, and ensuring care continuity, which is fundamental to achieving consistent results^12,16,31.

The analysis also confirmed known patient-related risk factors for mortality, such as advanced age (≥ 70 years), impaired baseline pulmonary function (FEV₁ < 60%), COPD, and cardiovascular disease. This underscores a key strength of the protocol: its structured yet adaptable framework allows for risk-stratified intensification of care. High-risk patients (e.g., those with advanced age, poor lung function, or comorbidities) may derive the greatest absolute benefit from strict adherence to all protocol elements, suggesting that future implementations can be tailored³². The protocol provides a standardized yet flexible template that can be adopted and adapted by other institutions seeking to systematize perioperative care, addressing the noted gap in standardized models for thoracic surgery¹⁸.

While the supporting results are promising, certain limitations must be considered when interpreting the protocol's efficacy and generalizability. The clinical outcomes are derived from a retrospective analysis using a historical control group across a limited number of centers, which may introduce selection bias and limit direct generalizability. Although statistical adjustments were made using multivariable logistic regression, unmeasured confounding factors cannot be entirely excluded. Furthermore, the presented data do not address long-term oncology outcomes such as cancer recurrence, overall survival, or quality of life, which are important for a holistic assessment. Finally, the specific contribution and ideal weighting of each component within the bundled protocol remain unclear; a “component-network” analysis would be a valuable future investigation to optimize the protocol.

Conclusion

In summary, this article provides a detailed methodological blueprint for a comprehensive perioperative management protocol in lung cancer surgery. The accompanying clinical outcome data illustrate its potential to significantly improve key surgical quality metrics, specifically protocol adherence, acute pain mitigation, and 90-day survival, supporting its clinical rationale and validity. The protocol translates evidence-based principles into a concrete, actionable clinical pathway. Future work should focus on prospective, multicenter randomized validation of this protocol, formal cost-effectiveness analyses, and research into tailoring specific interventions for high-risk patient subgroups to further enhance the quality and personalization of thoracic surgical care.

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Argyle Small-Bore Thoracic Catheter	Cardinal Health	8888571200	Straight single-use polyvinyl chloride chest tube (20-24 Fr) for optimized pleural drainage following VATS.
Celecoxib Capsules	Pfizer	https://www.pfizer.com	Baseline scheduled selective COX-2 inhibitor oral analgesic administered postoperatively (200 mg q12h).
da Vinci Xi Surgical System	Intuitive Surgical	IS4000	Advanced robotic surgical system utilized for minimally invasive anatomical lung resections.
Endo GIA Ultra Universal Stapler and Reloads	Medtronic	EGIAUSTND	Endoscopic linear cutting staplers utilized for secure division of pulmonary vessels, bronchi, and fissures.
GraphPad Prism	GraphPad Software	https://www.graphpad.com/	Statistical graphing software used for generating postoperative complication distribution bar charts.
High-End Anesthesia Workstation Primus	Draeger Medical	System Configuration	Advanced anesthesia platform for administering intraoperative lung-protective ventilation parameters during one-lung ventilation.
High-Protein Oral Nutritional Supplement	Nutricia	https://www.nutricia.com	High-protein oral formula prescribed for nutritionally at-risk patients (PG-SGA score $\ge$ 4) prior to resection.
Hospital Anxiety and Depression Scale	Western Psychological Services	https://www.wpspublish.com	Clinical psychometric questionnaire administered by the nurse specialist for preoperative psychological risk screening.
Numeric Rating Scale Assessment Tool	Standard Clinical Form	Clinical Standard Scale	10-point scale utilized every 4 hours for dynamic postoperative pain monitoring and targeted rescue analgesia titration.
Paracetamol Injection	Local Pharmaceutical Provider	Standard Pharmaceutical	Core component of the non-opioid multimodal analgesia regimen (1g IV/PO q6h).
PASS Power Analysis Software	NCSS, LLC	https://www.ncss.com/software/pass/	Power analysis and sample size software utilized during the initial study design phase.
Patient-Controlled Analgesia Pump	Baxter	7130P	Infusion pump system for delivering postoperative continuous regional or systemic analgesia.
Preoperative Carbohydrate Loading Drink	Local Clinical Provider	Clinical Nutrition Protocol	Clear 12.5% carbohydrate drink administered as a 400 mL oral dose 2 hours prior to anesthesia induction.
R Software	R Foundation for Statistical Computing	https://www.r-project.org/	Statistical programming environment used for data baseline balancing, multivariable regression, and survival analysis.
SPSS Statistics	IBM	https://www.ibm.com/spss	Statistical software utilized for baseline population clinical characteristics description and univariate filtering.
Thopaz+ Digital Chest Drainage and Monitoring System	Medela AG	77	Electronic digital chest drainage system providing continuous objective air leak tracking (mL/min) to accelerate tube removal.
Thoracic Epidural Analgesia Catheter Kit	Arrow International	AR-05500	Epidural catheter kit used for continuous intraoperative and postoperative regional analgesia delivery.
VATS Endoscopic Camera and Tower System	Karl Storz	IMAGE1 S	High-definition thoracoscopic visualization stack utilized for standard video-assisted thoracic surgery approaches.
Volumetric Incentive Spirometer Voldyne 5000	Teleflex	175502	Volumetric breathing training device utilized for supervised preoperative and postoperative pulmonary rehabilitation.