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 stu...

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...

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.