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A new era in relieving patients' suffering

Imagine the traumatizing process you have to go through in hospital after surgery, with continuous aching and possible complications during recovery.

But the situation is now much improved as doctors try to lessen the pain through various technical advancements in nursing, surgery and anesthesia.

Shanghai Chest Hospital, one of the top hospitals for thoracic surgery, has been working on enhanced recovery after surgery (ERAS) to help patients.

Quicker recovery means a shorter time in hospital, a reduction in medical expenses, and the efficient use of the medical resources.

“The development of enhanced recovery reflects the reform of the supply-side medical and health services in accordance with Healthy China 2030,” said Dr Pan Changqing, president of the hospital.

“Although the development of rapid rehabilitation is a small step, it plays a big role by reducing the medical burden on society. For patients, their life quality can be improved.”

ERAS technology was introduced to the hospital in 2018.

Dr Hou Xumin, the hospital’s vice president, said there were three main approaches: preoperative, intraoperative and postoperative in terms of nursing, surgery and anesthesia.

Before surgery, doctors conduct a comprehensive evaluation of patients so that they enter operation theater in an ideal state.

Following evaluation, the anesthesia team adopts a non-intubation method and multiple ways to reduce the use of drugs so patients can wake up more quickly and respiratory function is restored.

Finally, the nursing team will guide patients with nutritional recovery through various activities. Doctors will also help reduce any nausea caused by analgesics.

Hou said postoperative hospital stays had been shortened from the previous three and a half days to about two days. After patients are discharged, there’s a month’s follow-up.

Minimally invasive

Surgery is one of the key processes in ERAS. Apart from ensuring patients’ safety and the effect of the operation, advances in surgical technology alleviate their suffering.

In thoracic operations, the biggest advance in the past 20 years has been minimally invasive surgery including imaging systems, improved equipment and surgeons’ continuous learning.

Dr Fang Wentao, director of thoracic surgery, said more than 90 percent of thoracic operations at the hospital involve minimally invasive surgery.

Advanced equipment such as thoracoscopy and surgical robots are adopted to greatly accelerate patients’ recovery.

In traditional thoracotomy, patients usually stay in hospital for more than a week and many stay longer due to various problems.

“Now, most of our current patients after minimally invasive surgery can recover and be discharged from hospital within two or three days or even less,” said Fang.

The hospital, which specializes in cardiothoracic diseases, handles some of the most challenging surgeries in the medical field.

“Our early minimally invasive surgery started from relatively simple procedures, especially for some early-stage tumors which can be completed using endoscopy or robots,” said Fang.

Minimally Invasive technology is no longer limited to early-stage tumors. It has been applied in complicated operations, not only removal but also reconstruction, such as airway resection, esophageal surgery and mediastinal surgery.

“Minimally invasive surgery is more technically demanding for doctors, and requires a longer training period. But we make these efforts so that patients can benefit from it and suffer less,” said Fang.

Fast-track anesthesia

Fast recovery is a key consideration in thoracic anesthesia.

Dr Wu Jingxiang, director of the anesthesiology department, said there are two main factors affecting a patient's postoperative recovery — fatigue caused by residual anesthetics and pain.

“The pain caused by chest surgery is the strongest of all surgeries,” said Wu.

Since 2018, the hospital has been practicing “fast-track anesthesia,” which first started as a non-intubation technique for thoracoscopic surgery. Later, the fast-track process was developed in surgeries requiring intubation to benefit more patients.

To reduce any adverse effects on a patient's early recovery after surgery, the hospital has adopted precise anesthetic control to reduce residual anesthetics.

Short-acting anesthetics and multimodel analgesia are applied during the operation to make all the processes more controllable.

Doctors carry out continuous injections with a micro syringe pump with intelligent chips which can predict a patient’s blood drug concentration so that the dosage can be adjusted according to changes in blood pressure and heart rate.

“The amount of medicine we use, mostly sedation, analgesia and muscle relaxants, can be controlled accurately to make patients’ early extubation and postoperative recovery achievable,” said Wu.

The incidence of postoperative nausea and vomiting has been reduced from 30 percent to less than 10 percent, Wu said.

A patient surnamed Mao, 52, was able to get out of his bed the same day as his thoracoscopic surgery.

During his anesthetic process, propofol, a sedative, remifentanil, a short-acting analgesic drug, and muscle relaxant were injected.

“Everything was ok after I woke up,” said Mao. “The extubation process was a bit uncomfortable but I could take it.”

Mao was able to eat normally and take care of his body gradually by himself after extubation. Nurses also guided him with a three-month respiratory training to help improve his lung function.

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