Mesothelioma surgery is one of the most demanding procedures in thoracic oncology, and that’s why the Enhanced Recovery After Surgery (ERAS) protocol is so important for those diagnosed with this rare, asbestos-related disease. ERAS is a multidisciplinary, evidence-based framework for patient care designed to minimize the physical stress of major surgery, to reduce complications, and to accelerate the return to normal function. It offers an effective way to make operations safer and to help mesothelioma patients recover faster.[1]
What Is the ERAS Protocol?
ERAS stands for Enhanced Recovery After Surgery. It is a coordinated set of interventions conducted before, during, and after a surgical procedure that work together to reduce surgical stress and support the body’s ability to heal. Rather than relying on a single intervention, ERAS is structured to include approximately 20 evidence-based components across each phase of care.[2]
Rather than representing a single treatment, ERAS is considered a philosophy of care based on the principle that multiple modest interventions used in combination create a holistic benefit far greater than the sum of their parts.[3]
The Origins of ERAS
The ERAS concept was first created in the 1990s by Danish surgeon Professor Henrik Kehlet, who saw the need for a standardized, multimodal approach to patient care that would reduce variability in colorectal surgery outcomes across surgical centers. Originally called “fast-track surgery,” the protocol was formalized as ERAS in 2001 by a group of European surgeons. Over the following two decades, the ERAS principles were adapted to include a wide range of surgical specialties, including thoracic surgeries like pleurectomy decortication and extrapleural pneumonectomy.[4]
ERAS in Thoracic Surgery
In 2019, the ERAS Society and the European Society of Thoracic Surgeons (ESTS) published joint guidelines for Enhanced Recovery After Thoracic Surgery (ERATS). These evidence-based recommendations specifically introduced 45 elements across the three phases of perioperative care for patients being treated by thoracic centers worldwide.
For mesothelioma patients undergoing extrapleural pneumonectomy (EPP) or pleurectomy/decortication (P/D), the ERATS framework provides the same benefits as the original ERAS protocol, systematically optimizing every phase of the surgical process to provide a better overall experience that is both safer and provides faster recovery.
Why ERAS Matters for Mesothelioma Patients
Pleural mesothelioma surgery is one of the most complex procedures performed in thoracic oncology. EPP involves the removal of an entire lung, pleural tissue, portions of the diaphragm and pericardium, and lymph nodes, and though P/D surgery spares the affected lung, it still requires the removal of all visible tumor from pleural surfaces throughout the chest cavity.
The rate of serious complications after EPP surgery has been reported at up to 82.6 percent, and average hospital stays range from seven days for P/D to nine days for EPP. Even after the surgery has been completed, every day in the hospital carries the risk of infection and muscle loss, which can delay the start of post-surgical treatments such as chemotherapy or radiation.
ERAS addresses these risks directly. By preparing patients thoroughly before surgery, refining what happens in the operating room, and aggressively managing recovery almost immediately after the procedure, ERAS improves both safety and efficiency.
Benefits Documented in Thoracic Surgery
Several studies of the ERAS protocol’s impact on thoracic surgery have been conducted by noted thoracic surgeons and have demonstrated that it can:[5]
• Reduce postoperative complication rates
• Shorten hospital length of stay
• Decrease cardiac and pulmonary complications
• Reduce opioid use and fluid overload
• Lower hospital readmission rates
• Improve post-surgical quality of life and health-related outcomes
Research also suggests that the more ERAS elements are implemented, the better the clinical outcomes for the patient.[6]
The Three Phases of ERAS in Mesothelioma Surgery
ERAS addresses every phase of surgical care, from the weeks before the patient enters the operating room, to what happens during surgery, to what happens during recovery. Each phase contains its own specific interventions.
Phase 1: Preoperative Care
Traditionally, interventions before surgery have been limited to “nothing by mouth after midnight,” but the preoperative phase of ERAS is far more active, optimizing the patient’s physical and psychological condition.
Prehabilitation
Prehabilitation is a structured conditioning program that starts weeks before the scheduled surgery with the goal of improving the patient’s physical reserves. It typically includes aerobic exercise, respiratory training, and nutritional optimization because patients with poor aerobic fitness, nutritional deficits, or muscle loss face significantly higher risks of postoperative complications.[7]
Doing respiratory exercises before surgery has proven to offer particular benefits in mesothelioma surgery patients, including fewer postoperative pulmonary complications and improved postoperative lung function.
Patient Education and Counseling
ERAS emphasizes informing and preparing patients through clear, comprehensive information about what to expect before, during, and after surgery. This has been shown to reduce pre-surgical anxiety, improve compliance with recovery instructions, and even influence patients’ perception of their pain.[8] For mesothelioma patients, this type of proactive communication can make a real difference in how they experience the entire surgical process.
Nutritional Assessment and Optimization
Malnutrition is a significant risk factor for surgical complications and happens all too frequently in mesothelioma patients, whose appetite is often affected by their disease. The presurgical ERAS protocol includes nutritional screening and supplementation when appropriate. Patients are also encouraged to drink carbohydrate-rich beverages up to two hours before anesthesia. This is a far cry from the traditional fasting requirements, which were both uncomfortable and have been found to create physical stress.
Stopping Smoking and Alcohol
Both smoking and heavy alcohol use have a negative impact on the body’s ability to heal wounds, as well as on immune function and breathing. ERAS guidelines recommend addressing these habits before surgery, ideally creating a window of at least four weeks for cessation.
Phase 2: Intraoperative Care
The intraoperative phase of ERAS focuses on minimizing the traumatic impact created by the surgery itself. It includes the use of minimally invasive techniques where possible, as well as managing anesthesia to reduce stress on the body’s systems, all with an eye to minimizing the time needed for recovery.
Minimally Invasive Surgical Techniques
Where medically appropriate, minimally invasive approaches such as video-assisted thoracoscopic surgery (VATS) or robotic-assisted surgery reduce surgical trauma, pain, and recovery time. While the spread of mesothelioma tumors may necessitate open surgery, ERAS favors the use of the least invasive technique capable of achieving complete resection.
Multimodal, Opioid-Sparing Analgesia
One of the most important elements of intraoperative ERAS is its goal of moving away from opioid-dependent pain management. ERAS protocols recommend a combination of regional anesthesia, anti-inflammatory medications, and local nerve blocks to control pain. This minimizes the negative side effects of opioids, which include respiratory depression, nausea, ileus, and impaired mobility. For mesothelioma patients, the revised protocol often includes epidural analgesia, intercostal nerve blocks, or direct injection of local anesthetics.[5]
Goal-Directed Fluid Management
Too much fluid during and after thoracic surgery can cause significant pulmonary complications, including edema and a prolonged need for supplemental oxygen. ERAS protocols stress fluid management that maintains appropriate hydration without overdoing it. This helps protect the remaining lung tissue and reduces postoperative respiratory complications.
Phase 3: Postoperative Care
Postoperative ERAS interventions begin the moment the patient leaves the operating room. Its goals are early mobilization, prevention of complications, and a faster return to the patient’s normal physical condition.
Getting Moving as Quickly as Possible
Prolonged bed rest after major surgery leads to muscle loss, increases the risk of blood clots, and makes it harder to return to normal pulmonary function. ERAS emphasizes getting patients up and moving as soon as safely possible — often within hours of surgery. The ability to do this is facilitated by the use of adequate pain control, which means the multimodal approach to analgesia used during surgery carries into recovery.[9]
Earlier Oral Nutrition
While traditionally, surgical patients were placed on restricted diets after their procedures, ERAS favors early reintroduction of oral nutrition. This supports healing, preserves gut function, and helps patients maintain strength. Under the ERAS protocol, food is typically introduced within hours of surgery for most thoracic surgery patients.
Chest Tube and Drain Management
The chest tubes required during pleural surgery are a major source of pain as well as a real barrier to getting patients moving again. ERAS protocols favor the earliest possible removal of chest drains based on the precise measurement of drainage rather than on visual assessments. The protocol also recommends cutting the number of drains where possible.
Avoidance of Urinary Catheters and Nasogastric Tubes
Routine use of urinary catheters and nasogastric tubes prolongs hospital stays and increases the risk of infection. ERAS calls for them to be avoided entirely if possible and removed as quickly as is medically appropriate to reduce patient discomfort and encourage earlier independence.
ERAS and Quality of Life After Mesothelioma Surgery
Both EPP and P/D surgeries for mesothelioma are major surgeries, and the significant change in chest anatomy that they create carries an obvious negative impact on function. This decline is generally short-term; research has shown that most patients experience a return to their preoperative quality of life by approximately four months after surgery.[10] ERAS directly supports and improves this timeline by reducing complications, minimizing pain, promoting early mobilization, and shortening hospital stays. It lets patients begin rebuilding strength and function sooner, which is especially important for mesothelioma patients, as getting patients home and recovering more quickly also means getting them to the next phase of care sooner. ERAS reduces the time between the surgery itself and post-surgical treatments, including chemotherapy, immunotherapy, and/or radiation.
Mesothelioma Patients Can Ask Their Care Team About ERAS
If you or a loved one is being evaluated for mesothelioma surgery, it’s worth asking your care team whether they use an ERAS protocol and what it includes. Not all centers use every element of the protocol.
Questions worth asking include:
• Does your center have a formal ERAS or enhanced recovery program for mesothelioma surgery patients?
• What preoperative preparation is recommended, and how early should it begin?
• How will my pain be managed during and after surgery to reduce reliance on opioids?
• When can I expect to be up and moving after the operation?
• What nutritional support will be available before and after surgery?
• How long do you think I will be in the hospital, and what milestones will determine when I can go home?
The answers to these questions will help you understand what to expect and may even spur greater use of the ERAS protocols.
