Sylvester Surgeons Implement Innovative Pain-Reduction Strategy

Cyril Ramlakah, a patient at Sylvester Comprehensive Cancer Center, part of the University of Miami Health System, had a remarkably low-pain recovery from lung surgery at UHealth Tower.

For the past three years, the ERATS protocol has been implemented for all patients undergoing thoracic procedures at UHealth Tower.

“I had a cancer removed from the upper right lobe of my lung in December,” said Ramlakah, an Ocala resident who drove to Miami for treatment. “I was fortunate that my primary care doctor saw those spots on my lungs. My surgery went well, and I was able to go back to work in February.”

Ramlakah is one of the many chest surgery patients who have benefited from the skills and experience of Dao Nguyen, M.D., professor of clinical surgery, chief of thoracic surgery, and the Donald Carlin Endowed Chair of Thoracic Surgical Oncology at the Sylvester.

As surgeon-in-chief and director of Minimally Invasive/Robotic Thoracic Surgery at UHealth Tower, Dr. Nguyen uses an innovative pain-reduction strategy called “Enhanced Recovery After Thoracic Surgery” (ERATS) to help patients feel better more quickly without relying on potent opioids.

“Optimal pain control after a surgical operation is of paramount importance for a satisfactory recovery,” Dr. Nguyen said. “This is particularly true for lung cancer patients who may also have emphysema, obesity, diabetes or cardiovascular disorders. They have a higher risk of complications after surgery if pain is not well controlled or if they take high doses of potentially addictive opioid medications.”

A collaborative effort

For the past three years, Dr. Nguyen and his colleague, Nestor Villamizar, M.D., assistant professor of clinical surgery and associate program director of the Cardiothoracic Surgery Fellowship Program, have implemented the ERATS protocol for all patients undergoing thoracic procedures at UHealth Tower. This is a collaborative effort that includes Michael Fabbro II, D.O., program director for the Adult Cardiothoracic Anesthesiology Fellowship, the nursing staff, led by Joy A. Stephen-McDonough, APRN, and the UHealth Tower therapeutic committee.

“We have had very positive results from this protocol, which includes extensive patient education about the nature of the operation, realistic expectations of postoperative cares and methods of pain management, as well as discharge planning,” Dr. Nguyen said. “Originally developed by specialists in Europe, U.S. colorectal, neurological and thoracic surgeons have been gradually adopting this approach, although it is still not widely available.”

Dr. Nguyen was the lead author of a study, “Optimization Of An Established Enhanced Recovery After Thoracic Surgery Protocol: Aiming For Schedule II Opioid-free Pain Control Following Robotic Surgery,” presented at the April 30 annual meeting of the American Association for Thoracic Surgery. Co-authors were Dr. Villamizar, Stephen-McDonough, Karishma Kodia, M.D., resident; and Joanne Szewczyk, post-doctoral associate.

The researchers found significant reduction in post-operative use of Schedule II opioids for pain management following robotic surgery in the study’s 324 patients. Only 42 percent of the patients required some form of prescribed narcotics for at-home pain management after surgery compared with 83 percent before protocol optimization. Only 9 percent of patients received prescriptions for schedule II opioids compared with 66 percent prior to protocol modification.

“An important part of ERATS is continual evaluation of clinical outcomes and implementation modifications to achieve more superior quality improvement,” Dr. Nguyen said. “We are very gratified with our results showing a drastically reduced reliance on opioids. I would encourage all thoracic surgeons to consider incorporating such perioperative care protocol to their practice.”

Reflecting on his practice, Dr. Nguyen said, “Our minimally invasive approach using the DaVinci robotic system, combined with our nursing staff’s comprehensive approach to pain management and the ERATS protocol, results in a much better surgical experience for our patients. Almost half of our patients undergoing robotic thoracoscopic surgery can be discharged with very low opioid doses or without any opioids at all.”

A positive experience

One example was Rhona Leff, who had a positive experience after her lung surgery in 2020.

“Dr. Nguyen did a great job with my surgery, and when I went home all I had to take was ibuprofen [an over-the-counter pain reliever],” she said. “Fortunately, my cancer was slow-growing and I can take a medication once a month to keep it under control.”

Dr. Nguyen said the UHealth team is committed to delivering excellent care while taking steps to address the nationwide opioid abuse epidemic.

“Minimizing opioid prescriptions at discharge of our thoracic patients contributes to the fight against opioid abuse by reducing availability and lessening the potential for misuse,” he said

Both Ramlakah and Leff credit Dr. Nguyen for their rapid recovery from lung cancer surgery.

“Dr. Nguyen is exactly the type of surgeon you want if you are diagnosed with a serious illness,” Leff said. “He and his team will ensure you receive the most advanced treatment with the best outcomes. You will also be discharged from the hospital as quickly as possible with a minimum of pain. Most important, he will help save your life.”

Tags: Dr. Dao Nguyen, Dr. Michael Fabbro, Dr. Nestor Villamizar, Sylvester Comprehensive Cancer Center, thoracic surgery