EFFECTIVENESS AND FEASIBILITY OF THE ENHANCED RECOVERY AFTER SURGERY (ERAS) PROTOCOL IN THORACIC SURGERY: A COMPARATIVE ANALYSIS ACROSS TWO CENTERS

Background: Enhanced Recovery After Surgery (ERAS) protocols are multimodal, evidence-based perioperative pathways designed to reduce surgical stress and accelerate functional recovery. In thoracic surgery, ERAS has been associated with improved clinical outcomes. However, most available evidence derives from high-volume tertiary centres, with limited comparative data on feasibility and effectiveness across institutions with varying levels of maturity and resources. Objective: This thesis aimed to evaluate the feasibility, adherence, and clinical impact of ERAS protocol implementation in thoracic surgery across two contrasting healthcare settings: a tertiary referral centre and a newly established thoracic surgery unit. A secondary objective was to explore organisational factors influencing ERAS adoption and sustainability. Methods: A prospective, multicentric observational study was conducted in two hospitals with distinct organisational profiles. A personalised ERAS protocol comprising 25 evidence-based items was developed and implemented. Adult patients undergoing elective anatomical lung resection were enrolled. The primary outcome was ERAS adherence, assessed globally and by perioperative phase. Secondary outcomes included length of hospital stay, postoperative complications, chest drainage duration, and functional recovery. Qualitative observations were also collected to identify barriers and facilitators to implementation. Results: ERAS implementation was feasible in both centres, although adherence levels and implementation trajectories differed according to institutional context. Higher adherence was associated with shorter LOS (median: 5 days), reduced chest drainage duration (median: 4 days), and faster functional recovery (Barthel Index scores approaching baseline within two weeks post-discharge). Severe postoperative complications were low (15.4%), with no perioperative mortality. Qualitative findings identified team motivation, multidisciplinary collaboration, and organisational culture as key facilitators of successful ERAS integration. Conclusion: ERAS protocols can be effectively implemented in thoracic surgery across institutions with different levels of organisational maturity. Adherence to ERAS pathways represents a modifiable determinant of recovery, while institutional context significantly influences implementation processes. Context-sensitive, multidisciplinary approaches are essential for sustainable ERAS adoption in both established and emerging thoracic surgical services.