Phase I Safety and Feasibility Pilot Study of Same-Day Discharge After Video-Assisted Thoracoscopic Surgery (VATS) Anatomical Lung or Wedge Resection (VALUE Trial)
Phase: NA
Conditions: Lung Cancer, Surgery
Sponsor: McGill University Health Centre/Research Institute of the McGill University Health Centre

Protocol – Same-Day Discharge for VATS Anatomical Lung or Wedge Resection 
Version 4.0 – 27 July 2022 
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Study Protocol 
 
 
PROTOCOL TITLE: Phase I Safety and Feasibility Pilot Study of Same-Day Discharge after 
Video-Assisted Thoracoscopic Surgery (VATS) Anatomical Lung or Wedge Resection  
 
 
PRINCIPAL INVESTIGATOR: 
Jonathan D. Spicer, MD PhD  
 
CO-INVESTIGATORS: 
Caroline Huynh, MD 
 
Severin Schmid, MD 
 
Lorenzo Ferri, MD PhD  
 
Christian Sirois, MD 
 
Jonathan Cools-Lartigue, MD PhD  
 
Sara Najmeh, MD MSc  
 
Florin Costescu, MD 
 
Gabriele Baldini, MD MSc 
 
David Bracco, MD 
 
Andrew Owen, MD 
 
Danielle Shafiepour, MD 
 
Alexander Amir, MD 
 
Francesco Donatelli, MD 
 
Juan Francisco Asenjo, MD 
 
 
INSTITUTION: 
Montreal General Hospital (MGH) 
 
PROTOCOL VERSION:  
4.0 
 
PROTOCOL DATE:  
27-July -2022 
 
 
 
 

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1.0 BACKGROUND 
 
Over the last decade, video-assisted thoracoscopic surgery (VATS) has become the standard of 
care for surgical resections of early stage lung cancers with proven benefit in terms of 
perioperative morbidity, length of stay and post-operative pain, while providing equivalent long-
term and oncological outcomes when compared to conventional open surgery (1-5).  
 
Enhanced recovery after surgery (ERAS) has been implemented in many surgical specialties and 
has shown positive outcomes. Key principles and concepts of ERAS include pre-operative 
counselling, nutrition optimization, standardized multimodal analgesia and early mobilization (6). 
Our institution has adopted enhanced recovery pathways (ERP) for a variety of surgical 
procedures, including esophageal and upper gastrointestinal surgeries, which led to shorter 
length of stay (LOS) and cost savings (7-9). For lung surgery, few studies have been published 
describing outcomes with ERPs (10, 11). Larger prospective trials are therefore needed. 
 
A shorter LOS is an attractive concept with regards to hospital resource management, but 
moreover for improving patient factors such as recovery, function and quality of life. Our centre 
implemented an ERP for open and VATS lobectomy in 2012 which led to shorter LOS, lower 
complication rates, but no difference in readmissions or chest tube reinsertions (12). A cost 
analysis of this ERP was performed to evaluate the economic impact and revealed significantly 
reduced societal costs (average of $4396 per patient) (13). 
 
Our institution therefore recently performed a feasibility analysis of a 23-hour enhanced recovery 
pathway (ERP) for VATS lobectomy by retrospectively reviewing a 10-year cohort of patients (14). 
This study revealed that a significant proportion of patients could be discharged safely through 
this ERP. Patients discharged within 23 hours had shorter chest tube duration, lower clinical stage 
disease, lower pathological stage lesions, fewer surgical complications and shorter operative 
time. However, only clinical stage and surgeon were predictive factors of a shorter length of stay. 
30-day mortality for this cohort was 0% and major complication rate was 8.3%. Interestingly, even 
without a dedicated 23-hour recovery pathway, the proportion of patients discharged within 23 
hours increased starting in 2016 compared with years prior, and became close to 25% in the later 
portion of the study. Furthermore, in a recently conducted trial with data from 2019, discharge 
rates on postoperative day 1 were as high as 68 % (Kaafarani et al, “Trending towards day surgery 
in anatomical lung resections”, unpublished data, manuscript in preparation). Therefore, we 
believe that by further optimizing perioperative care, same-day discharges after anatomical lung 
resection are feasible and safe. 
 
With the current ERP for VATS lung surgery, the standard of care target for discharge is on post-
operative day 2. This prospective observational study therefore aims to evaluate the safety and 
feasibility of pre-operatively enrolling patients undergoing a VATS anatomical lung or wedge 
resection into an ERP allowing for a same-day discharge from the hospital. By demonstrating the 
feasibility of same-day discharge, this can be more widely applied and could further improve 
patient care. 
 
 
2.0 HYPOTHESIS 
 
For patients undergoing an uncomplicated VATS anatomical lung or wedge resection and enrolled 
in an ERP, same-day discharge is safe and feasible, and will not result in a higher rate of adverse 
events as compared to patients on a same-day admission pathway with an expected length of 
stay of 2 days.  

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3.0 OBJECTIVES AND PURPOSE 
 
The aim of this phase I study is to evaluate the safety and feasibility of same-day discharge in 
participants undergoing anatomical lung resection (segmentectomy or lobectomy) or wedge 
resection by VATS with an ERP.  
 
Primary Outcomes 
1. Adverse event rate* 
2. Same-day discharge rate 
3. Readmission rate 
4. Rate of presentation to the emergency room after surgery 
 
Secondary Outcomes 
1. Quality of life 
2. Duration of indwelling chest tube catheter 
3. Rate of screen failure 
4. Percent of eligible participants consented 
5. Pathway adherence rate 
 
*Post-operative complications: recurrent pneumothorax, subcutaneous emphysema, 
prolonged air leak, pneumonia, pulmonary embolism, atrial fibrillation, bleeding, uncontrolled 
pain, chest tube reinsertion, wound infection, pleural empyema.  
 
Postoperative complications will be classified according to the Ottawa Thoracic Surgery 
Mortality and Morbidity classification (15). 
 
Feasibility of the Pilot Study 
This pilot study design will be deemed feasible for larger investigations if: 
1. The sample population size can be achieved 
2. Greater than fifty per cent (>50%) of consented participants are able to continue with 
same-day discharge post-operatively  
3. There are no Serious Adverse Events (SAE) raising concerns about the safety of this ERP  
 
4.0 PARTICIPANTS 
 
This trial will be enrolling 20 participants from the Montreal General Hospital (MGH) at McGill 
University who are scheduled for an elective anatomical lung or wedge resection with suspected 
or confirmed pulmonary malignancy. When 20 participants are successfully consented the trial 
will close to accrual.  
 
4.1 Inclusion criteria 
- 
Signed or verbal informed consent by participant 
- 
Male and female adults, age 18 and above 
- 
Clinical stage I-II lung cancer (suspected, proven, unproven), or secondary pulmonary 
malignancy 
- 
BMI < 35 
- 
ECOG 0-1 
- 
Eligible for surgery and lung cancer resection (FEV1 > 60%, DLCO > 60%) 

Protocol – Same-Day Discharge for VATS Anatomical Lung or Wedge Resection 
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- 
Elective VATS anatomic resection (segmentectomy or lobectomy), or wedge resection 
- 
Capable caregiver for discharge home 
 
4.2 Exclusion criteria 
- 
Clinical stage III lung cancer 
- 
Surgery requiring pneumonectomy 
- 
Neoadjuvant therapy 
- 
Active pregnancy or breastfeeding  
- 
History of chronic pain syndromes 
- 
History of chronic opioid use 
- 
Concomitant major surgery indicated with current admission to hospital 
- 
Intraoperative complication including conversion to thoracotomy, major bleeding 
requiring blood transfusion, extensive adhesiolysis, injury to mediastinal structures, 
airway injury, nerve injury (phrenic, recurrent) 
- 
Need for epidural or patient-controlled intravenous analgesia 
- 
Need for urinary catheter  
 
 
5.0 DESIGN, METHODOLOGY AND ANALYSIS 
 
5.1 Study Design 
 
(a) Study phase and type: Phase I, prospective observational pilot study 
(b) Study blinding: Open-label 
(c) Study allocation: N/A, single-arm study 
(d) Study setting: Single center, Division of Upper Gastrointestinal and Thoracic Surgery at 
McGill University Health Centre (Montreal General Hospital) 
(e) Research intervention: Enhanced recovery pathway (ERP) for VATS anatomical lung 
resection or wedge resection for same-day discharge from hospital 
(f) Estimated enrolment period: September 2022 to September 2023 
(g) Estimated duration of trial: Up to 1 year from first participant enrolled with verbal or signed 
informed consent to last study-related participant follow-up. 
(h) Estimated duration of trial per participant involvement: From day of consent, to surgery, 
through follow-up within trial terms (for 4-6 weeks) for a total of approximately 2-3 months. 
Further follow-up according to usual treatment plan / lung cancer follow-up. 
 
5.2 Participant accrual 
 
(a) Estimated enrolment: 20 participants  
(b) Surgeons:  
- 
Dr. Jonathan Spicer 
- 
Dr. Lorenzo Ferri 
- 
Dr. Jonathan Cools-Lartigue 
- 
Dr. Sara Najmeh 
(c) Study estimated start date: October 2022 
(d) Study estimated completion date: October 2023 
 
5.3 Description of procedures  
 
SOC - Standard of care; RP – Research procedure  
 

Protocol – Same-Day Discharge for VATS Anatomical Lung or Wedge Resection 
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(a) Pre-operative ERP: 
- 
Participant education: Tailored preoperative education protocol with information 
booklet that includes daily goals. [SOC] 
- 
Participant education: Addendum to the information booklet “VATS Guide Addendum” 
with specifics regarding this research protocol. [RP] 
- 
Participants will be booked as first case of the day. [RP] 
- 
All standard COVID-19 mitigation strategies for thoracic surgery patients will be 
employed. [SOC] 
- 
Proposed perioperative anesthesia care pathway consensus [See Appendix 1 for 
more details]. [SOC and RP] 
§ 
All participants will be booked as the first case of the day to allow for a 
prolonged PACU stay, if needed. [RP] 
 
(b) Intraoperative ERP: 
- 
Proposed perioperative anesthesia care pathway consensus [See Appendix 1 for 
more details]. [SOC and RP] 
- 
Extubation: In the operating room. [SOC] 
 
(c) Lung resection: Patients will be placed under General Anesthesia and intubated with a 
double-lumen endotracheal tube. Patient will be rotated in lateral decubitus so as to 
elevate the surgical side (16). Standard sterilization and draping will be performed. A 3-5 
cm incision will be performed in the fifth or fourth intercostal space and a 1cm incision in 
the eighth intercostal space. Some surgeons might choose to place a third access port 
that is 1-3 cm. The pleural cavity will be inspected and the site of tumor, identified. A 
segmentectomy or lobectomy will be performed in standard protocol. A 20F or 24F tube 
will be advanced to the thoracic apex and connected to Mini-Atrium dry seal drainage 
system (Mini-Atrium 500, Atrium, USA). Skin incisions will be closed in standard fashion. 
The procedures will be performed by staff surgeons from the Division of Upper 
Gastrointestinal and Thoracic Surgery. [SOC] 
 
(d) Post-operative ERP: 
- 
Proposed perioperative anesthesia care pathway [See Appendix 1 for more 
details].[SOC] 
- 
Urinary catheter: None, avoid. [SOC] 
- 
Chest tube: Will be connected to a small portable dry seal drainage system (Mini-
Atrium 500, Atrium, USA) with which the participants will be discharged. Chest tube 
will be removed upon the absence of an air-leak and a drainage of less than 800 ml of 
non-bloody, non-chylous fluid. [Note: Chest tube insertion is SOC, and patients can 
be discharged with or without tube if they fit removal criteria. Usually, if they are 
discharged home with the tube, they are seen between post-operative days 5 and 7 in 
follow-up and removal of chest tube. As part of RP, because participants will be 
discharged on the same day as surgery, they will all keep the tube and been seen on 
post-operative day 2 or no later than day POD 7. 
- 
Short-term follow-up: Participants will be seen on post-operative day (POD) 2, and on 
POD 5 if the chest tube was not removed on POD 2 after surgery. Upon arrival in the 
outpatient clinic, the participant’s chest tube will be clamped and a chest x-ray will be 
performed 2 hours later. Moreover, participants will be called daily until chest tube 
removal or POD 5. Further follow-up will be tailored to participants’ needs. [RP] 
 
(e) Criteria for safe discharge on the day of surgery [SOC]: 
- 
Pain well controlled (VAS <3 at rest and <5 when moving) 

Protocol – Same-Day Discharge for VATS Anatomical Lung or Wedge Resection 
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- 
Non-bloody chest tube drainage quality, of no more than 100 cc/h over last 4 hours 
before planned discharge 
- 
No subcutaneous emphysema, clinically and on post-operative x-ray 
- 
Participant independently ambulating to bathroom 
- 
No oxygen requirement and oxygen saturation (SpO2) > 92% on room air at rest 
- 
Stable vital signs (match vitals before surgery) and no documented perioperative 
tachyarrhythmia  
- 
Dry dressings for the last 4 hours prior to planned discharge 
- 
Participant awake, oriented and cooperative (Glasgow Coma Scale (GCS) 15) 
- 
Bedside swallowing assessment performed by surgeon or thoracic surgery fellow; 
participant must be able to drink clear liquids without clinical signs of aspiration 
- 
Capable caregiver for discharge home 
 
(f) Quality of life: 
Quality of life will be assessed using the Functional Assessment of Cancer Therapy - Lung 
(FACT-L) and the Edmonton Symptom Assessment System (ESAS) questionnaires at the 
following time points [RP]:  
- 
At the time of consent 
- 
On the day of surgery 
- 
After removal of the chest tube 
- 
30 days after surgery 
    
5.4 Description of outcomes 
 
Primary Outcomes 
1. Adverse event rate: Proportion of participants experiencing complications related to 
surgery (classified per type of complication). 
2. Same-day discharge rate: Proportion of participants enrolled in the trial that go home 
on the day of the surgery. 
3. Readmission rate: Proportion of participants requiring hospitalization due to 
complications or conditions related to the surgery. 
4. Rate of presentation to the emergency room after surgery: Proportion of participants 
presenting to the emergency room due to complications or conditions related to 
surgery. 
 
Secondary Outcomes 
1. Quality of life: Assessed using the Functional Assessment of Cancer Therapy - Lung 
(FACT-L) and the Edmonton Symptom Assessment System (ESAS) questionnaires. 
[See Appendix 2, 3] 
a. FACT-L: Rating questions regarding physical, social/family, emotion and 
function well-being as well as general questions regarding medical health, on 
a scale of 0-4 (from ‘Not at all’ to ‘Very much’). 
b. ESAS: Rating pain, fatigue, nausea, depression, anxiety, drowsiness, appetite, 
well-being and shortness of breath, on a scale of 1 to 10. 
2. Duration of indwelling chest tube catheter: In days, from insertion until removal of chest 
tube catheter. 
3. Rate of screen failure: Proportion of participants who were screened, but did not meet 
one or more inclusion or exclusion criteria that was required for participation in the 
study.  
4. Percent of eligible patients consented: Proportion of participants enrolled vs. not 
enrolled who meet all inclusion and exclusion criteria.  

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5. Pathway adherence rate: Proportion of participants enrolled that remained on the 
enhanced recovery pathway and followed all measures for same-day discharge vs. 
those that did not. 
 
 
 

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5.5 Statistical analysis 
 
Participants that meet criteria (inclusion and exclusion) will be prospectively enrolled into this trial. 
Clinical data will be prospectively collected according to the Thoracic Surgery Quality monitoring, 
Information management, and Clinical documentation (TSQIC) software data management 
system and subsequently extracted for analysis; https://tsqic.org/tsqic/. [See Appendix 4] 
 
Demographic characteristics (sex, age), baseline characteristics (past medical and surgical 
history, smoking status, occupational exposure), diagnostic data (pulmonary function [FEV1, 
FVC, DLCO], diagnosis, clinical staging), pathological data (pathological stage, margin status, 
lymphovascular invasion, pleural visceral invasion) and operative data (operative time, timing of 
surgery, morbidity and mortality including post-operative complications and major complications) 
will be collected.  
 
*Post-operative complications: recurrent pneumothorax, subcutaneous emphysema, 
prolonged air leak, pneumonia, pulmonary embolism, atrial fibrillation, bleeding, uncontrolled 
pain, chest tube reinsertion, wound infection, pleural empyema. 
 
Complications will be scored using the Ottawa Thoracic Morbidity and Mortality classification 
system (15); https://ottawatmm.org/. 
 
Clinical and pathological staging will be performed according to AJCC TNM 8th edition.  
 
Specific research data, such as admission/discharge/emergency visit/readmission dates and 
secondary outcomes data, will be collected in a password-protected document behind the firewall 
of the MUHC. Only principal investigators and members of the research team will have access to 
the password.  
 
Descriptive and observational sample analyses will be performed using proportions for categorical 
variables, means with standard deviations for normally distributed variables and medians with 
interquartile ranges (IQRs) for skewed distribution variables. 
 
5.6 Benefits and risks  
 
Benefits 
 
Participants may or may not personally benefit from their participation in this research study. The 
safety and feasibility information collected during the research will help guide future decisions with 
regards to implementing a same-day discharge ERP for patients undergoing VATS lung surgery.  
 
Risks 
 
Although this protocol is designed and optimized to minimize any harm to the participants, there 
are possible risks related to the research procedures: 
§ 
ERP: unrecognized and more severe surgical complications (bleeding, urinary retention, 
arrhythmias, pneumothorax) requiring revisit to hospital 
§ 
Quality of life questionnaire: discomfort, distress 
§ 
Chest tube: inconvenience of returning for following on post-operative day 2, chest tube 
fall-out, wound care issues or infection 
 
 
 

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6.0 ETHICAL CONSIDERATIONS 
 
6.1 Consent 
 
Participants will be approached for consent during their pre-procedure (pre-op) visit. A detailed 
explanation of the study will be discussed including its purpose in regards to assessing the safety 
and feasibility of this enhanced recovery pathway. While the treating surgeon will be the one 
explaining the standard of care procedures in detail, the study details will be provided and consent 
obtained by the study’s research coordinator. Consent will be documented by the participant’s 
signed or verbal dated consent along with the signature of the person conducting the consent 
process and a witness, if applicable. A witness will be present for a verbal consent. The consent 
statement will be read aloud and participants will be given time to ask their questions. After verbal 
consent is given, the participants name, witness’ name, and name of who is obtaining consent 
will be put on the informed consent document. No signatures will be collected for verbal consent. 
Verbal consent shall be collected if the participant has a reading disability or inability to read, 
communicates in a foreign language requiring an interpreter, or they are capable of consenting 
but unable to write. A copy of the consent form will be provided to the participant prior to 
participation in the study.  A copy of the signed consent form should be given to the participant, 
or mailed to the participant’s home address, if signature is required. For remote consent (over the 
phone), participants will receive a copy to sign when they arrive on site for their scheduled 
procedure.  
 
The consent process will adhere to REB requirements, applicable laws and regulations including 
Health Canada’s guidance on consent during the COVID-19 pandemic. 
 
Should remote consent be required or requested, a digital copy of a signed consent form (photo 
or PDF) that has been emailed to the clinic will be accepted.  
 
The total period of study for participant involvement will be approximately 2-3 months (surgical 
procedure + ERP + follow-up). The procedures and concepts included in the enhanced recovery 
pathway will be described and explained to the participant. 
 
General participant information collected will include participants’ demographic, diagnostic and 
pathological data. Information collected that is specific to this study will consist of adverse events 
and feasibility measures. All information will be de-identified to maintain participant confidentiality. 
 
Study participation is completely voluntary. Patients may refuse participation or consent can be 
withdrawn at any time at the request of the participant without any consequence to their care.  
 
6.2 Confidentiality  
 
This study will be conducted in accord with the Tri-Council Policy Statement: Ethical Conduct for 
Research Involving Humans (2018), as well as in respect of the requirements set out in the 
applicable standard operation procedures of the Research Institute of the McGill University Health 
Centre Research Institute and of the McGill University Health Centre Research Ethics Board. The 
McGill University Health Centre Research Ethics Board will review this study and will be 
responsible for monitoring it.  
 
Only data relevant to this study as outlined in this protocol will be collected by the research team. 
All information collected during the research project will remain confidential to the extent required 

Protocol – Same-Day Discharge for VATS Anatomical Lung or Wedge Resection 
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and provided by law. Participant data will be de-identified and coded. The code will be kept by the 
Principal Investigator in a password-protected digital file behind the MUHC firewall.   
 
Data may be published or shared during scientific meetings, however all participant identifying 
information will be excluded. 
 
6.3 Maintenance of study records 
 
To enable evaluations and/or audits from regulatory authorities, the Principal Investigator agrees 
to keep records, including the identity of all participants, all original signed informed consent 
forms, source documents, and detailed records of treatment disposition.  
 
The data will be entered in an electronic secure database (TSQIC) and file, which will be 
maintained with up-to-date information by the Principal Investigator or their team. It is the Principal 
Investigator’s responsibility to ensure the accuracy of the data entered. 
 
The clinical data extracted from TSQIC and research data collected will be de-identified and 
coded in a password protected file behind the MUHC firewall.  
 
The data will be kept for a total of 7 years. 
 
6.4 Compensation and reimbursement 
 
Participants will be compensated 50$ for the additional follow-up visit after surgery, during which 
they will undergo removal of their chest tube. This compensation is provided by the Division of 
Thoracic Surgery Account.  
 
 
6.5 Reporting Serious Adverse Events 
 
In compliance with SOP 405A.001 Serious Adverse Events (SAE) must be reported to the REB 
through NAGANO. Follow the guidelines below: 
 
Local Serious Adverse Events: 
• 
The Researcher must report to the REB any local serious adverse event that, in the 
opinion of the Researcher, meets all of the following criteria: 
o Unexpected; 
o Related or possibly related to participation in the research; and 
o Suggests that the research places research participants or others at a greater risk 
of harm than previously identified at time of review and approval. 
Non-Local (External) Serious Adverse Events 
• 
The Researcher must report to the REB, any non-local serious adverse event that, in the 
opinion of the Researcher, meets all of the following criteria: 
o Unexpected; 
o Related or possibly related to participation in the research; and 
o Suggests that the research places research participants or others at a greater risk 
of harm than previously identified at time of review and approval. 
AND 
o Requires a change to the research and/or informed consent form and/or requires 
immediate notification to participants for safety reasons. 
 

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Report to the REB 
• 
The report submitted to the REB must include all of the following information: 
o The description of the adverse event; 
o Previous safety reports concerning similar events, if available; 
o An analysis of the significance of the current adverse event; and 
o If applicable, the proposed modifications to the conduct of the research project 
and/or to the informed consent form and/or a list of corrective actions to be taken 
in response to the event; 
o A copy of the sponsor’s report, if available.  
• 
Any applicable form completed/required by the sponsor, if any, (e.g. SAE form), must be 
uploaded to NAGANO 
• 
Subsequent, important follow-up reports related to the SAE should be submitted as soon 
as available.  
 
6.6 Stop Criteria 
This pilot study will be halted if any of following criteria is met: 
• 
>15% Grade 3 or 4 complications 
• 
Any Grade 5 complications 
• 
>10% readmission rate after 10 patients is discharged on same day 
 
Grading of Complications (17): 
• 
Grade I: Any deviation from normal postoperative course without the need for 
pharmacological treatment or surgical, endoscopic, and radiological interventions.  
• 
Grade II: Requiring pharmacological treatment with drugs other than such allowed for 
grade I complications. Blood transfusions and total parenteral nutrition are included 
• 
Grade III: Requiring surgical, endoscopic or radiological intervention 
• 
Grade IV: Life-threatening complications requiring IC/ICU management 
• 
Grade V: Death of Patient 
 
 
 
 

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7.0 APPENDICES 
 
Appendix 1 
Perioperative anesthesia care pathway for same-day discharge anatomical lung or wedge 
resection feasibility study 
 
SOC - Standard of care; RP – Research procedure  
 
A) PREOPERATIVE 
- 
All participants will be booked as the first case of the day to allow for a prolonged PACU 
stay, if needed. [RP] 
- 
All participants will be flagged by a thoracic surgeon, and seen in the MGH preoperative 
clinic by an anesthetist. [SOC] 
- 
All standard COVID-19 mitigation strategies for thoracic surgery patients will be employed. 
[SOC] 
- 
Upon being called to OR, the participant will receive acetaminophen 1000 mg and 
celecoxib 200 mg PO with a sip of water. [SOC] 
- 
Avoid routine use of midazolam. [SOC] 
 
B) INTRAOPERATIVE 
- 
Upon arrival to the operating room, preoperative checklist and consent will be verified. 
[SOC] 
- 
Vascular access will be established and Ringer’s Lactate will be started at 6 ml/kg/hour. 
[SOC] 
 
Antibiotic prophylaxis:  
- 
As per standard of care thoracic pathway. [SOC] 
 
Monitoring: 
- 
Standard monitoring will include ECG, arterial line, peripheral saturation, temperature, 
neuromuscular blockade at the adductor pollicis, lung mechanics and gas analyzer. [SOC] 
 
Anesthesia: 
- 
Inhalation anesthesia (sevoflurane or desflurane), or total intravenous anaesthesia (TIVA). 
[SOC] 
 
Opioid-sparing analgesia (one or more of the following techniques):  
- 
A preoperative single shot erector spinae plane nerve block will be performed at the T5 
level with 20 ml of bupivacaine 0.375% with epinephrine 1:200 000, and dexamethasone 
5 mg. [SOC] 
- 
Magnesium sulfate 2.5 g IV will be given as co-analgesic over the course of the surgery. 
[SOC] 
- 
Lidocaine 1.5 ml/kg following 2mg/kg/h. [SOC] 
- 
Ketamine 0.5 mg/kg. [SOC] 
 
Ventilation: 
- 
Lung isolation will be performed with a left-sided double lumen endotracheal tube, or a 
bronchial blocker through a single-lumen tube. [SOC] 

Protocol – Same-Day Discharge for VATS Anatomical Lung or Wedge Resection 
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- 
Tidal volumes will be maintained at 6 ml/kg of PBW on 2 lungs and 4 ml/kg of PBW on 
one lung. PEEP and FiO2 will be adjusted to maintain SpO2 above 92%. Aim for driving 
pressure below 15 cmH2O. [SOC] 
 
Temperature control:  
- 
Normothermia will be maintained with an underbody heated water blanket on the operating 
table and a surgical access forced air warmer on the participant.  [SOC] 
 
Post-operative nausea and vomiting (PONV) prophylaxis: 
- 
Dexamethasone 6 mg IV will be given at induction unless contraindicated. [SOC] 
- 
Ondansetron 4 mg IV will be given 30 minutes before emergence of anesthesia. [SOC] 
- 
Consider giving metoclopramide 10mg IV 30 minutes before emergence or use of TIVA 
if high PONV risk. [SOC] 
 
End of surgery analgesia:  
- 
At the end of the surgery, intercostal blocks will be performed by the surgeon, under direct 
visualization. A total a 20 ml of bupivacaine 0.25% with epinephrine 1:200,000 will be 
injected from T3 to T6. [SOC] 
 
Extubation:  
- 
At surgery completion, reverse neuromuscular blockade before extubating with 
suggamadex or neostigmine to achieve and document a ToF T4/T1 ratio > 0.9. [SOC] 
- 
Participants will be extubated in the operating room and transferred to PACU. [SOC] 
 
C) POST-OPERATIVE (IN PACU) 
 
Post-operative nausea and vomiting (PONV):  
- 
Avoid dimenhydrinate IV/PO. [SOC] 
- 
If nausea or vomiting occurs within 6 hours after surgery, participants should not receive 
a repeat dose of the prophylactic antiemetic received intra-operatively. Treat with one of 
the following instead:  [SOC] 
§ 
Ondansetron 4 mg IV  
§ 
Metoclopramide 10 mg IV 
§ 
Haloperidol 0.5-1 mg IV/IM 
 
Fluids:  
- 
Clear fluids PO as tolerated. [SOC] 
- 
Ringer’s Lactate IV at 10 mL/h (“Keep Vein Open” - KVO). [SOC] 
 
Analgesia:  
- 
Fentanyl 25 mcg IV to a maximum of 250 mcg. [SOC] 
- 
Non-IV analgesia as per pathway. [SOC] 
- 
Oxycodone 5mg PO q2h PRN or Dilaudid 1mg PO q2h PRN (to be standardized). [SOC] 
- 
Acetaminophen 1000 mg PO/PR q6h regular to be started 6h after the first dose. [SOC] 
 
Respiratory support:  
- 
Incentive spirometry in PACU. [SOC] 
- 
Possible physiotherapy in PACU. [SOC] 
 
 
 

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14 
Appendix 2 
Example of Functional Assessment of Cancer Therapy - Lung (FACT-L) questionnaire in English 
and French 
 
FACT-L (Version 4) 
English (Universal) 
 
16 November 2007 
Copyright  1987, 1997 
 
Page 1 of 3 
 
 
Below is a list of statements that other people with your illness have said are important. Please circle 
or mark one number per line to indicate your response as it applies to the past 7 days. 
 
 
 
 
 
PHYSICAL WELL-BEING 
 
Not 
at all 
A little 
bit 
Some-
what 
Quite
a bit 
Very 
much 
GP1 
I have a lack of energy .......................................................
0 
1 
2 
3 
4 
GP2 
I have nausea......................................................................
0 
1 
2 
3 
4 
GP3 
Because of my physical condition, I have trouble 
meeting the needs of my family.........................................
 
0 
 
1 
 
2 
 
3 
 
4 
GP4 
I have pain..........................................................................
0 
1 
2 
3 
4 
GP5 
I am bothered by side effects of treatment .........................
0 
1 
2 
3 
4 
GP6 
I feel ill ...............................................................................
0 
1 
2 
3 
4 
GP7 
I am forced to spend time in bed........................................
0 
1 
2 
3 
4 
 
 
 
SOCIAL/FAMILY WELL-BEING 
 
Not 
at all 
A little 
bit 
Some-
what 
Quite
a bit 
Very 
much 
GS1 
I feel close to my friends....................................................
0 
1 
2 
3 
4 
GS2 
I get emotional support from my family ............................
0 
1 
2 
3 
4 
GS3 
I get support from my friends.............................................
0 
1 
2 
3 
4 
GS4 
My family has accepted my illness ....................................
0 
1 
2 
3 
4 
GS5 
I am satisfied with family communication about my 
illness..................................................................................
 
0 
 
1 
 
2 
 
3 
 
4 
GS6 
I feel close to my partner (or the person who is my main 
support) ..............................................................................
 
0 
 
1 
 
2 
 
3 
 
4 
Q1 
Regardless of your current level of sexual activity, please 
answer the following question. If you prefer not to answer it, 
please mark this box           and go to the next section. 
 
 
 
 
 
GS7 
I am satisfied with my sex life ............................................
0 
1 
2 
3 
4 

Protocol – Same-Day Discharge for VATS Anatomical Lung or Wedge Resection 
Version 4.0 – 27 July 2022 
15 
 
FACT-L (Version 4) 
English (Universal) 
 
16 November 2007 
Copyright  1987, 1997 
 
Page 2 of 3 
 
 
Please circle or mark one number per line to indicate your response as it applies to the past 7 
days. 
 
 
 
 
EMOTIONAL WELL-BEING 
Not 
at all 
A little 
bit 
Some-
what 
Quite
a bit 
Very 
much 
GE1 
I feel sad ..............................................................................
0 
1 
2 
3 
4 
GE2 
I am satisfied with how I am coping with my illness..........
0 
1 
2 
3 
4 
GE3 
I am losing hope in the fight against my illness..................
0 
1 
2 
3 
4 
GE4 
I feel nervous.......................................................................
0 
1 
2 
3 
4 
GE5 
I worry about dying.............................................................
0 
1 
2 
3 
4 
GE6 
I worry that my condition will get worse............................
0 
1 
2 
3 
4 
 
 
 
 
 
FUNCTIONAL WELL-BEING 
 
Not 
at all 
A little 
bit 
Some-
what 
Quite
a bit 
Very 
much 
GF1 
I am able to work (include work at home) ..........................
0 
1 
2 
3 
4 
GF2 
My work (include work at home) is fulfilling.....................
0 
1 
2 
3 
4 
GF3 
I am able to enjoy life..........................................................
0 
1 
2 
3 
4 
GF4 
I have accepted my illness...................................................
0 
1 
2 
3 
4 
GF5 
I am sleeping well ...............................................................
0 
1 
2 
3 
4 
GF6 
I am enjoying the things I usually do for fun ......................
0 
1 
2 
3 
4 
GF7 
I am content with the quality of my life right now..............
0 
1 
2 
3 
4 
 

Protocol – Same-Day Discharge for VATS Anatomical Lung or Wedge Resection 
Version 4.0 – 27 July 2022 
16 
  
 
 
 
FACT-L (Version 4) 
English (Universal) 
 
16 November 2007 
Copyright  1987, 1997 
 
Page 3 of 3 
 
 
Please circle or mark one number per line to indicate your response as it applies to the past 7 
days. 
 
 
 
 
ADDITIONAL CONCERNS 
 
Not at 
all 
A little 
bit 
Some-
what 
Quite 
a bit 
Very 
much 
B1 
I have been short of breath..................................................
0 
1 
2 
3 
4 
C2 
I am losing weight...............................................................
0 
1 
2 
3 
4 
L1 
My thinking is clear ............................................................
0 
1 
2 
3 
4 
L2 
I have been coughing ..........................................................
0 
1 
2 
3 
4 
B5 
I am bothered by hair loss ...................................................
0 
1 
2 
3 
4 
C6 
I have a good appetite .........................................................
0 
1 
2 
3 
4 
L3 
I feel tightness in my chest..................................................
0 
1 
2 
3 
4 
L4 
Breathing is easy for me......................................................
0 
1 
2 
3 
4 
Q3 
Have you ever smoked?  
No ___  Yes ___  If yes: 
L5 
I regret my smoking ............................................................
0 
1 
2 
3 
4 
 

Protocol – Same-Day Discharge for VATS Anatomical Lung or Wedge Resection 
Version 4.0 – 27 July 2022 
17 
Appendix 3 
Example of Edmonton Symptom Assessment System questionnaire in English 
 
Participant code: 
____________________ 
 
Date (AAAA/MM/DD):  ____________________ 
 
 
For each of the following items, please circle the number that best describes your health  
during THE LAST 24 HOURS. 
 
 
No pain 
0 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
Worst possible pain 
 
Not tired 
0 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
Worst possible tiredness 
 
Not nauseated 
0 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
Worst possible nausea 
 
Not depressed 
0 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
Worst possible depression 
 
Not anxious 
0 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
Worst possible anxiety 
 
Not drowsy 
0 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
Worst possible drowsiness 
 
Best appetite 
0 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
Worst possible appetite 
Best feeling of well-being 
0 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
Worst possible feeling of 
well-being 
No shortness of breath 
0 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
Worst possible shortness of 
breath 
 
Other problem 
0 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
 
 
Would you like to receive some help for one or the other problem you may have mentioned above 
 Yes            No 
 
 
 
 
 
 

Protocol – Same-Day Discharge for VATS Anatomical Lung or Wedge Resection 
Version 4.0 – 27 July 2022 
18 
Appendix 4 
Examples of Thoracic Surgery Quality monitoring, Information management, and Clinical 
documentation (TSQIC) software forms 
 
 
 

Protocol – Same-Day Discharge for VATS Anatomical Lung or Wedge Resection 
Version 4.0 – 27 July 2022 
19 
 

Protocol – Same-Day Discharge for VATS Anatomical Lung or Wedge Resection 
Version 4.0 – 27 July 2022 
20 
 

Protocol – Same-Day Discharge for VATS Anatomical Lung or Wedge Resection 
Version 4.0 – 27 July 2022 
21 
 
 
 

Protocol – Same-Day Discharge for VATS Anatomical Lung or Wedge Resection 
Version 4.0 – 27 July 2022 
22 
 

Protocol – Same-Day Discharge for VATS Anatomical Lung or Wedge Resection 
Version 4.0 – 27 July 2022 
23 
 
 

Protocol – Same-Day Discharge for VATS Anatomical Lung or Wedge Resection 
Version 4.0 – 27 July 2022 
24 
 
 

Protocol – Same-Day Discharge for VATS Anatomical Lung or Wedge Resection 
Version 4.0 – 27 July 2022 
25 
  
 
  

Protocol – Same-Day Discharge for VATS Anatomical Lung or Wedge Resection 
Version 4.0 – 27 July 2022 
26 
 
 
 
 

Protocol – Same-Day Discharge for VATS Anatomical Lung or Wedge Resection 
Version 4.0 – 27 July 2022 
27 
Optional Form 
 
  
 

Protocol – Same-Day Discharge for VATS Anatomical Lung or Wedge Resection 
Version 4.0 – 27 July 2022 
28 
 
 
 
 

Protocol – Same-Day Discharge for VATS Anatomical Lung or Wedge Resection 
Version 4.0 – 27 July 2022 
29 
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Long H, Tan Q, Luo Q, Wang Z, Jiang G, Situ D, et al. Thoracoscopic Surgery 
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the 
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and&#xa0;Mortality Classification System. Journal of the American College of 
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