The Impact of Initiation of ERAS Pathway in VATS and Robotic Lobectomy on Surgical Outcomes and Costs
Shiwei Han, Christina Jander, Madhan Kuppusamy, Joel Sternbach, Michal Hubka
General & Thoracic Surgery, Virginia Mason Medical Center, Seattle, Washington, United States
Objective: The surgical robot enhances dexterity, stability, and visualization. However, operative outcomes and costs associated with robotic and video-assisted thoracoscopic (VATS) lobectomy vary. Enhanced recovery after surgery (ERAS) pathways have shown benefit in many surgical settings, however the impact of ERAS on VATS and robotic lobectomy is unclear. We interrogated our institutional lobectomy database, to determine the impact of ERAS implementation on outcomes and cost associated with VATS and robotic lobectomy.
Methods: We retrospectively reviewed consecutive VATS and robotic lobectomies in the pre-ERAS (Oct 2018-Sep 2019) and ERAS (Oct 2019-Sep 2020) period. Simple or multiple generalized liner models were used to determine the impact of ERAS and operative approach alone and combination of ERAS with each operative approach on two primary outcomes of length of hospital stay (LOS) and overall cost. Secondary outcomes included chest tube removal time, surgery duration, pain score on post-op day 1, first chair time, first oral intake, Clavien-Dindo score, 30-day readmission, supply cost, inpatient stay cost, and OR minutes cost.
Results: 116 lobectomies (49.1% VATS, 50.9% robotic, 44.8% pre-ERAS, 55.2% ERAS) were analyzed (median age 68, 65.52% female) (Table 1). Robotic approach had shortened LOS by 2.03 days (P<0.0001), chest tube removal time by 42.9 hours (P<0.0001), reduced surgery duration by 32.6 mins (P=0.002), decreased inpatient stay cost by $3,369 (P<0.0001), and overall cost by $5,755 (P=0.001) compared with VATS (Table 2) . Furthermore, improvement in LOS (Figure 1A) and cost (Figure 1B) was seen in robotic approach with ERAS over time. ERAS implementation decreased LOS by 1.23 days (P=0.001), shortened chest tube removal time by 31.7 hours (P=0.002), shortened first oral intake time by 8.3 hours (P=0.001), decreased inpatient stay cost by $2,361 (P<0.0001) and overall cost by $5,133 (P < 0.0001) compared to pre-ERAS era (Table 2). Multivariable analysis showed combined ERAS+ robotic approach was associated with shortest LOS (1.35 days vs. pre-ERAS+VATS 4.34 days vs. pre-ERAS+ robotic 2.41 days vs. ERAS+VATS 3.37 days; P<0.0001) (Fig 1C), lowest inpatient stay cost ($2,247 vs. pre-ERAS+VATS $7,417 vs. pre-ERAS+ robotic $4,028 vs. ERAS+VATS $5,749; P<0.0001) and lowest overall cost ($13,588 vs. pre-ERAS+VATS $21,342 vs. pre-ERAS+ robotic $18,664 vs. ERAS+VATS $19,800;P<0.0001) (Figure 1D).
Conclusions: Robotic approach and ERAS implementation are independently associated with shorter LOS and cost savings for minimally invasive lobectomy without increasing post-operative complications or 30-day readmission compared to VATS approach. A combination of ERAS and robotic approach synergistically decreases hospital stay and overall cost compared to other strategies.
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