Abstract
Objective: Protocol optimization to improve postoperative outcomes is a key component of enhanced recovery after surgery program. The aim of this study is to determine the long-term impact of protocol optimization on postoperative outcomes of robotic pulmonary anatomic resections. Methods: A retrospective analysis of a prospectively maintained database was performed. All elective robotic anatomic pulmonary resections between February 1, 2018, and December 31, 2023, were included and stratified into original Enhanced Recovery After Thoracic Surgery (ERATS) - group A (February 1, 2018, to December 31, 2019, n = 184) and optimized ERATS - group B (January 1, 2020, to December 31, 2023, n = 557). Propensity-score matching yielded highly comparable cohorts for outcome analysis. Data included demographics, operative details, postoperative outcomes (hospital length of stay [LOS], postoperative opioid use, 30-day complications), patient-reported subjective pain, and cost-savings resulting from reducing observed LOS versus expected LOS on the basis of Medicare Severity Diagnosis-Related Group classification and estimated institution per-diem cost of $1100.00. Results: Of the 732 eligible patients, 499 were matched with 173 to group A and 326 group B. Protocol optimization was associated with significant improvement of postoperative outcomes: shorter LOS, greater percentages of postoperative day 1 discharge, substantial less opioid requirements with increasing number of opioid-free postdischarges, and greater cost-savings either collectively or per individual DRGs attributable to the reduction of LOS. Annual auditing of the optimized ERATS cohort demonstrated consistent improvements in key metrics over time. Conclusions: Successful ERATS protocol optimization and maintenance was associated with durable and significantly superior postoperative outcomes along with greater cost-savings attributable to a reduction of LOS in patients undergoing elective robotic pulmonary anatomic resections.