作者：广东省肺癌研究所 杨学宁 & LAMP

173. Is Less Really More? Reexamining VATS Versus Open Lobectomy in the Setting of an Enhanced Recovery Protocol

Elizabeth D. Krebs, J. Hunter Mehaffey, Bethany M. Sarosiek, *Alexander S. Krupnick, Randal S. Blank, *Christine L. Lau, Linda W. Martin

University of Virginia, Charlottesville, VA

Invited Discussant: *Sudish C. Murthy

Objective: Video assisted thoracic surgery (VATS) lobectomy has been associated with decreased pain, shorter length of stay, and fewer complications when compared to lobectomy via open thoracotomy. However, enhanced recovery protocols (ERP) decrease pain and length of stay in both open and minimally invasive procedures. We hypothesized that a thoracic ERP will reduce differences in pain, length of stay, and outcomes between open and VATS lobectomy.
  Methods: All patients undergoing lobectomy for lung cancer at a single institution since adoption of a thoracic ERP (05/2016-06/2018) were evaluated and stratified by open vs. VATS status. This multidisciplinary ERP includes conservative fluid management, early ambulation, patient education, and opioid-sparing analgesia with subarachnoid opioid and intercostal nerve blocks with liposomal bupivacaine. Data including pain scores and protocol adherence were prospectively collected and demographics and outcomes were obtained from an institutional Society of Thoracic Surgeons (STS) database. Variables were compared using Chi-Square, Fisher’s exact, and Wilcoxon rank sum tests. A subgroup analysis evaluated outcomes in patients with cStage I lung cancer. 
  Results: A total of 52 patients underwent open lobectomy, while 53 underwent VATS lobectomy since institution of thoracic ERP. The open lobectomy group had a greater proportion of males, fewer stage I cancers, and higher rate of neoadjuvant therapy, with similar age and comorbidities as the VATS group (Table). Use of subarachnoid morphine (75.0% vs. 74.5%, p=0.95) and liposomal bupivacaine intercostal nerve block (92.3% vs. 84.3%, p=0.21) was similar. There was no difference in length of stay, postoperative pain scores, total morphine use, atrial arrhythmias, reoperation, and 30-day mortality (Table). However, 30-day readmission rates were higher in the thoracotomy group (18% vs. 0%, p<0.01). Notably, the index hospitalization median length of stay was 7 days in the open patients who were readmitted. In a subgroup of cStage I patients (24 open, 44 VATS), length of stay (4 vs. 4 days, p=0.12) and morphine use (47.5 mg vs. 32 mg, p=0.57) were similar, with higher readmission rate in open patients (22.7% vs. 0%, p<0.01).
  Conclusions: VATS and open lobectomy patients exhibited equivalent length of stay, pain scores, and morphine use, but higher readmission rate for thoracotomy patients. Surgical incision may have less impact on outcomes in the setting of a comprehensive thoracic ERP.