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Objective
Enhanced post-operative recovery and early discharge programmes can improve outcomes and reduce hospital costs. We introduced an enhanced recovery programme (ERP) in early 2011. This involved a focus on pre-operative education, day-of-surgery admission, peri-operative nutritional support, regional analgesia with paravertebral catheters, early ambulation, and the introduction of VATS lobectomy for selected patients.
This study aimed to quantify the effect of VATS lobectomy on hospital stay, in patients managed within an ERP protocol.
Methods
All patients undergoing isolated lobectomy in our institution after the introduction of ERP were included. Length of stay (LOS) was the primary outcome. Potential predictors were studied by univariate linear regression. Selected variables were entered into a multivariable stepwise linear regression model.
Results
93 patents underwent lobectomy in the ERP programme.
Table 1: Demographics

Median Age (IQR) (years)	73 (65, 77)
Gender (male vs. female)	46:47 (49.5% male)
Mean ASA score (1 SD)	2.15 (0.48)
Pre op FEV (as % predicted)	86% (19)
Surgical approach (VATS vs. thoracotomy)	27:66 (29% VATS)
Analgesia (epidural vs. paravertebral)	25:62 (6 not recorded)
Median length of stay (days)	5 (4,7)
In hospital mortality	4 of 93 (4.3%)

There were 4 deaths after thoracotomy and none after VATS lobectomy (Fischer’s exact test p 0.32)
8 variables were examined by univariate linear regression.
Table 2: Selected univariate predictors of LOS

Potential predictor	Effect (per unit of predictor) on LOS in days	P value
Age (per additional year)	0.04	0.08
ASA grade (per additional point increase)	1.02	0.06
Approach VATS vs. thoracotomy	-1.41	0.01
Gender (male vs. female)	0.26	0.62
Pre-op FEV1 (as % predicted) per unit increase	-0.01	0.40

Age, ASA and surgical approach were included in the multivariable model.
Only VATS approach was retained in the final model, with a coefficient of -1.41 ( i.e. 1.4 day reduction in LOS with VATS vs. thoracotomy), p 0.01 (n=91).
Overall median length of stay after ERP implementation was 5 days, a reduction on historical levels.
Conclusions
Within an ERP protocol, VATS significantly reduces length of stay after lobectomy, with a mean reduction of 1.4 in-hospital days / patient. It should be a key component of lung resection enhanced recovery programmes.