Elsevier

Journal of Surgical Research

Volume 276, August 2022, Pages 242-250
Journal of Surgical Research

Thoracic Surgery
National Assessment of Early Discharge After Video-Assisted Thoracoscopic Surgery for Lung Resection

https://doi.org/10.1016/j.jss.2022.02.025Get rights and content

Highlights

  • Earlier discharge following VATS lung resection is not associated with increased rates of readmission or postdischarge complications among patients undergoing surgery for suspected lung cancer.

  • Shorter postoperative length of stay is safe for selected patients whose initial postoperative recovery is uncomplicated.

  • Overall, pneumothorax was the most common reason for readmission following VATS lung resection procedures.

Abstract

Introduction

Video-assisted thoracoscopic surgery (VATS) techniques permit shorter postoperative length of stay (LOS). However, it remains unknown whether earlier discharge increases the risk of adverse postoperative events. We examined whether shorter LOS following elective VATS lung resection was associated with increased rates of readmission or postoperative complications.

Methods

Patients who underwent elective thoracoscopic segmentectomy, lobectomy, or bilobectomy for lung neoplasms from 2011 to 2018 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) dataset. Postoperative LOS was treated as an ordinal variable. The examined outcomes were 30-d readmission and 30-d postdischarge death or serious morbidity (DSM). Multivariable logistic regression models evaluated the association of LOS with outcomes. The most common readmission diagnoses were identified for each operation.

Results

Among 14,418 patients, 12,410 (86.1%) underwent lobectomy, 1764 (12.2%) underwent segmentectomy, and 244 (1.7%) underwent bilobectomy. The median LOS was 3 d for patients undergoing lobectomy (IQR 2-5) and segmentectomy (IQR 2-4), and 4 d for bilobectomy (IQR 3-6). Readmission rates varied with admission time and ranged from 5.0% for patients with LOS ≤1 d to 8.5% for LOS ≥5 d. The most common readmission diagnoses were pneumothorax (19.0%) and wound complications (13.4%). Each one-day increase in LOS was associated with an increased risk of readmission (OR 1.10, 95% CI 1.04-1.17, P < 0.001). No association was seen between earlier discharge and DSM (OR 1.08, 95% CI 0.99-1.18, P = 0.070).

Conclusions

Early discharge following VATS lung resection is not associated with increased rates of readmission or postoperative complications among patients undergoing surgery for cancer, and may safely be considered for selected patients with uncomplicated postoperative recovery.

Introduction

Lobectomy is the standard of care for treatment of early-stage non-small cell lung cancer (NSCLC).1 Traditionally, lobectomy was conducted via thoracotomy, necessitating a period of hospital-based recovery following surgery. However, the introduction of video-assisted thoracoscopic surgery (VATS) has allowed the operation to be performed with less postoperative pain, fewer complications, and reduced operative time, resulting in a reduction in the average length of stay (LOS).2,3 Studies have also demonstrated that VATS approaches are associated with reduced perioperative blood loss, decreased frequency of infectious complications, improved postoperative respiratory function (FVC and FEV1),3 and overall lower rates of surgical morbidity and mortality.4

The emergence of minimally invasive procedures in many surgical specialties, including thoracic surgery, has resulted in an increased interest in “fast-track” enhanced recovery protocols and the possibility of a shorter postoperative LOS. Studies evaluating the safety of earlier discharge following complex procedures, including thoracic aortic aneurysm repair in vascular surgery,5 brain tumor resection in neurosurgery,6 total hip and knee arthroplasty in orthopedic surgery,7 and radical cystectomy in urology,8 have demonstrated that a shorter postoperative LOS following these procedures was not associated with an increase in postoperative complications or hospital readmission. In thoracic surgery, initial studies have suggested that a shorter inpatient stay following VATS lobectomy does not increase the risk of readmission or mortality.9,10 However, these studies were based largely on high-volume academic settings and primarily focused on the safety of discharge on postoperative day 1, which is likely feasible for only a small fraction of patients undergoing lung resection. Thus, it remains unknown whether earlier postoperative discharge following VATS lobectomy increases the risk of subsequent readmission or postoperative complications in routine practice.

In addition to allowing patients to return home sooner following surgery, there are other advantages to earlier discharge following surgical procedures. Early discharge results in reduced healthcare spending as shorter inpatient stays reduce the utilization of costly inpatient services.11 Many hospitals have adopted enhanced recovery after surgery (ERAS) programs, which reduce inpatient LOS after surgical procedures and have the added benefit of minimizing costs.12 Studies focused on earlier discharge following procedures in other surgical subspecialties described total savings from early discharge ranging from $2000 to $60,000 per patient depending on the type of procedure.5,12,13 Furthermore, earlier discharge following inpatient surgery, especially for older adults, has not resulted in increased costs for outpatient long-term supportive care.11

This study aims to evaluate the safety of early discharge following lung resection in a national dataset. Specifically, the objectives of this study are (1) to investigate whether earlier discharge following elective VATS lung resection for known or suspected cancer is associated with an increased risk of readmission or postdischarge complications and (2) to describe common reasons for readmission following lung resection.

Section snippets

Data source

Patient data were obtained from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) dataset. The ACS NSQIP dataset consists of prospectively collected data that have been abstracted by trained reviewers on surgical patients from approximately 700 participating hospitals.14,15 Variables collected include patient demographics and comorbidities, operative information, and postoperative outcomes within 30 d. In this time-to-event analysis, postoperative day 30

Results

Among 14,418 patients identified in ACS NSQIP, 1764 (12.2%) underwent segmentectomy, 12,410 (86.1%) underwent lobectomy, and 244 (1.7%) underwent bilobectomy (Table 1). The median LOS for the patient cohort was 3 d (IQR 2-5). Patients with longer LOS were older (range: 64.9 y for LOS ≤1 d to 68.7 y for ≥5 d, P < 0.001), and had longer operative times (range: 131.3 min for LOS ≤1 d to 198.6 min for ≥5 d, P < 0.001). Patients with longer LOS were also more likely to have an ASA classification of

Discussion

This study demonstrated that a shorter postoperative LOS was not associated with an increased risk of either readmission or DSM among patients undergoing VATS segmentectomy, lobectomy, or bilobectomy for cancer at NSQIP hospitals between 2011 and 2018. These findings suggest that earlier discharge may be safely considered for selected patients whose initial postoperative recovery following VATS lung resection is uncomplicated, without subjecting them to an increased risk for readmission or

Author Contributions

A.M. and B.B. were responsible for conducting statistical analysis, determination of significant trends, creation of tables and figures, and initial drafting of manuscript. S.K., A.B., and D.O. were responsible for the initial concept of evaluating the safety of early discharge, selecting the ACS NSQIP dataset for evaluation, direction of analytic approach, and overseeing final critical review of the manuscript. All authors made substantial contributions to the work and have given the final

Acknowledgments

BCB is funded by the American College of Surgeons, United States as part of the Clinical Scholars in Residence Program and by a training grant from the National Cancer Institute, United States (T32CA247801). DDO is supported by a grant from the National Cancer Institute, United States (K07CA216330).

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