Enhanced Recovery After Surgery Protocol Decreases Hospital Length of Stay and Post-Operative Opioid Use for Thoracic Outlet Syndrome Surgical Decompression.

Objective: First rib resection for thoracic outlet syndrome (TOS) requires inpatient hospital stay and causes post-operative pain. We hypothesized that an enhanced recovery after surgery (ERAS) protocol, including multimodal pain management, would reduce post-operative narcotic use and length of stay (LOS).

Methods: A retrospective single center case-control study (2016-2022) compared three protocols: 1) conventional peri-operative and pain management, 2) multimodal pain management with implantation of ropivacaine pump, and 3) ERAS peri-operative protocol including ropivacaine pump. Primary (inpatient opioid use and LOS) and secondary outcomes (complications and hospital cost) were assessed.

Results: 98 patients were evaluated (107 first rib resections). Compared to conventional pain management (median 33 mg/d), daily opioid use significantly decreased with both multimodal pain management alone (14 mg/d, P<0.0001) and full ERAS protocol (11 mg/d, P<0.0001). ERAS patients had shorter LOS than conventional management (1.44 d vs. 3.26 d, P<0.0001), but multimodal pain management alone did not. Complication rates were similar among the three groups, although ERAS patients had increased post-operative ED visits (n=4 (7.4%) vs. n=7 (27%), P=0.024) and readmissions (n=2 (3.7%) vs. n=5 (19%), P=0.034). Index hospital admission cost decreased between the ERAS and conventional groups (mean: $9,327 vs. $13,053, P=0.012). Total hospital cost including ED visits and readmissions, however, was similar between the three protocols.

Conclusions: Consistent with other areas of surgery, ERAS yielded a >2-fold decrease in LOS, multimodal pain management alone decreased opioid use, but did not reduce LOS. ERAS protocol increased ED visits and readmissions, suggesting that optimization to decrease readmissions will improve care and lower costs.