Early Hospital Discharge on Day Two Post Robotic Lobectomy with Telehealth Home Monitoring: A Pilot Study

Introduction: Recently, the adoption of telemedicine has become increasingly relevant and necessary during the Coronavirus 2019 (COVID-19) pandemic both in medical and surgical community. Perioperative telemonitoring is currently still rarely used in clinical practice, no applications are described in major thoracic surgery neither in ERAS protocols. We believe that the integration of telemedicine in mini-invasive enhanced recovery surgical programs can represent a useful tool to reduce LOS. Enhanced recovery programs based on mini-invasive surgery programs are the more recent innovations introduced in the field of surgery to improve surgical outcome. Despite these innovations the reported postoperative length of stay after robotic surgery is of 4 days even in highly specialized robotic centers. To date several non-medical factors (cultural, economic, and geographic) prevent an early discharge and his related advantages. Here we propose a pilot study for a new protocol of early discharge (on day 2) with telemonitoring device after robotic lobectomy for lung cancer. We report the preliminary results after his application in the first 10 patients. The aim of this study is to justify a further randomised protocol allowing his systematic application in clinical practice. Methods: This is a pilot study with as primary outcome the safety evaluated by the occurrence of postdischarge complications and readmissions. Secondary outcome was the evaluation of resources optimization (hospitalisation days) maintaining the standard of care. We enrolled all patients (PS ECOG 0-2) aged between 18 and 75 years undergoing robotic lobectomy for lung cancer diagnosed at early stage (cT1-2N0M0). All patients lived with a caregiver and were discharged on postoperative day 2 with a telemonitoring device if they satisfied the following discharge criteria: pain control (NRS95 92%. A teleconsultation was performed in the afternoon of postoperative day 2, two teleconsultations on postoperative day 3 and once a day in the following days until the chest tube was removed in outpatients visit. Post-discharge vital signs, and patient-reported symptoms were recorded by patients at least four times daily through the device and were available for consultation by two surgeons through phone application. In case of sudden variation of vital signs or occurrence of adverse events a direct telephone line was available for patients as well as a protected re-hospitalization path. Results: From July 2022 to the present article a total of 32 robotic procedures were performed; of these 20 patients were affected by early-stage NSCLC (cT1-2N0M0) and were managed in our department of Thoracic surgery and scheduled for a mini-invasive robotic surgery. Twelve patients satisfied all preoperative clinical criteria to be enrolled in NEW ERAS protocol. Two out of 12 enrolled patients were successively excluded by our study sample because of the occurrence of atrial fibrillation in one patient and desaturation in the second one, both on postoperative day 2. In the remaining 10 patients no postoperative complication occurred neither readmission was needed. The median time for outpatient chest tube removal was 4 days after surgery. A total of 27/427 vital sign measurements violated the threshold in 7 patients. Among the threshold violations only 1 out of 27 was a critical violation. The average hospitalisation costs per patient was 4631 euro, it was lower than VATS patients submitted to surgery in the study period with a mean number of 3 hospitalizations days avoided and an estimated economic benefit of more than 1500 euro for single patient. Conclusion: To the best of our knowledge, our pilot study is the first to combine remote home monitoring of vital signs and patient-reported symptoms in patients submitted to major thoracic oncological surgery instead of normal hospital stay. These preliminary results confirm as the integration of telemonitoring program allows, in selected patients, a safe discharge on postoperative day two after mini-invasive robotic surgery for early-stage NSCLC. A potential economic benefit could derive from this protocol if this data will be confirmed in larger sample.Funding Information: This work was supported by a specific grant from “Finanziamento 5x1000 Ministero della Salute”.Declaration of Interests: E. Bottoni has received honoraria from AB Medica SpA. The other authors have no conflicts of interest to declare with respect to research, authorship, and/or publication of this article.Ethics Approval Statement: The protocol was approved by the Ethical Committee of the IRCCS Humanitas Research Hospital (research register number #201900432), and this study was conducted in accordance with the STROBE guidelines and the Declaration of Helsinki.10 All patients signed an informed consent for the acquisition and the usage of clinical data for research purposes at admission.