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Objectives: Our Enhanced Recovery After Thoracic Surgery protocol was implemented on February 1, 2018, and firmly established 7 months later. We instituted protocol modifications on January 1, 2020, aiming to further reduce postoperative opioid consumption. We sought to evaluate the influence of such efforts on clinical outcomes and the use of both schedule II and schedule IV opioids following robotic thoracoscopic procedures., Methods: A retrospective study of patients undergoing elective robotic procedures between September 1, 2018, and December 31, 2020, was conducted. Essential components of pain management in the original protocol included nonopioid analgesics, intercostal nerve blocks with long-acting liposomal bupivacaine diluted with normal saline, and opioids (ie, scheduled tramadol administration and as-needed schedule II narcotics). Protocol optimization included replacing saline diluent with 0.25% bupivacaine and switching tramadol to as needed, keeping other aspects unchanged. Demographic characteristics, type of robotic procedures, postoperative outcomes, and in-hospital and postdischarge opioids prescribed (ie, milligrams of morphine equivalent [MME]) were extracted from electronic medical records., Results: Three hundred twenty-four patients met the inclusion criteria (159 in the original and 183 in the optimized protocol). There was no difference in postoperative outcomes or acute postoperative pain; there was a significant reduction of in-hospital and postdischarge opioid requirements in the optimized cohort. For anatomic resections: mean, 60.0 MME (range, 0-60.0 MME) versus mean, 105.0 MME (range, 60.0-150.0 MME), and other procedures: mean, 0 MME (range, 0-60 MME) versus mean, 140.0 (range, 60.0-150.0 MME) ( P  < .00001) with median schedule II opioids prescribed = 0., Conclusions: Small modifications to our protocol for pain management strategies are safe and associated with significant decrease of opioid requirements, particularly schedule II narcotics, during the postoperative period without influencing acute pain levels., (© 2022 The Author(s).)

Esophageal perforation is a catastrophic complication of anterior cervical discectomy and fusion (ACDF). While direct surgical repair has been reported as optimal for restoration of upper gut function, we present the case of a 58-year-old woman who achieved complete resolution when treated only with debridement and drainage. We find that a supportive approach, surgical management without direct repair, may play a vital role in select patient populations in order to avoid potentially long-term consequences or radical treatments, like esophageal diversion. Decisions regarding direct repair versus debridement and inspection only should be made on a case-by-case basis through a multidisciplinary approach.