Risk Factors for Persistent Postoperative Opioid Use After Surgery for IBD: An Observational Cohort Study.

BACKGROUND: Patients with IBD are at increased risk of persistent opioid use, wherein surgery plays an important role. OBJECTIVE: Identify risk factors for persistent postoperative opioid use in patients with IBD undergoing GI surgery and describe in-hospital postoperative opioid treatment. DESIGN: This was a retrospective observational cohort study. ORs for persistent postoperative opioid use were calculated using preoperative and in-hospital characteristics, and in-hospital opioid use was described using oral morphine equivalents. SETTING: This study was conducted at a university hospital with a dedicated IBD surgery unit. PATIENTS: Patients who underwent surgery for IBD from 2017 to 2022 were included. MAIN OUTCOME MEASURES: Our main outcome measure was persistent postoperative opioid use (1 or more opioid prescriptions filled 3-9 months postoperatively). RESULTS: We included 384 patients, of whom 36 (9.4%) had persistent postoperative opioid use, but only 11 (2.9%) of these patients were opioid naive preoperatively. We identified World Health Organization performance status >1 (OR 8.21; 95% CI, 1.19-48.68), preoperative daily opioid use (OR 12.84; 95% CI, 4.78-35.36), psychiatric comorbidity (OR 3.89; 95% CI, 1.29-11.43) and in-hospital mean daily opioid use (per 10 oral morphine equivalent increase; OR 1.22; 95% CI, 1.12-1.34) as risk factors for persistent postoperative opioid use using multivariable regression analysis. LIMITATIONS: Our observational study design and limited sample size because of it being a single-center study resulted in wide CIs. CONCLUSIONS: We identified risk factors for persistent postoperative opioid use in patients undergoing surgery for IBD. Results indicate a need for optimization of pain treatment in patients with IBD both before and after surgery. These patients might benefit from additional opioid-sparing measures. See Video Abstract. FACTORES DE RIESGO EN LA ADMINISTRACION DURADERA DE OPIOIDES EN EL POSTOPERATORIO EN CASOS DE CIRUGA POR ENFERMEDAD INFLAMATORIA INTESTINAL ESTUDIO OBSERVACIONAL DE COHORTES: ANTECEDENTES:Los pacientes con enfermedad inflamatoria intestinal (EII) tienen un mayor riesgo de recibir opioides de manera duradera, casos donde la cirugía juega un papel importante.OBJETIVO:Identificar los factores de riesgo en la administración duradera de opioides en el post-operatorio de cirugía gastrointestinal en casos de EII y describir el tratamiento intra-hospitalario con los mismos.DISEÑO:Estudio observacional retrospectivo de cohortes. La relación de probabilidades (odds ratio - OR) en la adminstracion duradera de opioides post-operatorios fué calculada utilizando las características pré-operatorias y hospitalarias, donde la administración de opioides intra-hospitalarios fué descrita con la utilización de equivalentes de morfina oral.AMBIENTE:Estudio realizado en un hospital universitario con una unidad de cirugía dedicada a la EII.PACIENTES:Se incluyeron todos los pacientes sometidos a cirugía por EII entre 2017 y 2022.PRINCIPALES MEDIDAS DE RESULTADO:Nuestra principal medida de resultado fué la administración post-operatoria duradera de opioides (≥1 receta completa de opioides entre 3 y 9 meses después de la operación).RESULTADOS:Incluimos 384 pacientes, de los cuales 36 (9,4%) recibieron opioides de manera duradera en el post-operatorio, de los cuales solamente 11 pacientes (2,9%) no habían recibido opioides antes de la operación. Identificamos el estado funcional de la OMS > 1 (OR 8,21, IC 95% 1,19-48,68), el uso diario de opioides pré-operatorios (OR 12,84, IC 95% 4,78-35,36), los casos de comorbilidad psiquiátrica (OR 3,89, IC 95% 1,29-11,43) y el uso medio diario de opioides en el hospital (por cada aumento de 10 equivalentes de morfina oral) (OR 1,22, IC del 95%: 1,12-1,34 como factores de riesgo para la administración de opioides de manera duradera en el post-operatorio mediante el análisis de regresión multivariable.LIMITACIONES:Nuestro diseño de estudio observacional y el tamaño de la muestra limitada debido a que fue un estudio en un solo centro, dando como resultado intervalos de confianza muy amplios.CONCLUSIONES:Se identificaron los factores de riesgo en la administración duradera de opioides en el post-operatorio de cirugía gastrointestinal en casos de EII. Los resultados demuestran la necesidad de optimizar el tratamiento del dolor en pacientes con EII, tanto antes como después de la cirugía. Estos pacientes podrían beneficiarse de medidas adicionales de ahorro de opioides. (Traducción-Dr. Xavier Delgadillo).

Epidural Analgesia and Recurrence after Colorectal Cancer Surgery: A Danish Retrospective Registry-based Cohort Study.

BACKGROUND: Surgery is the main curative treatment for colorectal cancer. Yet the immunologic and humoral response to surgery may facilitate progression of micro-metastases. It has been suggested that epidural analgesia preserves immune competency and prevents metastasis formation. Hence, the authors tested the hypothesis that epidural analgesia would result in less cancer recurrence after colorectal cancer surgery. METHODS: The Danish Colorectal Cancer Group Database and the Danish Anesthesia Database were used to identify patients operated for colorectal cancer between 2004 and 2018 with no residual tumor tissue left after surgery. The exposure group was defined by preoperative insertion of an epidural catheter for analgesia. The primary outcome was colorectal cancer recurrence, and the secondary outcome was mortality. Recurrences were identified using a validated algorithm based on data from Danish health registries. Follow-up was until death or September 7, 2018. The authors used propensity score matching to adjust for potential preoperative confounders. RESULTS: In the study population of 11,618 individuals, 3,496 (30.1%) had an epidural catheter inserted before surgery. The epidural analgesia group had higher proportions of total IV anesthesia, laparotomies, and rectal tumors, and epidural analgesia was most frequently used between 2009 and 2012. The propensity score-matched study cohort consisted of 2,980 individuals in each group with balanced baseline covariates. Median follow-up was 58 months (interquartile range, 29 to 86). Recurrence occurred in 567 (19.0%) individuals in the epidural analgesia group and 610 (20.5%) in the group without epidural analgesia. The authors found no association between epidural analgesia and recurrence (hazard ratio, 0.91; 95% CI, 0.82 to 1.02) or mortality (hazard ratio, 1.01; 95% CI, 0.92 to 1.10). CONCLUSIONS: In colorectal cancer surgery, epidural analgesia was not statistically significantly associated with less cancer recurrence.

Inhalation anaesthesia compared with total intravenous anaesthesia and postoperative complications in colorectal cancer surgery: an observational registry-based study†.

BACKGROUND: Postoperative complications are common after colorectal surgery, and possibly related to the type of anaesthesia. We aimed to determine associations between the type of anaesthesia and complications after colorectal cancer surgery using Danish registries. METHODS: Patients undergoing colorectal cancer surgery (2004-18) were identified in the Danish Colorectal Cancer Group Database. The cohort was enriched with the Danish Anaesthesia Database and Danish National Prescription Registry data linked by Danish Central Person Registration number. Patients were classified according to type of general anaesthesia: inhalation or TIVA. Confounders were adjusted by propensity score matching. The primary outcome was complications within 30 days postoperatively. Secondarily, we assessed specific medical and surgical complications. RESULTS: We identified 22 179 individuals undergoing colorectal cancer surgery with accompanying anaesthesia data. Propensity score matching yielded 8722 individuals per group. After propensity score matching, postoperative complications were seen in 1933 (22.2%) patients undergoing inhalation anaesthesia and in 2199 (25.2%) undergoing TIVA (odds ratio [OR]=0.84; 95% confidence interval [CI], 0.79-0.91). Although no difference was observed for medical complications, 1369 (15.7%) undergoing inhalation anaesthesia had surgical complications compared with 1708 (19.6%) undergoing TIVA (OR=0.76; 95% CI, 0.71-0.83). Rates of wound dehiscence, anastomotic leak, ileus, wound abscess, intra-abdominal abscess, and sepsis were statistically significantly lower in the inhalation anaesthesia group. CONCLUSION: In this propensity score-matched registry study, use of inhalation anaesthesia was associated with fewer postoperative complications after colorectal cancer surgery than use of TIVA. Inhalation anaesthesia was associated with fewer complications related to wound healing and surgical infections.

Epidural analgesia and postoperative complications in colorectal cancer surgery. An observational registry-based study.

BACKGROUND: In colorectal cancer, surgical resection is fundamental for curative treatment. Epidural analgesia mitigates the perioperative physiologic stress response caused by surgery, and reduction in perioperative stress may reduce postoperative complications. Nevertheless, epidural analgesia also causes hypotension and lower limb motor weakness that can impair postoperative recovery. Here, we aimed to assess the association between epidural analgesia and postoperative complications after colorectal cancer surgery. METHODS: We identified patients undergoing colorectal cancer surgery 2008-2018 in Denmark in the Danish Colorectal Cancer Group Database and obtained anaesthesia data from the Danish Anaesthesia Database. The Danish National Prescription Registry was used to obtain data on prescriptions filled preoperatively reflecting current comorbidities. Databases were linked using the Danish Central Person Registry number and the operation day. Patients were classified according to preoperative insertion of an epidural catheter for analgesia. Confounders were adjusted by propensity score matching. Logistic regression was used to compute effect estimates of epidural analgesia on postoperative complications. RESULTS: We identified 19 932 individuals undergoing colorectal cancer surgery with available anaesthesia data. Propensity score matching yielded 5691 individuals in each group with balanced preoperative covariates. In the epidural analgesia group 1400 (24.6%) experienced complications compared with 1453 (25.5%) without epidural analgesia. We found no statistically significant association between epidural use and postoperative complications (OR 0.95, 95% CI 0.87-1.04). CONCLUSION: In total, in this observational study based on Danish registries, we found no association between epidural analgesia and postoperative complications after colorectal cancer surgery.

Inhalation or total intravenous anaesthesia and recurrence after colorectal cancer surgery: a propensity score matched Danish registry-based study.

BACKGROUND: During colorectal cancer surgery, the immune-modulating effects of inhalation anaesthesia may create a favourable environment for metastasis formation, leading to increased risk of recurrence. Our aim was to assess the association between inhalation vs intravenous anaesthesia and cancer recurrence in patients undergoing colorectal cancer surgery. METHODS: Patients undergoing colorectal cancer surgery in 2004-18 were identified in the Danish Colorectal Cancer Group Database and Danish Anaesthesia Database. After exclusion of patients with residual tumour registered in postoperative pathology reports, local endoscopic resections, and stent insertions, we classified patients according to exposure to inhalation anaesthesia. The primary outcome was recurrence (time to recurrence), whereas secondary outcomes were all-cause mortality (time to death) and disease-free survival (time to either recurrence or death). Events of recurrence and death were identified using The Danish Civil Registration System, Danish National Pathology Registry, and Danish National Patient Registry. The sub-distribution hazards approach was used to estimate hazard ratios (HRs) for recurrence, and Cox regression was used for all-cause mortality and disease-free survival. RESULTS: We identified 5238 patients exposed to inhalation anaesthesia and 6322 to intravenous anaesthesia. Propensity score matching yielded 4347 individuals in each group with balanced baseline covariates. We found a weak association between recurrence and exposure to inhalation anaesthesia (HR=1.12; 95% confidence interval [CI], 1.02-1.23). The HR estimates for all-cause mortality and disease-free survival were 1.00 (95% CI, 0.93-1.07) and 1.04 (95% CI, 0.98-1.11) respectively. CONCLUSION: Exposure to inhalation anaesthesia was associated with increased risk of recurrence after colorectal cancer surgery.