Persistent long-term opioid use after trauma: Incidence and risk factors.

BACKGROUND: The opioid epidemic in the United States continues to lead to a substantial number of preventable deaths and disability. The development of opioid dependence has been strongly linked to previous opioid exposure. Trauma patients are at particular risk since opioids are frequently required to control pain after injury. The purpose to this study was to examine the prevalence of opioid use before and after injury and to identify risk factors for persistent long-term opioid use after trauma. METHODS: Records for all patients admitted to a Level 1 trauma center over a 1-year period were analyzed. Demographics, injury characteristics, and hospital course were recorded. A multistate Prescription Drug Monitoring Program database was queried to obtain records of all controlled substances prescribed from 6 months before the date of injury to 12 months after hospital discharge. Patients still receiving narcotics at 1 year were defined as persistent long-term users and were compared against those who were not. RESULTS: A total of 2,992 patients were analyzed. Of all patients, 20.4% had filled a narcotic prescription within the 6 months before injury, 53.5% received opioids at hospital discharge, and 12.5% had persistent long-term use after trauma with the majority demonstrating preinjury use. Univariate risk factors for long-term use included female sex, longer length of stay, higher Injury Severity Score, anxiety, depression, orthopedic surgeries, spine injuries, multiple surgical locations, discharge to acute inpatient rehab, and preinjury opioid use. On multivariate analysis, the only significant predictors of persistent long-term prescription opioid use were preinjury use and a much smaller effect associated with use at discharge. CONCLUSION: During a sustained opioid epidemic, concerns and caution are warranted in the use of prescription narcotics for trauma patients. However, persistent long-term opioid use among opioid-naive patients is rare and difficult to predict after trauma. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Clinical impact of the updated international postoperative pancreatic fistula definition in distal pancreatectomy.

BACKGROUND: Postoperative pancreatic fistula (POPF) remains the most common complication after distal pancreatectomy. The International Study Group on Pancreatic Surgery definition of POPF is used worldwide. Recently, an update of the definition was published. The aim of this study was to determine the clinical impact of the update. METHODS: An international retrospective validation study, including patients who underwent DP (2005 -2016) in 5 centers was performed. Distribution of complications amongst POPF grades were compared for the old and updated definition. RESULTS: In total, 1089 patients were included. The incidence of POPF decreased with the updated definition from 47% to 24% (P < 0.01), largely because a downgrade of grade A and grade B into biochemical leak. Comparable morbidity was seen in the old and updated 'no POPF group' (Clavien -Dindo 3 5% vs. 6% P = 0.320 and hospital stay (7 vs. 7 days P = 0.301). The change in definition of POPF grade B resulted in more Clavien -Dindo 3 (38% vs. 51%) P < 0.01) and longer hospital stay (9 [9 -13] vs. 9 days [7 -15] P < 0.01) in the updated `grade B group'. CONCLUSION: Applying the updated POPF definition showed improved discrimination between grades and should therefore be used to report POPF after DP.

Mild to moderate pulmonary hypertension in liver transplantation.

BACKGROUND: Patients with pulmonary hypertension (PHTN) are at increased risk for worse outcomes post-liver transplant (LT). This study evaluated LT outcomes and complications for a large number of LT patients with mild to moderate PHTN. MATERIALS AND METHODS: This is a retrospective review of data from 2001 to 2011. All cases of PHTN were diagnosed with catheterization (mean pulmonary artery pressure) and categorized according to standard criteria: low-mild, 25-29 mm Hg; high-mild, 30-34 mm Hg; moderate, 35-44 mm Hg; and severe, ≥45 mm Hg. Our center protocol excludes most patients with known moderate and severe PHTN from LT. Outcomes included early liver function, ventilator time, hospital length of stay, and graft and patient survival. RESULTS: We reviewed the cardiac and pulmonary records for 1263 patients. There were 102 patients with confirmed PHTN (8%): 63 low-mild, 30 high-mild, and 9 moderate. Patients with PHTN were older (P < 0.001). Patients with PHTN were more likely to have prolonged post-transplant ventilator weaning (40% versus 26% >48 h post-transplant; P < 0.01) and a longer length of hospital stay (12 versus 10 d; P = 0.08). The PHTN had a lower 1-y graft survival (79% versus 87%; P = 0.05). There were no statistical differences in early graft function or in long-term patient survival. CONCLUSIONS: These results suggest that PHTN patients require longer post-liver transplant ventilation and length of hospital stay, but have similar early graft function and long-term survival. The risk of PHTN in these patients increases with increasing age.