Effect of preoperative intravenous vs oral acetaminophen on postoperative opioid consumption in an enhanced recovery after surgery (ERAS) program in patients undergoing open gynecologic oncology surgery.

OBJECTIVE: Both intravenous (IV) and oral acetaminophen provide effective opioid-sparing analgesia after surgery when used as part of a multimodal preemptive pain management strategy. The purpose of this study was to compare postoperative opioid consumption in patients undergoing open gynecologic oncology surgery who received preoperative IV vs oral acetaminophen within an enhanced recovery after surgery (ERAS) program. METHODS: Retrospective data were collected on consecutive patients undergoing open gynecologic oncology surgery from May 1, 2016 to February 28, 2018 in patients receiving either 1 g IV or oral acetaminophen preoperatively. Patients were given a preoperative multimodal analgesia regimen including acetaminophen, celecoxib, pregabalin and tramadol. The primary outcomes were morphine equivalent daily doses (MEDD) on postoperative days (POD) 0 and 1. Secondary outcomes included highest patient-reported pain score in the post-anesthesia care unit (PACU) and intraoperative MEDD. Regression models adjusted by matched pairs were fit to estimate the average treatment effect of IV vs oral acetaminophen on MEDD. RESULTS: Of 353 patients, 178 (50.4%) received IV acetaminophen and 175 (49.6%) received oral acetaminophen. When balancing across the matched samples, there was no difference in postoperative MEDD for POD 0 between the IV and oral acetaminophen groups (Beta = -1.11; 95% CI: -4.83 to 2.60; p = 0.56). On POD 1, there was no difference between the IV and oral groups (Beta = 2.24; 95% CI: -2.76 to 7.25; p = 0.38). CONCLUSIONS: There was no difference in postoperative opioid consumption between patients receiving preoperative IV or oral acetaminophen within an ERAS program for patients undergoing open gynecologic oncology surgery.

Enhanced recovery for obese patients undergoing gynecologic cancer surgery.

OBJECTIVE: To compare post-operative length of stay and complication rates of matched obese and non-obese patients in an enhanced recovery (ERAS) program after open gynecologic cancer surgery. METHODS: We performed an observational cohort study of patients (n=1225) undergoing open surgery from November 2014 to November 2018 at a tertiary cancer center. Patients undergoing multidisciplinary procedures, non-oncologic surgery, or procedures in addition to abdominal surgery were excluded (n=190). Obese and non-obese patients were matched by date, age, disease status, and surgical complexity. The primary outcome was post-operative length of stay. Secondary outcomes included 30-day peri-operative complications, re-operation, re-admission, opioid use, and program compliance. RESULTS: After matching, 696 patients (348 obese, 348 non-obese) with median age of 57 years (IQR 48-66) were analyzed. Obese patients had a longer median procedure time (218 min vs 192.5 min, p<0.001) and greater median estimated blood loss (300 mL vs 200 mL, p<0.001). Median (IQR) post-operative length of stay was the same for obese and non-obese patients: 3 days (IQR 2-4). Obese and non-obese patients had similar rates of grade III-IV complications (10.9% and 6.6%, respectively, p=0.06), re-operation (2.3% and 1.4%, respectively, p=0.58), and re-admission (11.8% and 8.0%, respectively, p=0.13). Grade I-II complications were more common among obese patients (62.4% vs 48.3%, p<0.001) because they had more wound complications (17.8% vs 4.9%, p<0.001). Obese patients received more opioids both during surgery (morphine equivalent dose 57.25 mg (IQR 35-72.5) vs 50 mg (IQR 25-622.5), p=0.003) and after surgery (morphine equivalent daily dose 45 mg/day (IQR 10-96.2) vs 29.37 mg/day (IQR 7.5-70), p=0.01). Obese and non-obese patients had similar ERAS program compliance (70.1% and 69.8%, respectively, p=0.32). CONCLUSIONS: Neither post-operative length of stay nor the rate of serious complications differed significantly despite longer surgeries, greater blood loss, and more opioid use among obese patients. An ERAS program was safe, effective, and feasible for obese patients with suspected gynecologic cancer.

Patient characteristics and opioid use prior to discharge after open gynecologic surgery in an enhanced recovery after surgery (ERAS) program.

OBJECTIVE: To identify clinical and demographic characteristics associated with the absence of opioid usage on the day before discharge among patients undergoing open gynecologic surgery within an enhanced recovery after surgery (ERAS) program. METHODS: This was a single institution retrospective cohort study including all patients who underwent elective open gynecologic surgery as part of an ERAS program between November 1, 2014 and September 30, 2018 and who were discharged between post-operative day 2 and 7. Patients were excluded if they reported pre-existing chronic opioid use or underwent total pelvic exenteration. Descriptive statistics were used and multivariable logistic regression was used to identify factors associated with the absence of opioid usage on the day before discharge, after adjustment for relevant covariates. RESULTS: A total of 971 were included with a median length of stay of 3 days, and of these 526 (54.2%) used opioids on day before discharge and 445 (45.8%) did not. Absence of opioid use on the day before discharge was associated with age (P < .001), race (P = .04), Charlson Co-morbidity Index (P < .001), marital status (P = .004), and smoking status (P = .002) by univariate analysis. In a multivariable model, older age (adjusted OR 1.04; 95% CI 1.02-1.06; P < .001), current smoker status (adjusted OR 0.42; 95% CI 0.20-0.81; P = .01), and white or Caucasian race (adjusted OR 0.59; 95% CI 0.38-0.91; P = .02) were significantly associated with the absence of opioid use on the day prior to discharge. CONCLUSIONS: Nearly half of patients undergoing open gynecologic surgery within an established ERAS program did not consume any opioids on day before discharge. Safe, evidence-based reductions in post-operative opioid prescribing may be feasible for a subset of gynecologic surgery patients.

Validation and application of a module of the MD Anderson Symptom Inventory for measuring perioperative symptom burden in patients with gynecologic cancer (the MDASI-PeriOp-GYN).

OBJECTIVE: Using patient-reported outcomes (PROs) in perioperative care is increasingly common. We report the development, validation, and application of an MD Anderson Symptom Inventory version for use in patients undergoing surgery for gynecologic cancer or benign conditions (MDASI-PeriOp-GYN). METHODS: Our process included: (1) generating PeriOp-GYN-specific candidate items from qualitative interviews with patients, followed by input from an expert panel; (2) dropping items that lacked independent clinical relevance; (3) validating psychometric properties (reliability, validity) of the resulting MDASI-PeriOp-GYN; and (4) conducting cognitive debriefing interviews with patients to confirm ease of comprehension, relevance, and acceptability. RESULTS: Qualitative interviews with 40 patients generated 9 new PeriOp-GYN symptom items (bloating, abdominal cramping, constipation, hot flashes, dizziness, grogginess/confusion, urinary pain, difficulty urinating, and diarrhea) that, along with the core MDASI items, formed the new MDASI-PeriOp-GYN. A total of 150 patients (minimally invasive surgery (MIS) = 69, open surgery = 81) participated in the validation study; 121 patients also provided retest data. Cronbach alphas were 0.89 for symptoms and 0.86 for interference. Test-retest reliability was 0.88 for all symptom severity items. Known-group validity was supported by the detection of significant differences in symptom and interference levels by performance status (P < 0.01) and for all symptoms by surgery type (P < 0.01). Cognitive debriefing with 20 of the 150 patients demonstrated that the MDASI-PeriOp-GYN is an easy-to-use and understandable tool. CONCLUSIONS: The MDASI-PeriOp-GYN is a valid, reliable, concise tool for measuring symptom severity and functional interference in patients undergoing gynecologic surgery and can be useful in assessing postoperative symptom burden via PROs.