Are postoperative opioid stewardship protocols sustainable? Results from a 2-year quality improvement project.

BACKGROUND: Opioid stewardship protocols reduce opioid overprescription, but many require corrective action within 1 year. Because there are limited data on the sustainability of opioid reduction protocols, we sought to evaluate prescribing trends beyond 1 year. METHODS: We reviewed prescribing data from a tertiary care center to establish a consensus discharge opioid-prescribing guideline. Subsequently, we performed a prospective quality-improvement study for patients on an enhanced recovery protocol undergoing elective colectomies, proctectomies, and stoma-related procedures. We gathered process (protocol compliance), balance (rates of patient-controlled analgesia and nerve blocks, inpatient opioid utilization, pain scores within 48 hours of discharge), and clinical measures (median discharge opioid pills, postdischarge day 7 satisfaction). RESULTS: In total, 1,049 patients with similar ages, operative indications, and rates of substance use pre- and postintervention were included. Over 2 years, compliance was 88.6%, and there was a 43.6% reduction in the total discharge number of opioid pills. Phone calls for opioid refills were stable (10.2% pre- vs 7.8% postintervention, P = .16), and the following all decreased significantly: intraoperative nerve blocks, patient-controlled analgesia use, and final 48-hour and total median inpatient opioid use. There was a clinically negligible, statistically significant reduction in pain scores within 48 hours of discharge. Fifty patients provided satisfaction data, and 92% were satisfied or somewhat satisfied with their analgesia. CONCLUSION: Over 2 years, reduced opioid prescribing was maintained without escalating resources. Sustainability suggests that after successfully implementing an opioid reduction protocol, institutions may safely redeploy quality improvement resources elsewhere.

Predictors of opioid-free discharge after laparoscopic cholecystectomy.

BACKGROUND: Post-discharge opioid requirement after laparoscopic cholecystectomy (LC) is minimal, yet postoperative opioid prescriptions vary and opioid-free discharges are rare. STUDY DESIGN: Adult patients who underwent LC from 01/2019-12/2019 were reviewed. Univariate and multivariable logistic regression analyses were performed to identify predictors of opioid-free discharge. RESULTS: Of 393 included patients, 330 were discharged with opioids (median 12 oxycodone 5 mg pills) and 63 were discharged without opioids. One opioid-free discharge patient called for a prescription. Older age (OR = 1.02, 95% CI = 1.002-1.041) and non-elective procedure (OR = 0.35, 95% CI = 0.2291-0.8521) were independent predictors of opioid-free discharge. CONCLUSION: Significant opportunities for opioid reduction or elimination after discharge from LC exist. Non-elective procedure and older age are predictors of opioid-free discharge, and should be considered when individualizing prescription quantities as surgeons strive to reduce or eliminate opioid overprescription.

Outpatient endocrine surgery practice patterns are highly variable among US endocrine surgery fellowship programs.

BACKGROUND: Current studies and guidelines have reported that outpatient endocrine surgery is safe. However, none recommend specific postoperative protocols. METHODS: An internet-based survey, developed using expert input, was distributed to current (2021-2022) endocrine surgery fellows in American Association of Endocrine Surgeons-accredited programs (n = 23). Programs with ≤2% same-day discharge rate were compared with those with ≥2% same-day discharge rate. RESULTS: The survey response rate was 91% (21/23), representing 20 United States institutions performing >15,000 cervical endocrine operations annually. The same-day discharge rate after total thyroidectomy was not normally distributed across institutions (P < .0001) but appeared bimodal, highlighting dogmatic differences in the pursuit of same-day discharge. Nine programs had ≤2% same-day discharge rate, whereas seven had ≥90% same-day discharge rate. Fourteen (70%) reported minimum observation periods before discharge, without consistency across procedures or institutions. Total thyroidectomy patients were observed longer. Fourteen (70%) reported no geographic restrictions for same-day discharge. In programs with >2% same-day discharge (n = 11), clinical and operative factors inconsistently influenced same-day discharge after thyroidectomy. Living alone precluded same-day discharge in 3 programs. Lateral neck dissection and chronic anticoagulation each greatly reduced same-day discharge in one program and precluded same-day discharge in another. Central neck dissection, Graves' disease, substernal goiter, continuous positive airway pressure use, difficult/bloody operation, and signal on nerve stimulation had no or minimal effect on same-day discharge. Postoperative medication recommendations varied among programs. Although anticoagulation/antiplatelet agents were similarly held preoperatively across programs, resumption varied. Narcotics were routinely prescribed in 35%. CONCLUSION: Same-day discharge is not uniform across endocrine surgery training programs and is likely primarily driven by surgeon preference. Factors influencing same-day discharge vary significantly among programs.

Intrathecal Morphine and Effect on Opioid Consumption and Functional Recovery after Pancreaticoduodenectomy.

BACKGROUND: Single-shot intrathecal morphine (ITM) is an effective strategy for postoperative analgesia, but there are limited data on its safety, efficacy, and relationship with functional recovery among patients undergoing pancreaticoduodenectomy. STUDY DESIGN: This was a retrospective review of patients undergoing pancreaticoduodenectomy from 2014 to 2020 as identified by the institutional NSQIP Hepato-pancreato-biliary database. Patients were categorized by having received no spinal analgesia, ITM, or ITM with transversus abdominus plane block (ITM+TAP). The primary outcomes were average daily pain scores from postoperative days (POD) 0 to 3, total morphine equivalents (MEQ) consumed over POD 0 to 3, and average daily inpatient MEQ from POD 4 to discharge. Secondary outcomes included the incidence of opioid related complications, length of stay, and functional recovery. RESULTS: A total of 233 patients with a median age of 67 years were included. Of these, 36.5% received no spinal analgesia, 49.3% received ITM, and 14.2% received ITM+TAP. Average pain scores in POD 0 to 3 were similar by mode of spinal analgesia (none [2.8], ITM [2.6], ITM+TAP [2.3]). Total MEQ consumed from POD 0 to 3 were lower for patients who received ITM (121 mg) and ITM+TAP (132 mg), compared with no spinal analgesia (232 mg) (p < 0.0001). Average daily MEQ consumption from POD 4 to discharge was lower for ITM (18 mg) and ITM+TAP (13.1 mg) cohorts compared with no spinal analgesia (32.9 mg) (p = 0.0016). Days to functional recovery and length of stay were significantly reduced for ITM and ITM+TAP compared with no spinal analgesia. These findings remained consistent through multivariate analysis, and there were no differences in opioid-related complications among cohorts. CONCLUSIONS: ITM was associated with reduced early postoperative and total inpatient opioid utilization, days to functional recovery, and length of stay among patients undergoing pancreaticoduodenectomy. ITM is a safe and effective form of perioperative analgesia that may benefit patients undergoing pancreaticoduodenectomy.

Evaluating Age as a Predictor of Postoperative Opioid Use and Prescribing Habits in Older Adults With Cancer.

OBJECTIVE: To assess the narcotic use of older patients after oncologic resection. DESIGN: Retrospective review. SETTING AND PARTICIPANTS: Adults with neoplasms undergoing resection at a tertiary academic medical center. METHODS: Open and minimally invasive resections of the pancreas, bowel, rectum, lung, breast, and skin were included. Emergent procedures, chronic opioid users, and benign pathology were excluded. Narcotic use was measured using morphine equivalents (MEQs, milligrams of morphine) at multiple time points and compared between younger and older (aged ≥65 years) patients. Refill requests were within 30 days of index procedure. RESULTS: A total of 445 patients were eligible, and 245 were ≥65 years old. Despite longer length of stay (3 vs 2 days, P = .01), older patients used less narcotic medication [39.8 (150) mg vs 84 (229) mg, P = .004], and reported lower pain scores [1.3 (3.3) vs 2.8 (4.5), P = .0001] over the course of their hospitalization. Additionally, older patients had lower normalized narcotic use [15.3 (150) mg vs 77.4 (240) mg, P = .0001] in the last 48 hours of their admission. Following discharge, older patients had a lower median discharge MEQ (DC MEQ) compared with younger patients, 75 (150) mg vs 112.5 (102.5) mg, P = .002. Further stratifying older patients into age cohorts (65-74 years, 75-84 years, ≥85 years) revealed progressively less narcotic use as measured by total inpatient MEQ and final 48 hours. Additionally, progressively older patients were discharged with progressively lower DC MEQ compared with younger patients, 90 (112.5) mg, 50 (131.3) mg, and 0 (60) mg vs 112.5 (102.5) mg, P < .0001, respectively. Finally, older patients requested refills less often than younger counterparts, 6.5% vs 14.5%, P = .006. CONCLUSIONS AND IMPLICATIONS: Older patients with cancer reported lower pain scores, consumed less narcotics, were discharged with significantly less narcotics, and called for refills less often compared with younger patients after surgery. These data suggest this population may require less opioids for satisfactory pain control, and development of a guideline targeting postoperative multimodal analgesia in older adults is warranted.

Narcotic Free Cervical Endocrine Surgery: A Shift in Paradigm.

BACKGROUND AND OBJECTIVE: The opioid epidemic has stimulated initiatives to reduce the number of unnecessary narcotic prescriptions. We adopted an opt-in prescription system for patients undergoing ambulatory cervical endocrine surgery (CES). We hypothesized that empowering patients to decide whether or not to receive narcotics for pain control would result in fewer unnecessary opioid prescriptions. METHODS: We enrolled all patients scheduled for outpatient CES between July 2017 and June 2018 in a narcotic opt-in program. Patient demographics, procedure characteristics, and postoperative pain scores were collected prospectively. Statistical analyses were performed to correlate clinical predictors with narcotic request. Results were compared against a historical control group. The study was approved by the University IRB. RESULTS: A total of 216 consecutive patients underwent outpatient CES following implementation of the program. Only nine (4%) requested prescription narcotic medication at discharge, and no patient called after discharge to request analgesic medications. Compared with our prior treatment paradigm, we achieved a 96.6% reduction in the number of narcotic tablets prescribed, and a 98% reduction in unconsumed tablets. Univariate analysis suggested history of substance abuse (P < 0.001), anxiety (P = 0.01), depression (P < 0.001), baseline narcotic use (P = 0.004), highest pain postoperatively (P = 0.004), and incision length (P = 0.007) as predictive for narcotic request. Multivariate analysis retained significance with incision length and history of substance abuse. CONCLUSION: By empowering patients undergoing ambulatory CES to accept or decline a prescription, we reduced the number of prescribed narcotic tablets by 96.6%. Although longer incisions and prior substance abuse predict higher likelihood of requesting pain medication on discharge, 207 of 216 patients were treated with acetaminophen alone.

Early Prediction of Length of Stay After Pancreaticoduodenectomy.

BACKGROUND: Enhanced recovery after surgery (ERAS) is an evidence-based clinical pathway designed to standardize and optimize care. We studied the impact of ERAS and sought to identify the most important recommendations to predict shorter length of stay (LOS) after pancreaticoduodenectomy (PD). METHODS: We retrospectively reviewed all patients undergoing PD at our institution between January 2014 and June 2018. We compared clinicopathologic outcomes for patients before and after ERAS implementation. We defined "A-recommendations" as those that were graded "strong" and had "moderate" or "high" levels of evidence. We then compared outcomes of the ERAS group with adherence to "A-recommendations" and performed a subset analysis of "A-recommendations" over the first 72 h after surgery, which we termed "early factors". RESULTS: A total of 191 patients underwent PD during the study period. We excluded 87 patients who had minimally invasive PD (22), vascular reconstruction (53), or both (12). Of the 104 patients studied, 56 (54%) were pre-ERAS and 48 (46%) were ERAS. There were no differences in comorbidities or demographics between these groups, and morbidity, mortality, and readmission rates were also similar (P > 0.6). Median LOS was 3.5 d shorter in the ERAS group (7 versus 10.5 d, P < 0.001). Adherence to "A-recommendations" within ERAS was associated with a decreased LOS (r = -0.52 P = 0.0001). Patients with >5 "early factors" had a median LOS of 6 d, whereas patients with <5 "early factors" had a median LOS of 9 d (P = 0.008). CONCLUSIONS: ERAS is an effective protocol that standardizes care and reduces LOS after PD. Implementation of ERAS resulted in a 3.5-day reduction in our LOS with no change in morbidity, mortality, or readmissions. Adherence to ERAS protocol "A-recommendations" and ≥5 "early factors" may be predictive of shortened LOS.

Open adrenalectomy through a makuuchi incision: A single institution's experience.

BACKGROUND: Surgical techniques for adrenalectomy have evolved substantially over the last century. Although minimally invasive approaches are favored for benign disease, open adrenalectomy remains the gold standard for large tumors and those concerning for malignancy. Most reports describe the use of midline, subcostal, or thoracoabdominal incisions for open adrenalectomy. We studied our experience with the Makuuchi incision, designed to optimize exposure and minimize denervation of the abdominal wall. METHODS: All open adrenalectomies at the University of Rochester from 2009 to 2017 were retrospectively reviewed. Patient demographic characteristics, intraoperative details, and postoperative complications were investigated. Surgical site infection and hernia rates of Makuuchi incision were compared with non-Makuuchi incision patients and with published standards. The study was approved by the university Institutional Review Board. RESULTS: A total of 41 adrenalectomies were performed via Makuuchi incision. Population statistics included a mean age of 51.7 (19-86) years, a mean body mass index of 29.7 (17.3-45.8), and a mean tumor diameter of 8 cm (3.1-26 cm). Fourteen (34%) required multivisceral resection. Twenty-one (51%) were previous or current smokers, and 9 (22%) had hypercortisolemia. Median duration of stay was 6 days (4-73). Incisional hernia occurred in 5 patients (12%) and surgical site infection in 3 patients (7%), 2 patients had Cushing syndrome and 1 was immunosuppressed. Pain was managed with patient-controlled epidural anesthesia or patient-controlled anesthesia with postoperative day 1 daily morphine equivalents equating to 0.5 mg of hydromorphone q2h. Among 15 non-Makuuchi incision patients, there were 2 hernias (13%), 2 surgical site infections (13%), and 1 case of postoperative pneumonia. CONCLUSION: The Makuuchi incision is well tolerated and affords outstanding exposure of the adrenals and adjacent viscera. Incisional hernia and surgical site infection rates were favorable compared with published rates for midline or subcostal incisions, despite an obese population with a high incidence of hypercortisolism and immunosuppression.

Bilateral Pheochromocytomas in a Patient with Y175C Von Hippel-Lindau Mutation.

Von Hippel-Lindau (VHL) disease, caused by germline mutations in the VHL gene, is characterized by metachronously occurring tumors including pheochromocytoma, renal cell carcinoma (RCC), and hemangioblastoma. Although VHL disease leads to reduced life expectancy, its diagnosis is often missed and tumor screening guidelines are sparse. VHL protein acts as a tumor suppressor by targeting hypoxia-inducible factors (HIFs) for degradation through an oxygen-dependent mechanism. VHL mutants with more severely reduced HIF degrading function carry a high risk of RCC, while mutants with preserved HIF degrading capacity do not cause RCC but still lead to other tumors. VHL disease is classified into clinical types (1 and 2A-2C) based on this genotype-phenotype relationship. We report a case of bilateral pheochromocytomas and no other VHL-related tumors in a patient with Y175C VHL and show that this mutant preserves the ability to degrade HIF in normal oxygen conditions but, similar to the wild-type VHL protein, loses its ability to degrade HIF under hypoxic conditions. This study adds to the current understanding of the structure-function relationship of VHL mutations, which is important for risk stratification of future tumor development in the patients.

Have Recent Modifications of Operating Room Attire Policies Decreased Surgical Site Infections? An American College of Surgeons NSQIP Review of 6,517 Patients.

BACKGROUND: After a Department of Health site visit, 2 teaching hospitals imposed strict regulations on operating room attire, including full coverage of ears and facial hair. We hypothesized that this intervention would reduce superficial surgical site infections (SSIs). STUDY DESIGN: We compared NSQIP data from all patients undergoing operations in the 9 months before implementation (n = 3,077) to time-matched data 9 months post-implementation (n = 3,440). Univariate and multivariable analyses were used to examine patient, clinical, and operative factors associated with SSIs. Power analysis was performed using pre-intervention SSI rates. RESULTS: Despite a shift toward more clean cases, there were more SSIs post-implementation (33 vs 30 [1%]; p = 0.95). There were no differences in length of stay, complications, or mortality between the 2 time periods. Overall, SSI increased with wound class: 0.6%, 0.9%, 2.3%, and 3.8% in clean, clean-contaminated, contaminated, and infected cases, respectively. Limiting the review to clean or clean-contaminated cases, incisional SSIs increased from 0.7% (20 of 2,754) to 0.8% (24 of 3,115) (p = 0.85). A multivariable analysis showed that implementation of these policies was not associated with decreased SSIs (odds ratio 1.2; 95% CI 0.70 to 1.96; p = 0.56). The largest predictors of SSIs were preoperative infection, operative time >75th percentile, open wounds, and dirty/contaminated wounds. A hypothetical analysis revealed that a sample size of 485,154 patients would be required to demonstrate a 10% SSI reduction among patients with clean or clean-contaminated wounds. CONCLUSIONS: Implementation of stringent operating room attire policies do not reduce SSI rates. A study to prove this principle further would be impractical to conduct.

Speed Mentoring: An Innovative Method to Meet the Needs of the Young Surgeon.

OBJECTIVE: Speed mentoring has recently been used by several medical organizations as a strategy to establish mentoring relationships, which are felt to be critically important in the development of the surgeon. This study assesses a surgical speed-mentoring program at the 2015 American College of Surgeons (ACS) Clinical Congress. DESIGN: A steering committee designed the speed-mentoring program to match 60 ACS Resident and Associate Society mentees with a mix of junior and senior leadership of ACS. Each mentee met with 5 mentors for 10 minutes each during the 1 hour session. After participation in the activity, surveys were provided to assess the event. The survey included forced-choice questions using Likert-scales as well as open-ended questions. Mentor and mentee responses were compared using Medcalc software using comparison of means and comparison of proportion, with p < 0.05 considered significant. SETTING: The study was undertaken at the 2015 ACS Clinical Congress. PARTICIPANTS: A total of 60 mentors and 49 mentees participated in the inaugural ACS Speed-Mentoring activity. The postactivity survey was completed by 54 mentors (90%) and 39 mentees (79.5%). RESULTS: There was a high level of satisfaction with the activity, with 100% of mentors and mentees stating that they would recommend the activity to a colleague. There was overall high satisfaction with the organization of the session by both the mentors and the mentees although the mentors were more likely to feel that they needed more time for each interaction. More mentees (93%) than mentors (68.5%) felt they were likely to develop a mentoring relationship with one of their matches outside of the organized session. CONCLUSIONS: We demonstrated that a speed-mentoring event at a national surgical meeting offers an effective platform for mentoring and is mutually beneficial to both mentors and mentees. Data collected here will be used to modify and improve the design of future speed-mentoring sessions.

Incidental posterior mediastinal paraganglioma: The safe approach to management, case report.

INTRODUCTION: Paragangliomas are neuroendocrine tumors arising from chromaffin cells located in sympathetic paraganglia. Mediastinal paragangliomas are extremely rare and can be classified as functional or non-functional according to their ability for secreting catecholamines. Patients can be asymptomatic and the diagnosis is usually incidental. Complete surgical resection remains the standard of care for paragangliomas. PRESENTATION OF CASE: We present a 44-year-old woman with a functional mediastinal paraganglioma incidentally found during the perioperative imaging workup for a diagnosed breast carcinoma. Chest radiograph and computed tomography (CT) showed a well-defined lesion in the posterior mediastinum suspicious for an esophageal malignancy. Endoscopic and CT-guided biopsies were performed confirming the diagnosis of a neuroendocrine tumor. Laboratory studies showed elevated catecholamines and chromogranin A levels, consistent with a paraganglioma. Appropriate pre-operative management was done and successful surgical resection without catecholamine related complications was achieved. DISCUSSION: The workup and treatment of incidentally discovered adrenal and extra-adrenal lesions are controversial. Because of the absence of symptoms and the wider differential diagnosis of extra-adrenal lesions, an attempt for biopsying and surgically remove these lesions prior to biochemical testing is not an uncommon scenario, although this could be potentially harmful. Surgeons should have an index of suspicion for catecholamine-secreting tumors and hormonal levels should be assessed prior to biopsy or surgical resection. CONCLUSION: Surgeons should consider paragangliomas as a differential diagnosis for extra-adrenal lesions. Biochemical testing with catecholamines and chromogranin A levels should be performed prior to biopsy or surgical removal in order to avoid catastrophic complications.

Optimizing Outpatient Pain Management After Thyroid and Parathyroid Surgery: A Two-Institution Experience.

BACKGROUND: Thyroidectomy and parathyroidectomy are the most commonly performed endocrine operations, and are increasingly being completed on a same-day basis; however, few data exist regarding the outpatient postoperative pain requirement of these patients. We aimed to describe the outpatient narcotic medication needs for patients undergoing thyroid and parathyroid surgery, and to identify predictors of higher requirement. METHOD: We examined patients undergoing thyroid and parathyroid surgery at two large academic institutions from 1 January-30 May 2014. Prospective data were collected on pain scores and the oral morphine equivalents (OMEQs) taken by these patients by their postoperative visit. RESULTS: Overall, 313 adult patients underwent thyroidectomy or parathyroidectomy during the study period; 83% of patients took ten or fewer OMEQs, and 93% took 20 or fewer OMEQs. Patients who took more than ten OMEQs were younger (p < 0.001) and reported significantly higher overall mean pain scores at their postoperative visit (p < 0.001) than patients who took fewer than ten OMEQs. A multivariate model was constructed on pre- and intraoperative factors that may predict use of more than ten OMEQs postoperatively. Age <45 years (p = 0.002), previous narcotic use (p = 0.037), and whether parathyroid or thyroid surgery was performed (p = 0.003) independently predicted the use of more than ten OMEQs after surgery. A subgroup analysis was then performed on thyroidectomy-only patients. CONCLUSION: Overall, 93% of patients undergoing thyroidectomy and parathyroidectomy require 20 or fewer OMEQs by their postoperative visit. We therefore recommend these patients be discharged with 20 OMEQs, both to minimize waste and increase patient safety.

Risk Factors for Decreased Quality of Life in Thyroid Cancer Survivors: Initial Findings from the North American Thyroid Cancer Survivorship Study.

BACKGROUND: The prevalence of thyroid cancer survivors is rising rapidly due to the combination of an increasing incidence, high survival rates, and a young age at diagnosis. The physical and psychosocial morbidity of thyroid cancer has not been adequately described, and this study therefore sought to improve the understanding of the impact of thyroid cancer on quality of life (QoL) by conducting a large-scale survivorship study. METHODS: Thyroid cancer survivors were recruited from a multicenter collaborative network of clinics, national survivorship groups, and social media. Study participants completed a validated QoL assessment tool that measures four morbidity domains: physical, psychological, social, and spiritual effects. Data were also collected on participant demographics, medical comorbidities, tumor characteristics, and treatment modalities. RESULTS: A total of 1174 participants with thyroid cancer were recruited. Of these, 89.9% were female, with an average age of 48 years, and a mean time from diagnosis of five years. The mean overall QoL was 5.56/10, with 0 being the worst. Scores for each of the sub-domains were 5.83 for physical, 5.03 for psychological, 6.48 for social, and 5.16 for spiritual well-being. QoL scores begin to improve five years after diagnosis. Female sex, young age at diagnosis, and lower educational attainment were highly predictive of decreased QoL. CONCLUSION: Thyroid cancer diagnosis and treatment can result in a decreased QoL. The present findings indicate that better tools to measure and improve thyroid cancer survivor QoL are needed. The authors plan to follow-up on these findings in the near future, as enrollment and data collection are ongoing.