Multimodal Pain Management Protocol to Decrease Opioid Use and to Improve Pain Control After Thoracic Surgery.

BACKGROUND: Opioid addiction continues to be a devastating problem in our communities, and up to 40% of patients begin their addiction with legally prescribed opioids after injury or surgical procedure. An opioid-free multimodal pain regimen was developed with the goal of decreasing opioid exposure while maintaining adequate pain control. METHODS: A retrospective single-institution study was conducted of 313 consecutive patients undergoing minimally invasive lobectomy before (n = 211) and after (n = 102) implementation of an opioid-free protocol from 2016 to 2020. Data analysis was conducted on preoperative characteristics, postoperative opioid use at set time points (postoperative day 0, postoperative days 1 to 7, and total stay), pain scores, discharge with opioid prescription, and postoperative outcomes. RESULTS: Patients on the opioid-free protocol had significantly lower average total morphine milligram equivalents at all time points. In addition, 56% of patients in the opioid-free group received no oral opioids at all, and 91% did not receive a patient-controlled analgesia pump. Average pain scores were significantly lower in the opioid-free protocol patients along with percentage of time spent with pain scores <3 and <6. With implementation of the protocol, 62% of patients are discharged without an opioid prescription compared with only 7% previously. CONCLUSIONS: Implementation of an opioid-free protocol led to a significant decrease in the use of postoperative opioids at all time points while improving overall management of pain. In addition, most patients are discharged with no home opioid prescription, decreasing a potential source of community opioid spread.

Robotic-Assisted Thoracoscopic Repair of Right-Sided Bochdalek Hernia in Adults: A Two-Case Series.

Bochdalek hernia is a congenital diaphragmatic hernia that presents rarely in adulthood. Because of the paucity of cases, no standard repair technique has been identified. Here we present two cases of robotic, thoracoscopic repair of this rare hernia defect. Two separate adult patients with right-sided abdominal pain presented to the emergency department for evaluation. Both patients were diagnosed with right-sided Bochdalek hernia and repair was undertaken with a robotic, transthoracic approach. Repair technique is described in detail, including port placement, dissection technique, and repair strategy. Advantages of the robotic, transthoracic approach are discussed in detail. A transthoracic minimally invasive approach using a robotic platform is noted to be both feasible and practical in the treatment of adult Bochdalek hernia.

Delay in Oral Feeding is Associated With a Decrease in Anastomotic Leak Following Transhiatal Esophagectomy.

The cervical anastomotic leak is a major complication of transhiatal esophagectomy and results in chronic strictures in up to half of patients. A change in postoperative protocol to delaying initiation of oral intake was made with the goal of reducing anastomotic leak rate and associated sequelae. A postoperative protocol change was applied to all patients undergoing elective transhiatal esophagectomy. Rate of anastomotic leak and anastomotic stricture, defined as defect in the esophagogastric anastomosis and narrowing of the anastomosis, respectively, were compared between pre- and post-change groups. Between 2004 and 2013, 203 patients underwent transhiatal esophagectomy with cervical anastomosis. Historically, oral intake was resumed on postoperative day 3, and during the course of the study, a change was made to the protocol to delay oral intake until 15 days postoperatively. Eighty-three patients were in the early oral feeding group (postoperative day 3), and 120 were in the delayed oral intake group (postoperative day 15). There was a statistically significant decrease in the rate of anastomotic leak from 14.5% to 4.2% between the early and delayed intake groups, respectively (P = 0.0089). There was also a trend (P = 0.05) towards a lower rate of anastomotic stricture in all patients in the delayed intake group (15.8%) compared with those in the early feeding group (27.7%). By increasing the time to postoperative oral feeding, we have noted an associated improvement in both immediate and long-term outcomes of elective transhiatal esophagectomy patients.

Thoracic Surgery Considerations in the Mentally Ill or Handicapped Patient.

Increasing prevalence of mentally ill and handicapped populations requiring surgical thoracic interventions has brought to light their worse associated morbidity and mortality. Baseline functional status, caretaker environment, and mental limitations in day to day life have an impact in the short and long term from these interventions. Aggressive perioperative care, multispecialty approach, technical aspects, palliative procedures, and ethical considerations all play a part in improving outcomes. In this article real cases are presented illustrating points of care and situations for discussion.

Expanded level of sympathetic chain removal does not increase the incidence or severity of compensatory hyperhidrosis after endoscopic thoracic sympathectomy.

OBJECTIVE: Compensatory hyperhidrosis is a common devastating adverse effect after endoscopic thoracic sympathectomy for patients undergoing surgical treatment of primary hyperhidrosis. We sought to determine whether a correlation existed in our patient population between the level and extent of sympathetic chain resection and the subsequent development of compensatory hyperhidrosis. METHODS: All patients undergoing endoscopic thoracic sympathectomy in the T2-T3, T2-T4, T2-T5, or T2-T6 levels for palmar or axillary hyperhidrosis at the University of Iowa Hospital and Clinics (n = 97) from January 2004 to January 2013 were retrospectively reviewed. RESULTS: Differences in the preoperative patient characteristics were not statistically significant among the patients receiving T2-T3, T2-T4, T2-T5, or T2-T6 level resections. Of the 97 included patients, 28 (29%) experienced transient compensatory hyperhidrosis and 4 (4%) complained of severe compensatory hyperhidrosis and required additional treatment. No operative mortalities occurred, and the morbidity was similar among the groups. CONCLUSIONS: Most patients had successful outcomes after undergoing extensive resection without changes in the incidence of compensatory hyperhidrosis. Therefore, we recommend performing complete and adequate resection for relief of symptoms in patients with primary hyperhidrosis.

Pancreatic exocrine function is preserved after distal pancreatectomy.

INTRODUCTION: Our objective was to measure human stool elastase-1 to determine the effect of distal pancreatectomy on exocrine function. METHODS: During a 72-month period, 115 patients underwent resection. Stool elastase values were measured preoperatively in 83 patients and repeated at 3, 12, and 24 months. The amount of pancreas resected was divided into two categories-limited to the left of the portal vein and those resections over or extended to the right of the vein. RESULTS: Elastase values were normal in 84% (n = 70) of cases prior to resection (33% if chronic pancreatitis, 70% if pancreatic adenocarcinoma). In the 70 patients with normal preoperative values, exocrine function was maintained in those with resection that was limited to the left of the portal vein at 3, 12, and, 24 months. If the resection was over or extended to right of the portal vein, then 88% maintained normal exocrine function at 3 months, 92% at 12 months, and 100% were normal at 24 months. CONCLUSION: Of patients undergoing distal pancreatectomy, one sixth will have preoperative pancreatic insufficiency, most commonly those with pancreatic adenocarcinoma or chronic pancreatitis. Postoperative pancreatic insufficiency was seen transiently in those with resection that extended to the portal vein or beyond.

Results of completion gastrectomies in 44 patients with postsurgical gastric atony.

INTRODUCTION: Postsurgical gastric atony occurs infrequently after gastric surgery. However, the symptoms are disabling and refractory to medical management. The only effective treatment is completion gastrectomy. A few studies have examined in detail the long-term results of this radical procedure. METHODS: From 1988 through 2007, 44 patients (84% female, 16% male) underwent near-total or total completion gastrectomies for refractory postsurgical gastric atony. The average age was 52 (range 32-72). Gastric atony was documented using radionuclide solid food emptying studies. Charts were reviewed retrospectively to identify preoperative symptoms and long-term postoperative function, and the patients were contacted by phone to evaluate their current level of function. RESULTS: Of the original 44 patients, 66% (n = 29) were evaluated postoperatively at a mean of 5.6 + 4.5 years (range 0.5-15.0 years). Fourteen patients (32%) had died, and seven (16%) were lost to follow-up. Most common presenting symptoms were abdominal pain (98%), vomiting (98%), nausea (77%), diet limitation (75%), heartburn (64%), and weight loss (59%, average = 19% of BW). Postoperative complications occurred in 36% (n = 16), most commonly bowel obstruction (11%), anastomotic stricture (9%), and anastomotic leak (7%), and there was one perioperative death. At last follow-up, there were significant improvements in abdominal pain (97% to 59%, p < 0.001), vomiting (97% to 31%, p < 0.001), nausea (86% to 45%, p < 0.001), and diet limited to liquids or nothing at all (57% to 7%, p < 0.001). Some symptoms were more common postoperatively, including early satiety (24% to 89%, p < 0.001), and postprandial fullness (10% to 72%, p < 0.001). Average BMI at the time of surgery and at last follow-up were 23 and 21, respectively. Osteoporosis was diagnosed pre- and postoperatively in 17% and 67% of patients, respectively (p < 0.001). Seventy-eight percent of patients stated that they were in better health after surgery, while 17% were neutral, and 6% stated that they were worse off. Mean satisfaction with surgery was 4.7 (1-5 Likert scale). CONCLUSION: Completion gastrectomies in this patient population resulted in significant improvements in abdominal pain, vomiting, nausea, and severe diet limitations. Most patients, however, have significant ongoing gastrointestinal complaints, and the incidence of osteoporosis is high. Patient satisfaction is high; about 78% of patients believed their health status is improved. We believe these data support the selective use of completion gastrectomies in patients with severe postsurgical gastroparesis.