Longitudinal perioperative patient-reported outcomes in open compared with minimally invasive hysterectomy.

BACKGROUND: There are few prospective studies in the gynecologic surgical literature that compared patient-reported outcomes between open and minimally invasive hysterectomies within enhanced recovery after surgery pathways. OBJECTIVE: This study aimed to compare prospectively collected perioperative patient-reported symptom burden and interference measures in open compared with minimally invasive hysterectomy cohorts within enhanced recovery after surgery pathways. STUDY DESIGN: We compared patient-reported symptom burden and functional interference in 646 patients who underwent a hysterectomy (254 underwent open surgery and 392 underwent minimally invasive surgery) for benign and malignant indications under enhanced recovery after surgery protocols. Outcomes were prospectively measured using the validated MD Anderson Symptom Inventory, which was administered perioperatively up to 8 weeks after surgery. Cohorts were compared using Fisher exact and chi-squared tests, adjusted longitudinal generalized linear mixed modeling, and Kaplan Meier curves to model return to no or mild symptoms. RESULTS: The open cohort had significantly worse preoperative physical functional interference (P=.001). At the time of hospital discharge postoperatively, the open cohort reported significantly higher mean symptom severity scores and more moderate or severe scores for overall (P<.001) and abdominal pain (P<.001), fatigue (P=.001), lack of appetite (P<.001), bloating (P=.041), and constipation (P<.001) when compared with the minimally invasive cohort. The open cohort also had significantly higher interference in physical functioning (score 5.0 vs 2.7; P<.001) than the minimally invasive cohort at the time of discharge with no differences in affective interference between the 2 groups. In mixed modeling analysis of the first 7 postoperative days, both cohorts reported improved symptom burden and functional interference over time with generally slower recovery in the open cohort. From 1 to 8 postoperative weeks, the open cohort had worse mean scores for all evaluated symptoms and interference measures except for pain with urination, although scores indicated mild symptomatic burden and interference in both cohorts. The time to return to no or mild symptoms was significantly longer in the open cohort for overall pain (14 vs 4 days; P<.001), fatigue (8 vs 4 days; P<.001), disturbed sleep (2 vs 2 days; P<.001), and appetite (1.5 vs 1 days; P<.001) but was significantly longer in the minimally invasive cohort for abdominal pain (42 vs 28 days; P<.001) and bloating (42 vs 8 days; P<.001). The median time to return to no or mild functional interference was longer in the open than in the minimally invasive hysterectomy cohort for physical functioning (36 vs 32 days; P<.001) with no difference in compositive affective functioning (5 vs 5 days; P=.07) between the groups. CONCLUSION: Open hysterectomy was associated with increased symptom burden in the immediate postoperative period and longer time to return to no or mild symptom burden and interference with physical functioning. However, all patient-reported measures improved within days to weeks of both open and minimally invasive surgery and differences were not always clinically significant.

Rate of venous thromboembolism on an enhanced recovery program after gynecologic surgery.

BACKGROUND: Venous thromboembolism is a life-threatening complication of surgery. An Enhanced Recovery After Surgery program is a multimodal care pathway that facilitates faster recovery from surgery. The rate of venous thromboembolism after gynecologic surgery on an Enhanced Recovery After Surgery program is unknown. OBJECTIVE: This study aimed to evaluate the rate of venous thromboembolism within 30 days of gynecologic surgery on an Enhanced Recovery After Surgery pathway performed at a cancer center. STUDY DESIGN: Data were collected prospectively on Enhanced Recovery After Surgery pathway gynecologic patients undergoing open surgery (November 3, 2014, to March 31, 2021) and minimally invasive surgery (February 1, 2017, to March 31, 2021). Care was delivered at a tertiary cancer care center located in a large urban area. Patients undergoing emergency surgery or multispecialty surgeries were excluded. Patients undergoing open surgery were to receive heparin prophylaxis before surgery, sequential compression devices during surgery and admission, and low-molecular-weight heparin prophylaxis during admission. If diagnosed with malignancy, patients were to receive extended venous thromboembolism prophylaxis for 28 days after surgery. For minimally invasive surgery, patients received only sequential compression devices during surgery and no heparin prophylaxis before or after surgery. Venous thromboembolism events were included if detected on imaging obtained for symptoms or other indications. Descriptive statistics and bivariate statistical analyses were performed. RESULTS: Of 3329 patients, 1519 (45.6%) underwent laparotomy, 1452 (43.6%) underwent laparoscopy, and 358 (10.8%) underwent robotic surgery. The incidence rates of venous thromboembolism were 0.6% (n=21; 95% confidence interval, 0.4%-0.9%) overall, 1.1% (n=16, 95% confidence interval, 0.6%-1.7%) in the open approach, and 0.3% (n=5; 95% confidence interval, 0.3%-0.6%) in the minimally invasive approach (P=.02). The incidence rates of venous thromboembolism among the 1999 patients with malignancy were 0.9% (n=18; 95% confidence interval, 0.5%-1.4%) overall, 1.4% (n=15; 95% confidence interval, 0.7%-2.2%) in the open approach, and 0.3% (n=3; 95% confidence interval, 0.1%-0.9%) in the minimally invasive approach. The incidence rates of venous thromboembolism among the 1165 patients with benign disease were 0.3% (n=3; 95% confidence interval, 0.1%-0.7%) overall, 0.3% (n=1; 95% confidence interval, 0.0%-1.7%) in the open approach, and 0.2% (n=2; 95% confidence interval, 0.0%-0.9%) in the minimally invasive approach. CONCLUSION: The rate of venous thromboembolism among patients undergoing laparotomy and minimally invasive surgery on an Enhanced Recovery After Surgery pathway was ≤1%. This study established a benchmark for the rate of venous thromboembolism after gynecologic surgery on an Enhanced Recovery After Surgery pathway performed at a cancer center.

Evaluation of a tiered opioid prescription algorithm in an ERAS pathway: exploring opportunities for further refinement.

BACKGROUND: Opioid over-prescription is wasteful and contributes to the opioid crisis. We implemented a personalized tiered discharge opioid protocol and education on opioid disposal to minimize over-prescription. OBJECTIVE: To evaluate the intervention by investigating opioid use post-discharge for women undergoing abdomino-pelvic surgery, and patient adherence to opioid disposal education. METHODS: We analyzed post-discharge opioid consumption among 558 patients. Eligible patients included those who underwent elective gynecologic surgery, were not taking scheduled opioids pre-operatively, and received discharge opioids according to a tiered prescribing algorithm. A survey assessing discharge opioid consumption and disposal safety knowledge was distributed on post-discharge day 21. Over-prescription was defined as >20% of the original prescription left over. Descriptive statistics were used for analysis. RESULTS: The survey response rate was 61% and 59% in the minimally invasive surgery and open surgery cohorts, respectively. Overall, 42.8% of patients reported using no opioids after hospital discharge, 45.2% in the minimally invasive surgery and 38.6% in the open surgery cohort. Furthermore, 74.9% of respondents were over-prescribed, with median age being statistically significant for this group (p=0.004). Finally, 46.4% of respondents expressed no knowledge regarding safe disposal practices, with no statistically significant difference between groups (p>0.99). CONCLUSION: Despite implementation of the tiered discharge opioid algorithm aimed to personalize opioid prescriptions to estimated need, we still over-prescribed opioids. Additionally, despite targeted education, nearly half of all patients who completed the survey did not know how to dispose of their opioid tablets. Additional efforts are needed to further refine the algorithm to reduce over-prescription of opioids and improve disposal education.

Association between enrollment in an enhanced recovery program for colorectal cancer surgery and long-term recurrence and survival.

INTRODUCTION: Enhanced Recovery After Surgery (ERAS) programs have been shown to minimize the surgical inflammatory response in colorectal cancer. Our objective was to determine the association between an ERAS program for colorectal cancer surgery and oncologic recurrence and survival. METHODS: A before-after intervention study was designed, including patients who underwent colorectal cancer surgery between November 2010 and March 2016. Cox hazard regression analysis was performed per cumulative year of follow-up to evaluate the association between ERAS program exposure and overall survival. Subgroup analysis was performed by cancer stage (low [I/II] vs. advanced [III/IV]). RESULTS: In total, 646 patients were included, of which 339 were pre-ERAS and 307 were ERAS. Our overall median compliance rate with ERAS interventions was 90% (interquartile range: 85%-95%). Overall survival rates were higher in the ERAS group within the first 2 years after surgery (89.2% vs.  83.2%; p = 0.04). Multivariable analysis revealed that the ERAS enrollment was associated with a significantly lower risk in 5-year oncologic recurrence (adjusted hazard ratio [aHR]: 0.55; 95% confidence interval [CI]: 0.33-0.94; p = 0.03) and higher 3-year survival (aHR: 0.55; 95% CI: 0.33-0.93; p = 0.03) among patients with advanced cancer stage compared to pre-ERAS counterparts. CONCLUSIONS: Patients with advanced colorectal cancer were less likely to suffer oncologic recurrence when managed during the ERAS period.

Outcomes of open radical hysterectomy following implementation of an enhanced recovery after surgery program.

OBJECTIVE: Open surgery has become the standard approach for radical hysterectomy in early stage cervical cancer (International Federation of Gynecology and Obstetrics (FIGO) 2018 IA1 with lymphovascular space invasion-IIA1). Our primary objective was to compare the length of stay in patients undergoing open radical hysterectomy before and after implementation of an enhanced recovery after surgery (ERAS) program. METHODS: This was a single center, retrospective, before-and-after intervention study including patients who underwent open radical hysterectomy for cervical cancer from January 2009 to December 2020. Two groups were identified based on the time of ERAS implementation: pre-ERAS group included patients who were operated on between January 2009 and October 2014; post-ERAS group included patients who underwent surgery between November 2014 and December 2020. RESULTS: A total of 81 patients were included, of whom 29 patients were in the pre-ERAS group and 52 patients in the post-ERAS group. Both groups had similar clinical characteristics with no differences in terms of median age (42 years (interquartile range (IQR) 35-53) in pre-ERAS group vs 41 years (IQR 35-49) in post-ERAS group; p=0.47) and body mass index (26.1 kg/m2 (IQR 24.6-29.7) in pre-ERAS group vs 27.1 kg/m2 (IQR 23.5-33.5) in post-ERAS group; p=0.44). Patients in the post-ERAS group were discharged from the hospital earlier compared with those in the pre-ERAS group (median 3 days (IQR 2-3) vs 4 (IQR 3-4), p<0.01). The proportion of patients discharged within 48 hours was significantly higher in the post-ERAS group (47.3% vs 17.3%, p=0.013). There were no differences regarding either overall complications (44.8% pre-ERAS vs 38.5% post-ERAS; p=0.57) or readmission rates within 30 days (20.7% pre-ERAS group vs 17.3% ERAS group; p=0.40). Adherence to the ERAS pathway since its implementation in 2014 has remained stable with a median of 70% (IQR 65%-75%). CONCLUSIONS: Patients undergoing open radical hysterectomy on an ERAS pathway have a shorter length of hospital stay without increasing overall complications or readmissions rates.

Patient outcomes and adherence to an enhanced recovery pathway for open gynecologic surgery: a 6-year single-center experience.

OBJECTIVES: To evaluate compliance with an Enhanced Recovery After Surgery (ERAS) protocol for open gynecologic surgery at a tertiary center and the relationship between levels of compliance and peri-operative outcomes. METHODS: This retrospective cohort study was conducted between November 2014 and December 2020. Two groups were defined based on compliance level (<80% vs ≥80%). The primary outcome was to analyze overall compliance since implementation of the ERAS protocol. The secondary endpoint was to assess the relationship between compliance and 30-day re-admission, length of stay, re-operation, opioid-free rates, and post-operative complications. We also assessed compliance with each ERAS element over three time periods (P1: 2014-2016, P2: 2017-2018, P3: 2019-2020), categorizing patients according to the date of surgery. Values were compared between P1 and P3. RESULTS: A total of 1879 patients were included. Overall compliance over the period of 6 years was 74% (95% CI 71.9% to 78.2%). Mean overall compliance increased from 69.7% to 75.8% between P1 and P3. Compliance with ERAS ≥80% was associated with lower Clavien-Dindo complication rates (grades III (OR 0.55; 95% CI 0.33 to 0.93) and V (OR 0.08, 95% CI 0.01 to 0.60)), 30-day re-admission rates (OR 0.61; 95% CI 0.43 to 0.88), and length of stay (OR 0.59; 95% CI 0.47 to 0.75). No difference in opioid consumption was seen. Pre-operatively, there was increased adherence to counseling by 50% (p=0.01), optimization by 21% (p=0.02), and carbohydrate loading by 74% (p=0.02). Intra-operatively, compliance with use of short-acting anesthetics increased by 37% (p=0.01) and avoidance of abdominal drainage increased by 7% (p=0.04). Use of goal-directed fluid therapy decreased by 16% (p=0.04). Post-operatively, there was increased compliance with avoiding salt and water overload (8%, p=0.02) and multimodal analgesia (5%, p=0.02). CONCLUSIONS: Over the time period of the study, overall compliance increased from 69.7% to 75.8%. Compliance (≥80%) with ERAS is associated with lower complication rates, fewer 30-day re-admissions, and shorter length of stay without impacting re-operation rates and post-operative opioid use.

Effectiveness of Perioperative Opioid Educational Initiatives: A Systematic Review and Meta-Analysis.

BACKGROUND: Opioids are the most commonly prescribed analgesics in the United States. Current guidelines have proposed education initiatives to reduce the risk of chronic opioid consumption, yet there is lack of efficacy data on such interventions. Our study evaluates the impact of perioperative opioid education on postoperative opioid consumption patterns including opioid cessation, number of pills consumed, and opioid prescription refills. METHODS: The MEDLINE/PubMed, Embase, Cochrane Library, Scopus, and Google Scholar databases were systematically searched for randomized controlled trials (RCTs) assessing the impact of perioperative educational interventions (using either paper- or video-based instruments regarding pain management and drug-induced side effects) on postoperative opioid patterns compared to standard preoperative care among patients undergoing elective surgery. Our end points were opioid consumption (number of pills used), appropriate disposal of unused opioids, opioid cessation (defined as no use of opioids), and opioid refills within 15 days, 6 weeks, and 3 months. RESULTS: In total, 11 RCTs fulfilled the inclusion criteria, totaling 1604 patients (804 received opioid education, while 800 received standard care). Six trials followed patients for 15 days after surgery, and 5 trials followed patients up to 3 months. After 15 days, the opioid education group consumed a lower number of opioid pills than those in the control group (weighted mean difference [WMD], -3.39 pills; 95% confidence interval [CI], -6.40 to -0.37; P =.03; I2 = 69%) with no significant difference in overall opioid cessation (odds ratio [OR], 0.25; 95% CI, 0.04-1.56; P = .14; I2 = 83%). Likewise, perioperative opioid education did not have significant effects on opioid cessation at 6 weeks (OR, 0.69; 95% CI, 0.45-1.05; P = .10; I2 = 0%) and 3 months (OR, 0.59; 95% CI,0.17-2.01; P = .10; I2 = 0%) after surgery, neither reduced the need for opioid refills at 15 days (OR, 0.57; 95% CI, 0.28-1.15; P = .12; I2 = 20%) and 6 weeks (OR, 1.08; 95% CI, 0.59-1.98; P = .80; I2 = 37%). There was no statistically significant difference in the rate of appropriate disposal of unused opioids between both groups (OR, 1.99; 95% CI, 0.66-6.00; P = .22; I2 = 71%). Subgroup analysis by type of educational intervention showed a statistical reduction of opioid consumption at 15 days when implementing multimedia/audiovisual strategies (4 trials: WMD, -4.05 pills; 95% CI, -6.59 to -1.50; P = .002; I2 = 45%), but there was no apparent decrease when using only paper-based strategies (2 trials: WMD, -2.31 pills; 95% CI, -12.21 to 7.59; P = .65; I2 = 80%). CONCLUSIONS: Perioperative educational interventions reduced the number of opioid pills consumed at 15 days but did not demonstrate a significant effect on opioid cessation or opioid refills at 15 days, 6 weeks, and 3 months. Further randomized trials should focus on evidence-based educational interventions with strict homogeneity of material to draw a more definitive recommendation.

Early Return to Intended Oncologic Therapy after implementation of an Enhanced Recovery After Surgery pathway for gastric cancer surgery.

PURPOSE: Time to initiation and completion of adjuvant therapy are critical to improve postoperative oncologic outcomes. This study aims to determine whether an Enhanced Recovery After Surgery (ERAS) pathway for gastric cancer surgery promotes early Return to Intended Oncologic Therapy (RIOT). METHODS: This is a before-after intervention study including patients with gastric adenocarcinoma who underwent surgery from January 2016 to January 2021. Two periods were denoted based upon the implementation date of our institutional ERAS pathway (June 2018). Our primary outcome was time to RIOT after surgery. Hodges-Lehmann analysis was used to estimate median differences of non-parametric outcomes. RESULTS: Seventy patients with gastric adenocarcinoma were included (35 in pre-ERAS period and 35 in post-ERAS period). Fourteen of the pre-ERAS and twenty-two patients of the post-ERAS period received adjuvant therapy. Time to RIOT was reduced in the post-ERAS period (median 39 days, IQR 31-49) by 12 days (95% CI 3-14 days, p = 0.01) compared to the pre-ERAS period (median 51 days, IQR 42-62). Length of hospital stay (LOS) was lower in the ERAS group (6 days, IQR 5-11 vs 10 days, IQR 8-13, p < 0.01). CONCLUSION: Our institutional ERAS pathway for gastric cancer surgery was associated with earlier RIOT and shorter LOS.

Single Chest Drain Practice Reduces Discharge Opioid Prescriptions in Thoracic Surgery.

INTRODUCTION: Chest drains are placed following pulmonary resection to promote lung re-expansion. The superiority of two chest drains at preventing postoperative complications has not been established, and practice remains largely dictated by surgeon preference. We sought to compare patient outcomes based on number of chest drains used. METHODS: This is a retrospective analysis including patients undergoing lobectomies and segmentectomies between March 2016 and April 2020. Patients were categorized based on number of chest drains placed and were matched 1:1 using the nearest neighbor (greedy) technique. Our primary outcome was opioid prescriptions at discharge (in morphine equivalent daily dose [MEDD]). Associations were tested using multilevel mixed-effects regression to account for variability between surgeons. RESULTS: A total of 1,094 patients met inclusion criteria. Single chest drain was used in 922 patients, whereas 172 had two chest tubes. After matching, there were 111 patients in each group. In multilevel mixed-effects logistic regression, patients treated with a single chest drain received fewer opioid prescriptions (ß: -194 MEDD, 95% confidence interval [CI]: -302 to -86 MEDD, p < 0.01), were more likely to be opioid-free at hospital discharge (odds ratio [OR] = 2.11, 95% CI: 1.08-4.12, p = 0.03), and had lower readmission rates within 30 days (OR = 0.33, 95% CI: 0.13-0.84, p = 0.02). Single chest drain practice did not affect the risk of pulmonary complications and there was no statistically significant difference in length of hospital stay (3 days [interquartile range: 2-5] vs. 4 days [3-6], p = 0.08). CONCLUSION: Single chest drain practice in lobectomies and segmentectomies was associated with less opioid prescription requirement without any increase in complications.

Opioid-sparing anesthesia and patient-reported outcomes after open gynecologic surgery: a historical cohort study.

PURPOSE: Dexmedetomidine and ketamine may be administered intraoperatively as continuous infusions to provide opioid-sparing anesthesia. Recent evidence has yielded controversial results regarding the impact of opioid-free anesthesia on postoperative complications, and there is a gap in knowledge regarding patient-reported outcomes (PROs). This study aimed to determine the impact of opioid-sparing anesthesia and opioid-based anesthesia on PROs among gynecologic patients within an enhanced recovery after surgery (ERAS) program. METHODS: We formed a single-center historical cohort from patients enrolled in another study who underwent open gynecologic surgery on an ERAS program from November 2014 to December 2020 (n = 2,095). We identified two cohorts based on the type of balanced anesthesia administered: 1) opioid-sparing anesthesia defined as the continuous infusion of dexmedetomidine and ketamine (adjuvants) during surgery or 2) opioid-based anesthesia (no adjuvants). We measured the quality of postoperative recovery using the MD Anderson Symptom Inventory (MDASI), a 29-item validated tool that was administered preoperatively, daily while admitted, and weekly after discharge until week 6. The primary outcome was interference with walking. We matched both cohorts and used a multilevel linear mixed-effect model to evaluate the effect of opioid-sparing anesthesia on the primary outcome. RESULTS: In total, 498 patients were eligible (159 in the opioid-sparing anesthesia cohort and 339 in the opioid-based anesthesia cohort), of whom 149 matched pairs were included in the final analysis. Longitudinal assessment showed no significant or clinically important difference in interference with walking (P = 0.99), general activity (P = 0.99), or other PROs between cohorts. Median [interquartile range (IQR)] intraoperative opioid administration (expressed as morphine milligram equivalents [MME]) among matched patients in the opioid-sparing anesthesia cohort was 30 [25-55] mg vs 58 [8-70] mg in the opioid-based anesthesia cohort (P < 0.01). Patients in the opioid-sparing anesthesia cohort had a lower opioid consumption in the postanesthesia care unit than those in the opioid-based anesthesia cohort (MME, 3 [0-10] mg vs 5 [0-15] mg; P < 0.01), but there was no significant difference between cohorts in total postoperative opioid consumption (MME, 23 [0-94] mg vs 35 [13-95] mg P = 0.053). CONCLUSIONS: In this single-center historical cohort study, opioid-sparing anesthesia had no significant or clinically important effects on interference with walking or other PROs in patients undergoing gynecologic surgery compared with opioid-based anesthesia. Opioid-sparing anesthesia was associated with less short-term opioid consumption than opioid-based anesthesia.

RéSUMé: OBJECTIF: La dexmédétomidine et la kétamine peuvent être administrées en peropératoire sous forme de perfusions continues pour fournir une anesthésie avec épargne opioïde. Des données probantes récentes ont présenté des résultats controversés concernant l'impact d'une anesthésie sans opioïdes sur les complications postopératoires, et il existe une lacune dans les connaissances concernant les issues rapportées par les patients (IRP). Cette étude visait à déterminer l'impact d'une anesthésie avec épargne opioïde et d'une anesthésie à base d'opioïdes sur les IRP chez les patientes de chirurgie gynécologique dans le cadre d'un programme de Récupération rapide après la chirurgie (ERAS ­ Enhanced Recovery After Surgery). MéTHODE: Nous avons formé une cohorte historique monocentrique composée de patientes inscrites à une autre étude qui ont bénéficié d'une chirurgie gynécologique avec laparotomie dans le cadre d'un programme d'ERAS entre novembre 2014 et décembre 2020 (n = 2095). Nous avons identifié deux cohortes en fonction du type d'anesthésie équilibrée administrée : 1) anesthésie avec épargne opioïde, définie comme une perfusion continue de dexmédétomidine et de kétamine (adjuvants) pendant la chirurgie, ou 2) anesthésie à base d'opioïdes (sans adjuvants). Nous avons mesuré la qualité de la récupération postopératoire à l'aide de l'inventaire des symptômes MDASI, un outil validé comportant 29 éléments qui a été administré avant l'opération, quotidiennement pendant l'admission et chaque semaine après le congé jusqu'à la semaine 6. Le critère d'évaluation principal était l'interférence avec la marche. Nous avons apparié les deux cohortes et utilisé un modèle linéaire à effets mixtes à plusieurs niveaux pour évaluer l'effet de l'anesthésie avec épargne opioïde sur le critère d'évaluation principal. RéSULTATS: Au total, 498 patientes étaient éligibles (159 dans la cohorte d'anesthésie avec épargne opioïde et 339 dans la cohorte d'anesthésie à base d'opioïdes), dont 149 paires appariées ont été incluses dans l'analyse finale. L'évaluation longitudinale n'a révélé aucune différence significative ou cliniquement importante dans l'interférence avec la marche (P = 0,99), l'activité générale (P = 0,99), ou d'autres IRP entre les deux cohortes. L'administration médiane d'opioïdes peropératoires [écart interquartile (ÉIQ)] (exprimée en équivalents de morphine en milligrammes [EMM]) chez les patientes appariées de la cohorte d'anesthésie avec épargne opioïde était de 30 [25-55] mg vs 58 [8­70] mg dans la cohorte d'anesthésie à base d'opioïdes (P < 0,01). Les patientes de la cohorte d'anesthésie avec épargne opioïde avaient une consommation d'opioïdes plus faible en salle de réveil que celles de la cohorte d'anesthésie à base d'opioïdes (EMM, 3 [0-10] mg vs 5 [0­15] mg; P < 0,01), mais il n'y avait pas de différence significative entre les cohortes dans la consommation totale d'opioïdes postopératoires (EMM, 23 [0-94] mg vs 35 [13­95] mg; P = 0,053). CONCLUSION: Dans cette étude de cohorte historique monocentrique, l'anesthésie avec épargne opioïde n'a eu aucun effet significatif ou cliniquement important sur l'interférence avec la marche ou d'autres IRP chez les patientes bénéficiant d'une chirurgie gynécologique par rapport à l'anesthésie à base d'opioïdes. L'anesthésie avec épargne opioïde était associée à une consommation d'opioïdes moindre à court terme que l'anesthésie à base d'opioïdes.

Intraoperative Dexmedetomidine and Ketamine Infusions in an Enhanced Recovery After Thoracic Surgery Program: A Propensity Score Matched Analysis.

OBJECTIVES: To assess the impact of intraoperative dexmedetomidine and ketamine on postoperative pain and opioid consumption within an ERAS program in thoracic pulmonary oncologic surgery. DESIGN: Retrospective, propensity-score matched analysis SETTING: Enhanced Recovery After Surgery (ERAS) program. PARTICIPANTS: Patients undergoing thoracic pulmonary oncologic surgery between March 2016 and April 2020. INTERVENTIONS: Continuous infusion of dexmedetomidine and ketamine. MEASUREMENTS & MAIN RESULTS: The authors initially analyzed data of 1,630 patients undergoing thoracic pulmonary oncologic surgery within their ERAS program. In total, 117 matched pairs were included in this analysis. Patients in the intraoperative dexmedetomidine + ketamine group were more likely to be opioid-free (76.6% vs 60.9%, P<0.01). Raw analysis showed lower pain scores at PACU admission (2.8±2.0 vs 3.4±2.0, P=0.03) and less opioid consumption at PACU admission (5 MED [0-10] vs 7.5 MED [0-15], P=0.03) in the dexmedetomidine + ketamine group; however, these differences were not present after adjusting for multiplicity. There were no significant differences in the length of PACU stay (1.9 hours [1.5-2.8] vs 2.0 hours [1.4-2.9], P=0.48) or hospital stay (three days [two-five] vs three days [two-five], P=0.08). Both groups had similar rates of pulmonary complications (5.9% vs 9.4%, P=0.326), ileus (0.9% vs 0.9%, P=1.00), and 30-day readmission (2.6% vs 4.3%, P=0.722). CONCLUSIONS: There were no differences in postoperative pain scores and opioid consumption throughout their hospital stay between patients receiving concomitant dexmedetomidine and ketamine infusions versus patients who did not receive these infusions during thoracic surgery.

Matched Pairs Comparison of an Enhanced Recovery Pathway Versus Conventional Management on Opioid Exposure and Pain Control in Patients Undergoing Lung Surgery.

OBJECTIVE: The aim of this study was to assess the effect of an enhanced recovery after surgery (ERAS) pathway on pain and opioid use following lung resection. SUMMARY BACKGROUND DATA: A major component ERAS pathways is opioid-sparing analgesia; however, the effect on postoperative pain and opioid use in patients undergoing lung resection is unknown. METHODS: Following implementation of an ERAS pathway for lung resection, 123 consecutive patients were identified. Patients were propensity-matched 1:1 with a group of consecutive patients (n = 907) undergoing lung resection before ERAS. Differences regarding in-hospital opioid consumption, discharge prescribing of opioids, and postoperative pain scores were examined. Morphine milligram equivalents were separately calculated including and excluding tramadol as an opioid medication. RESULTS: There were no significant differences between matched patients regarding age, sex, performance status, receipt of preoperative treatment, extent of lung resection, or operative approach. Epidural analgesia was used in 66% of controls and in none of the ERAS group (P < 0.001). The number of adjunct analgesics used postoperatively was greater in the ERAS group (median 3 vs 2, P < 0.001). There was a major reduction in morphine milligram equivalents in the ERAS group whether tramadol was included (median 14.2 vs 57.8, P < 0.001) or excluded (median 2.7 vs 57.8, P < 0.001) and regardless of surgical approach. Average daily pain scores were lower in the ERAS group (median 1.3 vs 1.8, P = 0.004); however, this difference was present only among patients undergoing thoracotomy. The proportion of patients who were prescribed discharge opioids varied whether tramadol was included (96% each group, P = 1.00) or excluded (39% vs 80%, P < 0.001) in the analysis. CONCLUSIONS: Implementation of an ERAS pathway was associated with effective post-operative analgesia, major reductions in in-hospital consumption of opioids, and reduced pain, compared to conventional management.

Incidence of acute kidney injury after open gynecologic surgery in an enhanced recovery after surgery pathway.

OBJECTIVE: To determine the incidence of postoperative AKI after open gynecologic surgery within ERAS, compare AKI in pre-ERAS and ERAS cohorts, and identify factors associated with AKI. METHODS: We compared postoperative AKI in patients who underwent open gynecologic surgery at one institution before and after ERAS implementation. AKI was defined as acute risk, injury, or failure by RIFLE criteria. Pre-ERAS and ERAS cohorts were matched using propensity score analysis in a 1:1 fashion using the nearest neighbor technique. Chi-squared, Fisher's Exact, and Wilcoxon rank-sum tests were used. RESULTS: Among 1334 ERAS and 191 pre-ERAS patients, postoperative AKI incidence was higher in the ERAS cohort (13.1% vs 5.8%, p = .004). In 166 matched pairs, ERAS patients had higher incidence (16.9% vs 5.4%, p < .001) and odds (OR 3.54, 95% CI 1.61-7.76) of AKI. Within ERAS, AKI was associated with older age (median age 65 vs 57, p < .001), Charlson Comorbidity Index score ≥ 3 (71.4% vs 57.9%, p < .001), and higher intraoperative estimated blood loss (400 vs 225 mL, p < .001), fluid administration (net fluid balance +1535 vs 1261 mL, p < .001), and hypotension lasting >5 min (41.7% vs 30.7%, p < .001). ERAS patients with AKI had longer hospital stays (median 4 vs 3 days, p < .001) and more readmissions (19% vs. 10%, p < .001) and grade 3+ complications (26% vs. 7%, p < .001). CONCLUSIONS: The incidence and odds of postoperative AKI was higher after gynecologic surgery within ERAS, and patients with AKI were more likely to have complications. Potential strategies to prevent postoperative AKI include perioperative fluid and blood pressure optimization.

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.

A prospective randomized trial comparing liposomal bupivacaine vs standard bupivacaine wound infiltration in open gynecologic surgery on an enhanced recovery pathway.

BACKGROUND: Value in healthcare is reflected by patient-centered outcomes of care per health dollar expended. Although liposomal bupivacaine is more expensive, it has been shown to provide prolonged analgesia (up to 72 hours). OBJECTIVE: This study aimed to evaluate whether the addition of liposomal bupivacaine to standard bupivacaine could decrease opioid intake and improve pain control after laparotomy for gynecologic surgery compared with standard bupivacaine alone in an enhanced recovery after surgery pathway. STUDY DESIGN: A prospective randomized controlled single-blinded trial of wound infiltration with liposomal bupivacaine plus 0.25% bupivacaine (study arm) vs 0.25% bupivacaine (control arm) was performed at a National Cancer Institute-designated tertiary referral cancer center. Participants were patients aged ≥18 years undergoing exploratory laparotomy for a gynecologic indication. All patients were treated on an enhanced recovery pathway including local wound infiltration before closure. In this study, 266 mg of liposomal bupivacaine (free base; equal to 300 mg bupivacaine HCL)+150 mg of bupivacaine mixed in the same syringe was used in the study arm, and 150 mg of bupivacaine was used in the control arm. The primary outcome was the proportion of patients who were opioid-free within 48 hours after surgery. Secondary outcomes included number of opioid-free days from postoperative day 0 to postoperative day 3, days to first opioid administration, morphine equivalent daily dose, and patient-reported outcomes collected with the MD Anderson Symptom Inventory. The MD Anderson Symptom Inventory was administered as a preoperative baseline, daily while hospitalized, and at least weekly for 8 weeks after discharge. All outcomes were prespecified before data collection. RESULTS: In this study, 102 patients were evaluated. Among them, 16.7% of patients in the study arm received no opioids up to 48 hours compared with 14.8% in the control arm (P=.99). There were no significant differences in the amount of intraoperative opioids administered or days to first opioid use. There was no significant difference between the 2 arms in median cumulative morphine equivalent daily dose (21.3 [study arm] vs 33.8 [control arm]; P=.36) or between the groups in morphine equivalent daily dose per individual day. There were no significant differences in patient-reported pain or interference with walking between the 2 arms or other patient-reported outcomes. CONCLUSION: Within an enhanced recovery after surgery pathway, adding liposomal bupivacaine to 0.25% bupivacaine wound infiltration did not decrease the proportion of patients who were opioid-free within 48 hours after surgery, did not decrease opioid intake, or did not improve patient's self-reported pain and functional recovery compared with standard bupivacaine.

The quantra hemostasis analyzer compared to thromboelastography (TEG) in the surgical oncologic population: A prospective observational trial.

BACKGROUND: Management of coagulopathy during major oncologic surgery can be multifactorial and challenging. Viscoelastic assays (VEAs) can be useful in providing vital data about the mechanism of coagulopathy in these dynamic circumstances. OBJECTIVES: A prospective nonrandomized observational study with the aim of describing the coagulation parameters of patients undergoing major oncologic surgery using the Quantra® and TEG® 5000 systems. Our secondary objectives included the correlation between Quantra and TEG parameters, and the times to result for both technologies. METHODS: This study included 74 adults undergoing oncologic surgery with an anticipated blood loss of more than 500 ml. For each subject, whole blood samples for each device were collected at multiple points perioperatively for comparison. RESULTS: Correlation coefficients between Quantra and TEG parameters were 0.8 and above, indicating a very strong correlation (p < .001). Correlation coefficients between conventional laboratory tests and Quantra ranged from 0.74 to 0.83, indicating a moderate correlation (p < .001). The mean time to obtain results and total processing time was shorter for Quantra in comparison to TEG. CONCLUSIONS: Quantra parameters strongly correlated with TEG parameters; however, Quantra parameters were available in shorter amount of time as it is specifically designed as a closed point of care device.

Impact of anesthesia technique on post-operative opioid use in open gynecologic surgery in an enhanced recovery after surgery pathway.

OBJECTIVE: To examine the effect of anesthesia technique in an enhanced recovery after surgery (ERAS) pathway on post-operative opioid use. METHODS: Patients undergoing open gynecologic surgery under an ERAS pathway from November 2014 through December 2018 were included retrospectively. All patients received pre-operative analgesia consisting of oral acetaminophen, pregabalin, celecoxib, and tramadol extended release, unless contraindicated. Patients received local wound infiltration with bupivacaine; the post-operative analgesic regimen was standardized. Patients were categorized by anesthesia technique: (1) inhalational, (2) total intravenous anesthesia (TIVA), and (3) combined technique. The primary outcome was post-operative opioid consumption measured as morphine equivalent dose, recorded as the total opioid dose received post-operatively, including doses received through post-operative day 3. RESULTS: A total of 1184 patients underwent general anesthesia using either inhalational (386, 33%), TIVA (349, 29%), or combined (449, 38%) techniques. Patients who received combined anesthesia had longer surgery times (p=0.005) and surgical complexity was higher among patients who underwent TIVA (moderate/higher in 76 patients, 38%) compared with those who received inhaled anesthesia (intermediate/higher in 41 patients, 23%) or combined anesthesia (intermediate/higher in 72 patients, 30%). Patients who underwent TIVA anesthesia consumed less post-operative opioids than those managed with inhalational technique (0 (0-46.3) vs 10 (0-72.5), p=0.009) or combined anesthesia (0 (0-46.3) vs 10 (0-87.5), p=0.029). Similarly, patients who underwent the combined technique had similar opioid consumption post-operatively compared with those who received inhalational anesthesia (10 (0-87.5) vs 10 (0-72.5), p=0.34). CONCLUSIONS: TIVA technique is associated with a decrease in post-operative consumption of opioids after open gynecologic surgery in patients on an ERAS pathway.

Longitudinal patient-reported outcomes and restrictive opioid prescribing after minimally invasive gynecologic surgery.

OBJECTIVE: To determine post-discharge patient-reported symptoms before and after implementation of restrictive opioid prescribing among women undergoing minimally invasive gynecologic surgery. METHODS: We compared clinical outcomes and symptom burden among a cohort of 389 women undergoing minimally invasive gynecologic surgery at a single institution before and after implementation of a restrictive opioid prescribing quality improvement initiative in July 2018. Post-discharge symptom burdens were collected up to 42 days after discharge using the MD Anderson Symptom Inventory and analyzed using linear mixed effects models. RESULTS: The majority of women included in this study were white non-smokers and the median age was 55 (range 23-83). Most women underwent hysterectomy (64%), had surgery for malignancy (71%), and were discharged from the hospital on the day of surgery (65%). Women in the restrictive opioid prescribing group had a median reduction in morphine equivalent dose prescribed at discharge of 83%, corresponding to a median reduction in 25 tablets of 5 mg oxycodone per person. There was no difference between opioid prescribing groups in either the rate of refill requests (P=1) or hospital re-admission (P=1) up to 30 days after discharge. After adjustment for co-variates, there was no statistically significant difference in post-discharge symptom burden including patient-reported pain (P=0.08), sleep (P=0.30), walking interference (P=0.64), activity interference (P=0.12), or affective interference (P=0.67). There was a trend toward less reported constiptation in the restrictive opioid prescribing group that did not reach statistical significance (P=0.05). CONCLUSION: We found that restrictive post-operative opioid prescribing was not associated with differences in longitudinal symptom burden among women undergoing minimally invasive gynecologic surgery. These results provide the most comprehensive picture to date of post-operative symptom recovery under different opioid prescribing approaches, lending additional support for existing recommendations to reduce opioid prescribing following gynecologic surgery.

Impact of a tiered discharge opioid algorithm on prescriptions and patient-reported outcomes after open gynecologic surgery.

OBJECTIVE: To compare discharge opioid refills, prescribed morphine equivalent dose and quantity, and longitudinal patient-reported outcomes before and after implementation of a tiered opioid prescribing algorithm among women undergoing open gynecologic surgery within an enhanced recovery after surgery program. METHODS: We compared opioid prescriptions, clinical outcomes, and patient-reported outcomes among 273 women. Post-discharge symptom burden was collected up to 42 days after discharge using the validated 27-item MD Anderson Symptom Inventory and analyzed using linear mixed effects models and Kaplan-Meier curves for symptom recovery. RESULTS: Among 113 pre-implementation and 160 post-implementation patients there was no difference in opioid refills (9.7% vs 11.3%, p=0.84). The post-implementation cohort had a significant reduction in median morphine equivalent dose (112.5 mg vs 225 mg, p<0.01), with no difference in median hospital length of stay (3 days vs 3 days, p=1.0) or 30-day readmission rate (9.4% vs 7.1%, p=0.66). There was no difference in patient-reported pain between the pre- and post-implementation cohorts on the day of discharge (severity 4.93 vs 5.14, p=0.53) or in any patient-reported symptoms, interference measures, or composite scores by post-discharge day 7. The median recovery time for most symptoms was 7 days, except for pain (14 days), fatigue (18 days), and physical interference (21 days), with no differences between cohorts. CONCLUSIONS: After implementation of a tiered opioid prescribing algorithm, the quantity and dose of discharge opioids prescribed decreased with no change in post-operative refills and without negatively impacting patient-reported symptom burden or interference, which can be used to educate and reassure patients and providers.

Risk factors for acute kidney injury in an enhanced recovery pathway for colorectal surgery.

PURPOSES: Enhanced recovery pathways (ERPs) have been disseminated worldwide to improve the perioperative patient outcomes while lowering direct healthcare costs. Recent evidence has revealed a potential association between ERPs for colorectal surgery and acute kidney injury (AKI). We, therefore, sought to identify the risk factors associated with postoperative AKI among patients in an ERP for colorectal surgery. METHODS: We analyzed the data resulting from a large multicenter, prospective cohort study of patients in an ERP for colorectal surgery. A multivariable analysis was performed to identify factors independently associated with postoperative AKI. The receiver operating characteristic (ROC) curves and contour representations were plotted for the diagnostic prediction analysis. RESULTS: Among those patients included in the analysis (n = 1652), the overall incidence of postoperative AKI was 7.7% (95% CI 6.5-9.1%). After adjustment, the independent risk factors for AKI included age > 60 (OR 1.03, 95% CI 1.01-1.05), male gender (OR 2.33, 95% CI 1.36-4.02), ASA III-IV (OR 2.43, 95% CI 1.39-4.26), CKD (OR 2.45, 95% CI 1.42-4.23), open surgical approach (OR 2.62, 95% CI 1.63-4.21) and serum albumin < 3.5 g/dL (OR 1.68, 95% CI 1.02-2.79). An ROC analysis revealed that the composite of albumin, creatinine and age was a strong predictor of postoperative AKI [area under the curve (AUC) 0.756; 95% CI 0.705-0.808]. CONCLUSION: Postoperative AKI is common in the setting of ERPs for colorectal surgery and it is associated with a poor clinical outcome. Of those characteristics associated with postoperative AKI, one modifiable factor is a low preoperative albumin level. Screening for malnourished patients or optimizing the nutritional status may be a useful preoperative intervention to prevent postoperative AKI and associated complications.