Opioid Use After Open Resection or Video-Assisted Thoracoscopic Surgery for Early-Stage Lung Cancer

Impact of cryoablation on operative outcomes in thoracotomy patients

OBJECTIVES

Cryoablation is increasingly being utilized as an alternative to epidurals for patients undergoing thoracotomies. Current evidence suggests cryoablation may decrease postoperative analgesia utilization, but could increase operative times. We hypothesized that the adoption of intraoperative cryoablation to manage post-thoracotomy pain would result in reduced length of stay and reduced perioperative analgesia compared to routine epidural use.

METHODS

A retrospective analysis was performed from a single, quaternary referral centre, prospective database on patients receiving thoracotomies between January 2020 and March 2022. Patients undergoing transthoracic hiatal hernia repair, lung resection or double-lung transplant were divided between epidural and cryoablation cohorts. Primary outcomes were length of stay, intraoperative procedure time, crossover pain management and oral narcotic usage the day before discharge.

RESULTS

During the study period, 186 patients underwent a transthoracic hiatal hernia repair, lung resection or double-lung transplant with 94 receiving a preoperative epidural and 92 undergoing cryoablation. Subgroup analysis demonstrated no significant differences in demographics, operative length, length of stay or perioperative narcotic use. Notably, over a third of patients in each cryoablation subgroup received a postoperative epidural (45.5% transthoracic hiatal hernia repair, 38.5% lung resection and 45.0% double-lung transplant) for further pain management during their admission.

CONCLUSIONS

Cryoablation use was not associated with an increase in procedure time, a decrease in narcotic use or length of stay. Surprisingly, many cryoablation patients received epidurals in the postoperative period for further pain control. Additional analysis is needed to fully understand the benefits and costs of epidural versus cryoablation strategies.

Opioid-Free Discharge After Pancreatic Resection Through a Learning Health System Paradigm

Importance

Postoperative opioid overprescribing leads to persistent opioid use and excess pills at risk for misuse and diversion. A learning health system paradigm using risk-stratified pancreatectomy clinical pathways (RSPCPs) may lead to reduction in inpatient and discharge opioid volume.

Objective

To analyze the outcomes of 2 iterative RSPCP updates on inpatient and discharge opioid volumes.

Design, Setting, and Participants

This cohort study included 832 consecutive adult patients at an urban comprehensive cancer center who underwent pancreatic resection between October 2016 and April 2022, comprising 3 sequential pathway cohorts (version [V] 1, October 1, 2016, to January 31, 2019 [n = 363]; V2, February 1, 2019, to October 31, 2020 [n = 229]; V3, November 1, 2020, to April 30, 2022 [n = 240]).

Exposures

After V1 of the pathway established a baseline and reduced length of stay (n = 363), V2 (n = 229) updated patient and surgeon education handouts, limited intravenous opioids, suggested a 3-drug (acetaminophen, celecoxib, methocarbamol) nonopioid bundle, and implemented the 5×-multiplier (last 24-hour oral morphine equivalents [OME] multiplied by 5) to calculate discharge volume. Pathway version 3 (n = 240) required the nonopioid bundle as default in the recovery room and scheduled conversion to oral medications on postoperative day 1.

Main Outcomes and Measures

Inpatient and discharge opioid volume in OME across the 3 RSPCPs were compared using nonparametric testing and trend analyses.

Results

A total of 832 consecutive patients (median [IQR] age, 65 [56-72] years; 410 female [49.3%] and 422 male [50.7%]) underwent 541 pancreatoduodenectomies, 285 distal pancreatectomies, and 6 other pancreatectomies. Early nonopioid bundle administration increased from V1 (acetaminophen, 320 patients [88.2%]; celecoxib or anti-inflammatory, 98 patients [27.0%]; methocarbamol, 267 patients [73.6%]) to V3 (236 patients [98.3%], 163 patients [67.9%], and 238 patients [99.2%], respectively; P < .001). Total inpatient OME decreased from a median 290 mg (IQR, 157-468 mg) in V1 to 184 mg (IQR, 103-311 mg) in V2 to 129 mg (IQR, 75-206 mg) in V3 (P < .001). Discharge OME decreased from a median 150 mg (IQR, 100-225 mg) in V1 to 25 mg (IQR, 0-100 mg) in V2 to 0 mg (IQR, 0-50 mg) in V3 (P < .001). The percentage of patients discharged opioid free increased from 7.2% (26 of 363) in V1 to 52.5% (126 of 240) in V3 (P < .001), with 187 of 240 (77.9%) in V3 discharged with 50 mg OME or less. Median pain scores remained 3 or lower in all cohorts, with no differences in postdischarge refill requests. A subgroup analysis separating open and minimally invasive surgical cases showed similar results in both groups.

Conclusions and Relevance

In this cohort study, the median total inpatient OME was halved and median discharge OME reduced to zero in association with a learning health system model of iterative opioid reduction that is freely adaptable by other hospitals. These findings suggest that opioid-free discharge after pancreatectomy and other major cancer operations is realistic and feasible with this no-cost blueprint.

Surgical Approach and Persistent Opioid Use in Medicare Patients Undergoing Lung Cancer Resection

BACKGROUND

Robotic and video-assisted thoracoscopic surgery (VATS) approaches for lung resection are associated with decreased inpatient opioid use compared with open surgery. Whether these approaches affect outpatient persistent opioid use remains unknown.

METHODS

Non-small cell lung cancer patients aged 66 years or more who underwent lung resection between 2008 and 2017 were identified from the Surveillance, Epidemiology, and End Results-Medicare database. Persistent opioid use was defined as filling an opioid prescription 3 to 6 months after lung resection. Adjusted analyses were performed to evaluate surgical approach and persistent opioid use.

RESULTS

We identified 19,673 patients: 7479 (38%) underwent open surgery, 10,388 (52.8%) VATS, and 1806 (9.2%) robotic surgery. Persistent opioid use was 38% in the entire cohort, including 27% of opioid naïve patients, and highest after open surgery (42.5%), followed by VATS (35.3%) and robotic (33.1%, P < .001). In multivariable analyses, robotic (odds ratio 0.84; 95% CI, 0.72-0.98; P = .028) and VATS (odds ratio 0.87; 95% CI, 0.79-0.95; P = .003) approaches were both associated with decreased persistent opioid use compared with open surgery in opioid naïve patients. At 12 months, patients resected using a robotic approach had the lowest oral morphine equivalent per month compared with VATS (133 vs 160, P < .001) and open surgery (133 vs 200, P < .001). Among chronic opioid patients, surgical approach was not associated with postoperative opioid use.

CONCLUSIONS

Persistent opioid use after lung resection is common. Both robotic and VATS approaches were associated with decreased persistent opioid use compared with open surgery among opioid naïve patients. Whether a robotic approach yields additional long-term advantages over VATS warrants further investigation.

Randomized Trial of Bupivacaine Versus Liposomal Bupivacaine in Minimally Invasive Lobectomy

BACKGROUND

The objective of this single-blind randomized study is to compare local infiltration of bupivacaine or liposomal bupivacaine (LipoB) in narcotic naïve patients undergoing minimally invasive lobectomy for early stage lung cancer.

METHODS

Adult patients without previous lung surgery undergoing minimally invasive lobectomy (robotic or thoracoscopic) for early stage lung cancer were randomly assigned to bupivacaine (with epinephrine 0.25%, 1:200 000) or LipoB 1.3%. Pain level was documented using the visual analog scale and morphine equivalents for narcotic pain medications. Inhospital treatment cost and pharmacy cost were compared.

RESULTS

The study enrolled 50 patients (bupivacaine, 24; LipoB, 26). The mean age of patients was 66 years, 94% were non-Hispanic white, and 48% were male. There was no difference in baseline characteristics and comorbidities. Duration of surgery (105 vs 137 minutes, P = .152), chest tube duration (49 vs 55 hours, P = .126), and length of stay (2.45 vs 3.28 days, P = .326) were similar between treatments. Inhospital morphine equivalents were 42.7 mg vs 48 mg (P = .714), and the median pain score was 5.2 vs 4.75 (P = .602) for bupivacaine vs LipoB, respectively. There was no difference in narcotic use at 2 to 4 weeks (57.1% [12 of 21] vs 54.5% [12 of 22], P = 1.00), and at 6 months (5.9% [1 of 17] vs 9.5% [2 of 21], P = 1.00) after surgery. The overall cost ($20 252 vs $22 775, P = .225) was similar; however, pharmacy cost for LipoB was higher ($1052 vs $596, P = .0001).

CONCLUSIONS

In narcotic naïve patients undergoing minimally invasive lobectomy, short-term narcotic use, postoperative pain scores, length of stay, and long-term narcotic use were similar between bupivacaine and LipoB.

New, long-term opioid use after lung cancer surgery is associated with reduced 2-year survival: a retrospective population-based cohort study in South Korea

INTRODUCTION

We aimed to investigate the proportion and associated factors for new long-term opioid use and its long-term effects after lung cancer surgery.

METHODS

The South Korean National Health Insurance Database was used as a nationwide registration data source. All patients undergoing lung cancer surgery between 2011 and 2018 were included, and patients who were preoperative opioid users were excluded from the analysis. New long-term opioid use was defined as an active opioid prescription at 6 months postoperatively.

RESULTS

In total, 54 509 patients were included in the final analysis. At 6 months postoperatively, 3325 (6.1%) patients who were newly prescribed opioids comprised the new long-term opioid user group. Older age, male sex, wider surgical extent, open thoracotomy, increased Charlson Comorbidity Index score, neoadjuvant or adjuvant chemotherapy, preoperative anxiety disorder and insomnia disorder were associated with a higher rate of new long-term opioid use. The new long-term opioid user group showed a 40% (HR, 1.40; 95% CI 1.29 to 1.53; p<0.001) higher risk of 2-year all-cause mortality. Moreover, the new long-term potent opioid user and less potent opioid user groups showed a 92% (HR, 1.92; 95% CI 1.67 to 2.21; p<0.001) and 22% (HR, 1.22; 95% CI 1.10 to 1.36; p<0.001) higher risk of 2-year all-cause mortality, respectively.

CONCLUSIONS

Among preoperative opioid-naive patients in South Korea, 6.1% became new long-term opioid users after lung cancer surgery. Certain factors are potential risk factors for new long-term opioid use, which could be associated with poorer long-term survival outcomes.

A prospective feasibility study evaluating the 5x-multiplier to standardize discharge prescriptions in cancer surgery patients

Background

We designed a prospective feasibility study to assess the 5x-multiplier (5x) calculation (eg, 3 pills in last 24 hours × 5 = 15) to standardize discharge opioid prescriptions compared to usual care.

Methods

Faculty-based surgical teams volunteered for either 5x or usual care arms. Patients undergoing inpatient (≥ 48 hours) surgery and discharged by surgical teams were included. The primary end point was discharge oral morphine equivalents. Secondary end points were opioid-free discharges and 30-day refill rates.

Results

Median last 24-hour oral morphine equivalents was similar between arms (7.5 mg 5x vs 10 mg usual care, P = .830). Median discharge oral morphine equivalents were less in the 5x arm (50 mg 5x vs 75 mg usual care, P < .001). Opioid-free discharges included 33.5% 5x vs 18.0% usual care arm patients (P < .001). Thirty-day refill rates were similar (15.3% 5x vs 16.5% usual care, P = .742).

Conclusion

The 5x-multiplier was associated with reduced opioid prescriptions without increased refills and can be feasibly implemented across a diverse surgical practice.

Analysis of Opioid Use in Patients Undergoing Open Versus Robotic Gastrectomy

BACKGROUND

Minimally invasive, robotic gastrectomy is associated with better short-term outcomes and quicker functional recovery. However, the degree to which the robotic approach influences postoperative pain and opioid use after gastrectomy is unknown. Our primary aim was to determine whether the robotic approach to gastrectomy reduces postoperative opioid use compared with the open approach.

METHODS

Patients who underwent gastrectomy (November 2018 to September 2021) were identified retrospectively. Clinical characteristics, short-term surgical outcomes, oral morphine equivalent (OME) use, and pain scores were collected. Both groups were managed through an enhanced recovery program in the perioperative period.

RESULTS

Of 81 patients, 50 underwent open and 31 underwent robotic gastrectomy. Compared with open gastrectomy patients, robotic gastrectomy patients had longer surgery time (360 vs. 288 min), less blood loss (50 vs. 138 mL), and shorter hospital stay (4 vs. 6 days) (all medians, P < 0.001). Robotic gastrectomy patients used lower OMEs on postoperative days 0-4 (all P < 0.05) and in total for days 0-4 (total mean dose 65.0 vs. 169.5 mg; P < 0.001) than did open gastrectomy patients. The robotic gastrectomy patients were prescribed a lower mean OME dose than the open gastrectomy patients (19.0 vs. 29.0 mg, respectively; P = 0.001). Multivariable analysis showed that robotic approach was associated with lower opioid use (odds ratio 3.70; 95% CI 1.01-14.3; P = 0.049).

CONCLUSIONS

Compared with open gastrectomy, robotic gastrectomy reduces opioid use in the early postoperative period and is associated with fewer OME discharge prescriptions and shorter hospital stay.

Patterns and Trends in Receipt of Opioids Among Patients Receiving Treatment for Cancer in a Large Health System

BACKGROUND

Given limited evidence on opioid prescribing among patients receiving treatment for cancer during the ongoing opioid epidemic, our objective was to assess predictors of and trends in opioid receipt during cancer treatment, including how patterns differ by type of cancer.

METHODS

Using cancer registry data, we identified patients with a first lifetime primary diagnosis of breast, colorectal, or lung cancer from 2013 to 2017 who underwent treatment within a large cancer center network. Cancer registry data were linked to electronic health record information on opioid prescriptions. We examined predictors of and trends in receipt of any opioid prescription within 12 months of cancer diagnosis.

RESULTS

The percentage of patients receiving opioids varied by cancer type: breast cancer, 35% (1,996/5,649); colorectal, 37% (776/2,083); lung, 47% (1,259/2,654). In multivariable analysis, opioid use in the year before cancer diagnosis was the factor most strongly associated with receipt of opioids after cancer diagnosis, with 4.90 (95% CI, 4.10-5.86), 5.09 (95% CI, 3.88-6.69), and 3.31 (95% CI, 2.68-4.10) higher odds for breast, colorectal, and lung cancers, respectively. We did not observe a consistent decline in opioid prescribing over time, and trends differed by cancer type.

CONCLUSIONS

Our findings suggest that prescription of opioids to patients with cancer varies by cancer type and other factors. In particular, patients are more likely to receive opioids after cancer diagnosis if they were previously exposed before diagnosis, suggesting that pain among patients with cancer may commonly include non-cancer-related pain. Heterogeneity and complexity among patients with cancer must be accounted for in developing policies and guidelines aimed at addressing pain management while minimizing the risk of opioid misuse.

Enhanced Recovery After Surgery Protocol Minimizes Intensive Care Unit Utilization and Improves Outcomes Following Pulmonary Resection

Background

Enhanced recovery after surgery (ERAS) protocols have been associated with improved postoperative outcomes but require further validation in thoracic surgery. This study evaluated outcomes of patients undergoing pulmonary resection before and after implementation of an ERAS protocol.

Methods

Electronic medical records were queried for all patients undergoing pulmonary resection between April 2017 and April 2019. Patients were grouped into pre- and post-ERAS cohorts based on dates of operation. The ERAS protocol prioritized early mobilization, limited invasive monitoring, euvolemia, and non-narcotic analgesia. Primary outcome measures included intensive care unit (ICU) utilization, postoperative pain metrics, and perioperative morbidity. Regression analyses were performed to identify predictors of morbidity. Subgroup analyses were performed by pulmonary risk profile and surgical approach.

Results

A total of 64 pre- and 67 post-ERAS patients were included in the study. ERAS implementation was associated with reduced postoperative ICU admission (pre: 65.6% vs. post: 19.4%, p < 0.0001), shorter ICU median length of stay (LOS) (pre: 1 vs. post: 0, p < 0.0001), and decreased opioid usage measured by median morphine milligram equivalents (pre: 40.5 vs. post: 20.0, p < 0.0001). Post-ERAS patients also reported lower visual analog scale (VAS) pain scores on postoperative days (POD) 1 and 2 (pre: 6.3/5.6 vs. post: 5.3/4.2, p = 0.04/0.01) as well as average VAS pain score over POD0-2 (pre: 6.2 vs. post: 5.2, p = 0.005).

Conclusions

Implementation of an ERAS protocol for pulmonary resection, which dictated reduced ICU admissions, did not increase major postoperative morbidity. Additionally, ERAS-enrolled patients reported improved postoperative pain control despite decreased opioid utilization.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00268-021-06259-1.

Predicting Persistent Opioid Use, Abuse, and Toxicity Among Cancer Survivors

BACKGROUND

Although opioids play a critical role in the management of cancer pain, the ongoing opioid epidemic has raised concerns regarding their persistent use and abuse. We lack data-driven tools in oncology to understand the risk of adverse opioid-related outcomes. This project seeks to identify clinical risk factors and create a risk score to help identify patients at risk of persistent opioid use and abuse.

METHODS

Within a cohort of 106 732 military veteran cancer survivors diagnosed between 2000 and 2015, we determined rates of persistent posttreatment opioid use, diagnoses of opioid abuse or dependence, and admissions for opioid toxicity. A multivariable logistic regression model was used to identify patient, cancer, and treatment risk factors associated with adverse opioid-related outcomes. Predictive risk models were developed and validated using a least absolute shrinkage and selection operator regression technique.

RESULTS

The rate of persistent opioid use in cancer survivors was 8.3% (95% CI = 8.1% to 8.4%); the rate of opioid abuse or dependence was 2.9% (95% CI = 2.8% to 3.0%); and the rate of opioid-related admissions was 2.1% (95% CI = 2.0% to 2.2%). On multivariable analysis, several patient, demographic, and cancer and treatment factors were associated with risk of persistent opioid use. Predictive models showed a high level of discrimination when identifying individuals at risk of adverse opioid-related outcomes including persistent opioid use (area under the curve [AUC] = 0.85), future diagnoses of opioid abuse or dependence (AUC = 0.87), and admission for opioid abuse or toxicity (AUC = 0.78).

CONCLUSION

This study demonstrates the potential to predict adverse opioid-related outcomes among cancer survivors. With further validation, personalized risk-stratification approaches could guide management when prescribing opioids in cancer patients.

Sustained reduction in discharge opioid volumes through provider education: Results of 1168 cancer surgery patients over 2 years

BACKGROUND

An opioid reduction education program to decrease discharge opioid prescriptions was initiated in our Department of Surgical Oncology. The study's aim was to measure the results and sustainability of these interventions 1 year later.

METHODS

This prospective quality improvement project identified patients undergoing resection in five index tumor sites (peritoneal surface, sarcoma, stomach, pancreas, liver) at a high-volume cancer center. Patients were grouped into pre-education (PRE: July 2017-July 2018) and posteducation (POST: September 2018-July 2019) periods, before and after departmental education talks and videos in August 2018. Opioids were converted to oral morphine equivalents (OME) to compare the groups.

RESULTS

Of 1168 evaluable patients (PRE 646, 55%; POST 522, 45%), the median last-24-h inpatient OME was 15 mg in PRE patients and 10 mg in POST patients (p < .001). Median discharge OME decreased from 200 mg in PRE to 100 mg in POST patients (p < .001). The frequency of patients with zero discharge opioids increased from 11% to 19% (p < .001). This discharge OME reduction amounted to 52,200 mg OME saved, or the equivalent of 6960 5-mg oxycodone pills not disseminated.

CONCLUSIONS

A perioperative opioid reduction education program targeted to providers halved discharge OME, with sustained reductions 1 year later.

Analysis of the differences in lung cancer research trends between China and the United States based using project funding data

Background

Lung cancer is the leading cause of cancer-related death, and countries all over the world have given considerable support to lung cancer research. However, analysis on the status of funding in the field of lung cancer is still lacking.

Methods

We visited the National Natural Science Foundation of China (NSFC) and National Institutes of Health (NIH) official websites to gather lung cancer research information between 2008 and 2020. RSTCM6 software was used to extract the keywords of funded projects which were then imported into CiteSpace software for visual analysis of word frequency.

Results

A total of 1,745 and 5,939 search results were finally obtained from the NSFC and NIH websites, respectively. The amount of NSFC funding for projects in the field of lung cancer increased steadily from 2008 to 2012, while the NIH funding for lung cancer was significantly higher in even years than in odd years between 2008 to 2018. The Shanghai Jiaotong University, Sun Yat-sen University, and Guangzhou Medical University were the top three research institutions that had received the most projects funded by the NSFC. Apoptosis, proliferation, invasion, metabolism, the pathogenesis of lung cancer, cell signal transduction, epithelial-mesenchymal transformation (EMT), and immune-related research were the most frequently funded research areas by the NSFC. Biomarkers, targeted therapy, signal pathway, genomics, and immune-related research were funded most the most frequently funded research areas by the NIH. Both the NIH and NSFC funding for lung cancer immune-related research has increased in recent years.

Conclusions

NIH funding in the United States is decreasing year by year, whereas NSFC funding is increasing in China. There are some differences in research focus in lung cancer research funding between China and the United States. However, both countries have increased the support for immune-related research in recent years.

Perceptions of opioid use and prescribing habits in oncologic surgery: A survey of the society of surgical oncology membership

BACKGROUND

The objective of this study was to assess current perceptions surrounding opioid prescribing in surgical oncology to inform perioperative quality improvement initiatives.

METHODS

After the Society of Surgical Oncology (SSO) approval, a survey was distributed to its membership. Five sample procedures were used to assess provider perceptions and prescribing habits. Data were summarized and compared by self-reported demographics.

RESULTS

One hundred and seventy-five participants completed the survey: 149 (85%) faculty, 24 (14%) trainees, and 2 (1%) advanced practice providers. Most participants (76%) practiced in academic programs and 21% practiced in non-US locations. Few differences were identified based on clinical role, academic rank, or practice years. Compared with non-US providers, US providers expected higher pain scores at discharge, recommended greater opioid prescriptions, and estimated more days of opioid use for almost every procedure. More non-US providers believed discharge opioids should not be distributed to patients who are opioid-free in their last 24 inpatient hours (80% vs 50%, P = .001). All providers ranked education as "very important" for reducing opioid prescriptions.

CONCLUSIONS

Compared with their international counterparts, US surgical oncology providers expected greater opioid needs and recommended higher prescription numbers. Educating providers on multimodal opioid-sparing bundles, accelerated weaning protocols, and standardized discharge prescribing habits could have a positive impact the US opioid epidemic.

Comparison of Double Sleeve Lobectomy by Uniportal Video-Assisted Thoracic Surgery (VATS) and Thoracotomy for NSCLC Treatment

Background

With the development of the surgical technique and experience of surgeons, uniportal VATS has been used in double sleeve lobectomy to treat non-small cell lung cancer (NSCLC). This retrospective study aims to evaluate the efficacy and safety of uniportal VATS in NSCLC treatment.

Methods

We reviewed 42 NSCLC patients who underwent double sleeve lobectomy in Shanghai Pulmonary Hospital from June 2015 to November 2017. 21 patients received double sleeve lobectomy through uniportal VATS and 21 through conventional thoracotomy with large incision.

Results

The characteristics of patients were similar between the two groups. The operation time was longer in the uniportal VATS group (p=0.021) and the drainage on postoperation day 1 was significantly less in the uniportal VATS group (p=0.004). Patients reported a lower postoperative pain level in the uniportal VATS group than in the thoracotomy group (p=0.002). No statistically significant difference showed in other aspects.

Conclusion

Uniportal VATS double sleeve lobectomy for NSCLC treatment is safe and effective. Lower postoperative pain level was found in the uniportal VATS group. Its complication rate and postoperation survival were similar to the conventional thoracotomy approach with large incision. But a large randomized clinical trial is still necessary for further investigation.

Multiportal subxiphoid thoracoscopic major pulmonary resections

Background

New subxiphoid video-assisted thoracoscopic surgery (SVATS) approaches are emerging for major pulmonary resection. The underlying concept is to reduce invasiveness and morbidity, by minimising intercostal nerve trauma, without any concession on safety and carcinologic issues. This study describes and evaluates our initial experience in multiportal SVATS, compared to conventional VATS (CVATS).

Methods

Between June 2016 and October 2017, 75 consecutive patients underwent major pulmonary resection with an original multiportal SVATS approach developed through a single or double access under the costal arch, unsystematically associated with intercostal ports for 5-mm instruments only. We retrospectively compared results of this SVATS group (n=75) against an historic CVATS group (n=75).

Results

Fifty-one lobectomies, 20 segmentectomies and 4 pneumonectomies were achieved through multiportal SVATS. Sixty-eight malignant lesions and 7 benign lesions were noted. All patients with primary lung cancer underwent R0 resection and complete lymphadenectomy, with 11% of clinical N0 upstaging. When compared, the SVATS and CVATS groups were similar in terms of demographics and pathology. No statistical differences were observed in terms of conversion (9% vs. 12%), mean operative time (157 vs. 155 min), morbidity (24% vs. 32%) and 30-day mortality (0% vs. 1.3%). The SVATS group had a significantly shorter length of drainage (median: 1 vs. 3 days, P<0.001), and a shorter postoperative length of stay (median: 2 vs. 4 days, P<0.001). Comfortable pain relief on postoperative day 1 (Numeric Rating Scale ≤3) was equally achieved (96% vs. 93%) with a significantly simplified SVATS analgesic protocol (local block and opioid-free oral analgesia) compared to the CVATS analgesic protocol (paravertebral catheter and opioid-free oral analgesia). SVATS group presented significantly less patients with persistent morphine use at day 7 (4% vs. 15%, P=0.04).

Conclusions

Multiportal SVATS is a safe, carcinologic and reproducible approach for major pulmonary resection. By avoiding intercostal strains, it enables a high compliance to opioid-free analgesic protocol, contributing to significantly shorter hospitalisation and better recovery, compared to CVATS.

Enhanced recovery in liver surgery decreases postoperative outpatient use of opioids

BACKGROUND

Pathways of enhanced recovery in liver surgery decrease inpatient opioid use; however, little data exist regarding their effect on discharge prescriptions and post-discharge opioid intake.

METHODS

For consecutive patients undergoing liver resection from 2011-2018, clinicopathologic factors were compared between patients exposed to enhanced recovery vs. traditional care pathways. Multivariable analysis was used to determine factors predictive for traditional opioid use at the first postoperative follow-up. The enhanced recovery in liver surgery protocol included opioid-sparing analgesia, goal-directed fluid therapy, early postoperative feeding, and early ambulation.

RESULTS

Of 244 cases, 147 enhanced recovery patients were compared with 97 traditional pathway patients. Enhanced recovery patients were older (median 57 years vs 52 years, P = .031) and more frequently had minimally invasive operations (37% vs 16%, P < .001), with fewer major complications (2% vs 9%, P = .011). Enhanced recovery patients were less likely to be discharged with a prescription for traditional opioids (26% vs 79%, P < .001) and less likely to require opioids at their first postoperative visit (19% vs 61%, P < .001) despite similarly low patient-reported pain scores (median 2/10 both groups, P = .500). On multivariable analysis, the traditional recovery pathway was independently associated with traditional opioid use at the first follow-up (odds ratio 6.4, 95% confidence interval 3.5-12.1; P < .001).

CONCLUSION

The implementation of an enhanced recovery in liver surgery pathway with opioid-sparing techniques was associated with decreased postoperative discharge prescriptions for opioids and outpatient opioid use after oncologic liver surgery, while achieving the same level of pain control. For this and other populations at risk of persistent opioid use, enhanced recovery strategies can eliminate excess availability of opioids.

Inpatient Opioid Use After Pancreatectomy: Opportunities for Reducing Initial Opioid Exposure in Cancer Surgery Patients

BACKGROUND

Despite advances in enhanced surgical recovery programs, strategies limiting postoperative inpatient opioid exposure have not been optimized for pancreatic surgery. The primary aims of this study were to analyze the magnitude and variations in post-pancreatectomy opioid administration and to characterize predictors of low and high inpatient use.

METHODS

Clinical characteristics and inpatient oral morphine equivalents (OMEs) were downloaded from electronic records for consecutive pancreatectomy patients at a high-volume institution between March 2016 and August 2017. Regression analyses identified predictors of total OMEs as well as highest and lowest quartiles.

RESULTS

Pancreatectomy was performed for 158 patients (73% pancreaticoduodenectomy). Transversus abdominus plane (TAP) block was performed for 80% (n = 127) of these patients, almost always paired with intravenous patient-controlled analgesia (IV-PCA), whereas 15% received epidural alone. All the patients received scheduled non-opioid analgesics (median, 2). The median total OME administered was 423 mg (range 0-4362 mg). Higher total OME was associated with preoperative opioid prescriptions (p < 0.001), longer hospital length of stay (LOS; p < 0.001), and no epidural (p = 0.006). The lowest and best quartile cutoff was 180 mg of OME or less, whereas the highest and worst quartile cutoff began at 892.5 mg. After adjustment for inpatient team, only epidural use [odds ratio (OR) 0.3; p = 0.04] predicted lowest-quartile OME. Preoperative opioid prescriptions (OR 8.1; p < 0.001), longer operative time (OR 3.4; p = 0.05), and longer LOS (OR 1.1; p = 0.007) predicted highest-quartile OME.

CONCLUSIONS

Preoperative opioid prescriptions and longer LOS were associated with increased inpatient OME, whereas epidural use reduced inpatient OME. Understanding the predictors of inpatient opioid use and the variables predicting the lowest and highest quartiles can inform decision-making regarding preoperative counseling, regional anesthetic block choice, and novel inpatient opioid weaning strategies to reduce initial postoperative opioid exposure.

Educating Surgical Oncology Providers on Perioperative Opioid Use: Results of a Departmental Survey on Perceptions of Opioid Needs and Prescribing Habits

BACKGROUND

Patients undergoing oncologic surgery are at risk for persistent postoperative opioid use. As a quality improvement initiative, this study sought to characterize provider perceptions regarding opioid-prescribing after oncologic procedures.

METHODS

Surgical oncology attending physicians, clinical fellows, and advanced practice providers (APPs) at a high-volume cancer center were surveyed before and after educational sessions focusing on the opioid epidemic with review of departmental data.

RESULTS

The pre-education response rates were 72 (70%) of 103: 22 (65%) of 34 attending physicians, 19 (90%) of 21 fellows, and 31 (65%) of 48 APPs. For five index operations (open abdominal resection, laparoscopic colectomy, wide local excision, thyroidectomy, port), the fellows answered that patients should stop receiving opioids sooner than recommended by the attending surgeons or APPs. For four of five procedures, the APPs recommended higher discharge opioid prescriptions than the attending surgeons or fellows. Almost half of the providers (n = 46, 45%) responded to both the pre- and post-education surveys. After the intervention, the providers recommended lower numbers of opioid pills and indicated that patients should be weaned from opioids sooner for all the procedures. Compared with pre-education, more providers agreed post-education that discharge opioid prescriptions should be based on a patient's last 24 h of inpatient opioid use (83 vs 91%; p = 0.006). The providers who did not attend a session showed no difference in perceptions or recommendations at the repeat assessment.

CONCLUSIONS

Variation exists in perioperative opioid-prescribing among provider types, with those most involved in daily care and discharge processes generally recommending more opioids. After education, providers lowered discharge opioid recommendations and thought patients should stop receiving opioids sooner. The next steps include assessing for quantitative changes in opioid-prescribing and implementing standardized opioid prescription algorithms.

Enhancing the study of enhanced recovery after thoracic surgery: methodology and population-based approaches for the future

Achieving optimal outcomes following thoracic surgery requires a complex multidisciplinary effort spanning the entire peri-operative period. Enhanced recovery after surgery (ERAS) protocols aim to codify essential elements in care across all perioperative settings. As thoracic surgeons have begun to embrace ERAS, identification of optimal protocol elements and novel study endpoints is necessary. In this review we will briefly review the current available evidence for ERAS in thoracic surgery, while focusing on study methods and design. We will discuss methodology for future studies and how a population-based approach can improve the current level of evidence supporting broad implementation of ERAS to thoracic surgery.