1
|
Saroya J, Singh A, Chang JL, Durr ML. Opioid Prescription Trends Among Sleep Surgeons in the United States. Laryngoscope 2024. [PMID: 38877817 DOI: 10.1002/lary.31543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 04/19/2024] [Accepted: 05/08/2024] [Indexed: 06/16/2024]
Abstract
OBJECTIVE This study aimed to describe trends in opioid prescriptions among US sleep surgeons between 2013 and 2021 via a retrospective analysis conducted using publicly available data. METHODS Utilizing the CMS part D database, we analyzed data from 82 sleep surgeons, focusing on metrics including number of opioid beneficiaries and claims, opioid cost, and opioid day supply per beneficiary. We employed statistical methods including ANOVA, t-tests, Fisher's exact test with Monte Carlo Simulation, and regression models. RESULTS There were no significant changes in the number of opioid claims (p = 0.782) or beneficiaries per provider (p = 0.590) nor was there a decrease in opioid day supply per beneficiary (p = 0.489) over time. Surgeons who graduated residency before 2000 prescribed significantly more opioids over the course of the study period compared to those graduating after 2000 with higher opioid day supply per beneficiary (13.34 vs. 7.42, p < 0.001), higher opioid beneficiaries per provider (21.62 vs. 19.36, p = 0.028), and higher opioid claims per provider (30.30 vs. 21.78, p < 0.001). A significant annual decrease in opioid cost per beneficiary (ANOVA, p = 0.006) was noted. CONCLUSIONS This study illuminates a significant impact of provider years in practice on opioid prescribing trends, alongside a decreasing trend in opioid cost per beneficiary. Despite the evolving paradigm emphasizing opioid reduction and evidence of decreasing opioid prescriptions in other otolaryngology subspecialties, our findings depict that opioid prescriptions among sleep surgeons remained stable from 2013 to 2021. LEVEL OF EVIDENCE III Laryngoscope, 2024.
Collapse
Affiliation(s)
- Jasmeet Saroya
- Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, U.S.A
| | - Amritpal Singh
- Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, U.S.A
| | - Jolie L Chang
- Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, U.S.A
- Surgical Services, San Francisco Veterans Affairs Health Care System, San Francisco, California, U.S.A
| | - Megan L Durr
- Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, U.S.A
| |
Collapse
|
2
|
Ferreira PRC, De Oliveira RIP, Vaz MD, Bentes C, Costa H. Opioid-Free Anaesthesia Reduces Complications in Head and Neck Microvascular Free-Flap Reconstruction. J Clin Med 2023; 12:6445. [PMID: 37892584 PMCID: PMC10607324 DOI: 10.3390/jcm12206445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 09/29/2023] [Accepted: 10/03/2023] [Indexed: 10/29/2023] Open
Abstract
Head and neck free-flap microvascular surgeries are complex and resource-intensive procedures where proper conduct of anaesthesia plays a crucial role in the outcome. Flap failure and postoperative complications can be attributed to multiple factors, whether surgical- or anaesthesia-related. The anesthesiologist should ensure optimised physiological conditions to guarantee the survival of the flap and simultaneously decrease perioperative morbidity. Institutions employ different anaesthetic techniques and results vary across centres. In our institution, two different total intravenous approaches have been in use: a remifentanil-based approach and a multimodal opioid-sparing approach, which is further divided into an opioid-free anaesthesia (OFA) subgroup. We studied every consecutive case performed between 2015 and 2022, including 107 patients. Our results show a significant reduction in overall complications (53.3 vs. 78.9%, p = 0.012), length of stay in the intensive care unit (3.43 ± 5.51 vs. 5.16 ± 4.23 days, p = 0.046), duration of postoperative mechanical ventilation (67 ± 107 vs. 9 ± 38 h, p = 0.029), and the need for postoperative vasopressors (10% vs. 46.6%, p = 0.001) in the OFA group (vs. all other patients). The multimodal and OFA strategies have multiple differences regarding the fluid therapy, intraoperative type of vasopressor used, perioperative pathways, and various drug choices compared to the opioid-based technique. Due to the small number of cases in our study, we could not isolate any attitude, as an independent factor, from the success of the OFA strategy as a whole. Large randomised controlled trials are needed to improve knowledge and help define the ideal anaesthetic management of these patients.
Collapse
Affiliation(s)
- Paulo-Roberto Cardoso Ferreira
- Centro Hospitalar de Vila Nova de Gaia, 4434-502 Vila Nova de Gaia, Portugal
- Medical Sciences Department, University of Aveiro, 3810-193 Aveiro, Portugal
| | | | - Marta Dias Vaz
- Centro Hospitalar de Vila Nova de Gaia, 4434-502 Vila Nova de Gaia, Portugal
| | - Carla Bentes
- Centro Hospitalar de Vila Nova de Gaia, 4434-502 Vila Nova de Gaia, Portugal
| | - Horácio Costa
- Centro Hospitalar de Vila Nova de Gaia, 4434-502 Vila Nova de Gaia, Portugal
- Medical Sciences Department, University of Aveiro, 3810-193 Aveiro, Portugal
| |
Collapse
|
3
|
List MA, Knackstedt M, Liu L, Kasabali A, Mansour J, Pang J, Asarkar AA, Nathan C. Enhanced recovery after surgery, current, and future considerations in head and neck cancer. Laryngoscope Investig Otolaryngol 2023; 8:1240-1256. [PMID: 37899849 PMCID: PMC10601592 DOI: 10.1002/lio2.1126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 11/15/2022] [Indexed: 10/31/2023] Open
Abstract
Objectives Review of the current and relevant literature to develop a list of evidence-based recommendations that can be implemented in head and neck surgical practices. To provide rationale for the multiple aspects of comprehensive care for head and neck surgical patients. To improve postsurgical outcomes for head and neck surgical patients. Methods Extensive review of the medical literature was performed and relevant studies in both the head and neck surgery and other surgical specialties were considered for inclusion. Results A total of 18 aspects of perioperative care were included in this review. The literature search included 276 publications considered to be the most relevant and up to date evidence. Each topic is concluded with recommendation grade and quality of evidence for the recommendation. Conclusion Since it's conception, enhanced recovery after surgery (ERAS) protocols have continued to push for comprehensive and evidence based postsurgical care to improve patient outcomes. Head and neck oncology is one of the newest fields to develop a protocol. Due to the complexity of this patient population and their postsurgical needs, a multidisciplinary approach is needed to facilitate recovery while minimizing complications. Current and future advances in head and neck cancer research will serve to strengthen and add new principles to a comprehensive ERAS protocol. Level of Evidence 2a.
Collapse
Affiliation(s)
- Marna A. List
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - Mark Knackstedt
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - Lucy Liu
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - Ahmad Kasabali
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
- College of MedicineLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - Jobran Mansour
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - John Pang
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - Ameya A. Asarkar
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - Cherie‐Ann Nathan
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
- Feist‐Weiller Cancer CenterShreveportLouisianaUSA
| |
Collapse
|
4
|
Liu Z, Cheng S, Wang C, Liu X, Huang H, Zhu Y, Zhou B, Wu H, Cao M. Preoperative flurbiprofen diminishes the rate of reoperation after free flap reconstruction: A retrospective study. J Craniomaxillofac Surg 2023; 51:560-567. [PMID: 37620245 DOI: 10.1016/j.jcms.2023.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 01/09/2023] [Accepted: 08/14/2023] [Indexed: 08/26/2023] Open
Abstract
This study aimed to evaluate the association between preoperative flurbiprofen, a non-selective COX inhibitor, and reoperation for flap crisis after free flap reconstruction. In this retrospective study, patients who underwent head and neck surgery with free flap reconstructions were collected. To identify risk factors for reoperation from demographic features and perioperative variables, univariate and multivariate logistic analyses were conducted. After propensity score matching (PSM), univariate and adjusted multivariate analyses were employed to explore the impact of preoperative flurbiprofen on reoperation after free flap reconstruction. This study comprised 437 patients, 33 of whom underwent reoperations for flap crisis. After multivariate analysis, radiotherapy history (P = 0.005; odds ratio [OR] = 0.225; 95% CI, 0.080-0.636) and preoperative flurbiprofen (P = 0.038; OR = 5.059; 95% CI, 1.094-23.386) were identified as independent factors for reoperation. PSM was achieved, and preoperative flurbiprofen was found to diminish the reoperation rate (P = 0.046; OR = 4.765; 95% CI, 1.029-22.202) without increasing bleeding complications. Within the limitations of the study, flurbiprofen should be administered preoperatively to reduce the rate of reoperations for flap crisis whenever appropriate.
Collapse
Affiliation(s)
- Zhongqi Liu
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shi Cheng
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chengli Wang
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiaoqing Liu
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Haoquan Huang
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yingying Zhu
- Clinical Research Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Bin Zhou
- Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Haixuan Wu
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Minghui Cao
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.
| |
Collapse
|
5
|
Hanba C, Lewis C. Enhanced Recovery After Surgery for Head and Neck Oncologic Surgery Requiring Microvascular Reconstruction. Otolaryngol Clin North Am 2023; 56:801-812. [PMID: 37380326 DOI: 10.1016/j.otc.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
It has been demonstrated since the 1990's that surgical outcomes can be improved through protocolized perioperative interventions. Since then, multiple surgical societies have engaged in adopting Enhanced Recovery After Surgery (ERAS) Societal recommendations to improve patient satisfaction, decrease the cost of interventions, and improve outcomes. In 2017, ERAS released consensus recommendations detailing the perioperative optimization of patients undergoing head and neck free flap reconstruction. This population was identified as a high resource demand, oftentimes burdened with challenging comorbidity, and poorly described cohort for which a perioperative management protocol could help to optimize outcomes. The following pages aim to further detail perioperative strategies to streamline patient recovery after head and neck reconstructive surgery.
Collapse
Affiliation(s)
- Curtis Hanba
- Department of Otolaryngology-Head and Neck Surgery, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
| | - Carol Lewis
- Department of Otolaryngology-Head and Neck Surgery, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| |
Collapse
|
6
|
Savic Vujovic K, Zivkovic A, Dozic I, Cirkovic A, Medic B, Srebro D, Vuckovic S, Milovanovic J, Jotic A. Oxidative Stress and Inflammation Biomarkers in Postoperative Pain Modulation in Surgically Treated Patients with Laryngeal Cancer-Pilot Study. Cells 2023; 12:1391. [PMID: 37408225 DOI: 10.3390/cells12101391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 05/09/2023] [Accepted: 05/11/2023] [Indexed: 07/07/2023] Open
Abstract
(1) Background: Surgical treatment of laryngeal carcinoma includes different types of laryngectomies with neck dissection. Surgical tissue damage triggers an inflammatory response, leading to the release of pro-inflammatory molecules. This increases reactive oxygen species production and decreases antioxidant defense mechanisms, leading to postoperative oxidative stress. The aim of this study was to assess the correlation between oxidative stress (malondialdehyde, MDA; glutathione peroxidase, GPX; superoxide dismutase, SOD) and inflammation (interleukin 1, IL-1; interleukin-6, IL-6; C-reactive protein, CRP) parameters and postoperative pain management in patients surgically treated with laryngeal cancer. (2) Methods: This prospective study included 28 patients with surgically treated laryngeal cancer. Blood samples were taken for the analysis of oxidative stress and inflammation parameters before the operative treatment and after the operative treatment (1st postoperative day and 7th postoperative day). The concentrations of MDA, SOD, GPX, IL-1, IL-6, and CRP in the serum were determined by coated enzyme-linked immunosorbent assay (ELISA). The visual analog scale (VAS) was used for pain assessment. (3) Results and conclusion: There was a correlation between oxidative stress and inflammation biomarkers and postoperative pain modulation in surgically treated patients with laryngeal cancer. Age, more extensive surgery, CRP values, and use of tramadol were predictors for oxidative stress parameters.
Collapse
Affiliation(s)
- Katarina Savic Vujovic
- Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, Dr Subotica 1, 11129 Belgrade, Serbia
| | - Andjela Zivkovic
- Faculty of Medicine, University of Belgrade, Dr Subotica 1, P.O. Box 38, 11129 Belgrade, Serbia
| | - Ivan Dozic
- Department of Pathology, School of Dental Medicine, University of Belgrade, Dr Subotica-Starijeg 1, 11000 Belgrade, Serbia
| | - Andja Cirkovic
- Institute for Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, 11129 Belgrade, Serbia
| | - Branislava Medic
- Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, Dr Subotica 1, 11129 Belgrade, Serbia
| | - Dragana Srebro
- Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, Dr Subotica 1, 11129 Belgrade, Serbia
| | - Sonja Vuckovic
- Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, Dr Subotica 1, 11129 Belgrade, Serbia
| | - Jovica Milovanovic
- Faculty of Medicine, University of Belgrade, Dr Subotica 1, P.O. Box 38, 11129 Belgrade, Serbia
- Clinic for Otorhinolaryngology and Maxillofacial Surgery, University Clinical Center of Serbia, Pasterova 2, 11000 Belgrade, Serbia
| | - Ana Jotic
- Faculty of Medicine, University of Belgrade, Dr Subotica 1, P.O. Box 38, 11129 Belgrade, Serbia
- Clinic for Otorhinolaryngology and Maxillofacial Surgery, University Clinical Center of Serbia, Pasterova 2, 11000 Belgrade, Serbia
| |
Collapse
|
7
|
Towfighi P, Hill A, Crossley JR, Walsh A, Leonard JA, Giurintano JP, Pierce ML, Reilly MJ. A retrospective analysis of pain and opioid usage in head and neck free flap reconstruction. World J Otorhinolaryngol Head Neck Surg 2023. [DOI: 10.1002/wjo2.87] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Affiliation(s)
- Parhom Towfighi
- Georgetown University School of Medicine Washington District of Columbia USA
| | - Alison Hill
- Georgetown University School of Medicine Washington District of Columbia USA
| | - Jason R. Crossley
- Department of Otolaryngology—Head and Neck Surgery Medstar Georgetown Washington District of Columbia USA
| | - Amanda Walsh
- Department of Otolaryngology—Head and Neck Surgery Medstar Georgetown Washington District of Columbia USA
| | - James A. Leonard
- Department of Otolaryngology—Head and Neck Surgery Medstar Georgetown Washington District of Columbia USA
| | - Jonathan P. Giurintano
- Department of Otolaryngology—Head and Neck Surgery Medstar Georgetown Washington District of Columbia USA
| | - Matthew L. Pierce
- Department of Otolaryngology—Head and Neck Surgery Medstar Georgetown Washington District of Columbia USA
| | - Michael J. Reilly
- Department of Otolaryngology—Head and Neck Surgery Medstar Georgetown Washington District of Columbia USA
| |
Collapse
|
8
|
Castellanos CX, Paoletti M, Ulloa R, Kim C, Fong M, Xepoleas M, Sinha U, Kokot N, Swanson MS. Opioid Sparing Multimodal Analgesia for Transoral Robotic Surgery: Improved Analgesia and Narcotic Use Reduction. OTO Open 2023; 7:e17. [PMID: 36998552 PMCID: PMC10046737 DOI: 10.1002/oto2.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 10/23/2022] [Indexed: 03/15/2023] Open
Abstract
Objective To compare postoperative pain scores and opioid consumption in patients after transoral robotic surgery (TORS). Study Design Single institution retrospective cohort study. Setting TORS was performed at a single academic tertiary care center. Methods This study compared traditional opioid-based and opioid-sparing multimodal analgesia (MMA) regimens in patients with oropharyngeal and supraglottic malignancy after TORS. Data were obtained from the electronic health records from August 2016 to December 2021. The average postoperative pain scores and total opioid consumption in morphine milligram equivalents were calculated for postoperative days (PODs) 0 to 3. The secondary objectives were to quantify and characterize opioid prescriptions upon hospital discharge. Results A total of 114 patients were identified for this study, 58 patients in the non-MMA cohort and 56 in the MMA cohort. Postoperative pain levels in the MMA cohort were statistically lower on POD 0 (p = 0.001), POD 1 (p = 0.001), and POD 3 (p = 0.004). Postoperative opioid consumption decreased significantly in the MMA cohort from 37.7 to 10.8 mg on POD 0 (p = 0.002), 65.9 to 19.9 mg on POD 1 (p < 0.001), 36.0 to 19.3 mg on POD 2 (p = 0.02), and 45.4 to 13.8 mg on POD 3 (p = 0.02). The number of patients discharged from the hospital with a prescription for narcotics was significantly lower in the MMA cohort (71.4%) compared with the non-MMA cohort (98.3%) (p < 0.001). Conclusion Implementation of our MMA pain protocol reduced pain levels and narcotic consumption in the immediate postoperative period.
Collapse
Affiliation(s)
- Carlos X. Castellanos
- Caruso Department of Otolaryngology‐Head & Neck SurgeryKeck Medicine of University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Marcus Paoletti
- Caruso Department of Otolaryngology‐Head & Neck SurgeryKeck Medicine of University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Ruben Ulloa
- Caruso Department of Otolaryngology‐Head & Neck SurgeryKeck Medicine of University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Celeste Kim
- Caruso Department of Otolaryngology‐Head & Neck SurgeryKeck Medicine of University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Michelle Fong
- Caruso Department of Otolaryngology‐Head & Neck SurgeryKeck Medicine of University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Meredith Xepoleas
- Caruso Department of Otolaryngology‐Head & Neck SurgeryKeck Medicine of University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Uttam Sinha
- Caruso Department of Otolaryngology‐Head & Neck SurgeryKeck Medicine of University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Niels Kokot
- Caruso Department of Otolaryngology‐Head & Neck SurgeryKeck Medicine of University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Mark S. Swanson
- Caruso Department of Otolaryngology‐Head & Neck SurgeryKeck Medicine of University of Southern CaliforniaLos AngelesCaliforniaUSA
| |
Collapse
|
9
|
Shnayder Y, Baumanis MM, Brown A, Reese A, Bur AM, Kakarala K, Sykes KJ. The Use of Dissemination and Implementation to Improve Multimodal Analgesia in Head and Neck Surgery. Laryngoscope 2022; 133 Suppl 5:S1-S11. [PMID: 36305511 DOI: 10.1002/lary.30469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 09/22/2022] [Accepted: 10/09/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To optimize the delivery of multimodal analgesia to patients undergoing major head and neck oncologic surgeries. METHODS Pilot study included patients enrolled to receive either scheduled acetaminophen and as-needed opioids (control group) or scheduled acetaminophen, gabapentin, ketorolac, and as-needed opioids (experimental group). RCT, a hybrid type 1 effectiveness-implementation pragmatic trial, was designed to test the effectiveness of the intervention. Arm A received scheduled acetaminophen and as-needed opioids. Arm B received scheduled gabapentin, ketorolac, a regional nerve block at the free tissue donor site, scheduled acetaminophen and as-needed opioids. RESULTS Pilot: Thirty-one patients undergoing major head and neck surgery were enrolled. Mean MMEs administered in control group (n = 15) was 251.60 mg (SD = 224.57 mg); mean MMEs in Experimental group (n = 16) was 195.78 mg (SD = 131.08 mg), p = 0.401. LOS was 8.0 days in control versus 7.0 days in experimental group (p = 0.054). RCT: Interim analysis for safety and futility was planned during trial's design after 30 patients (n = 14 Arm A, and n = 16 Arm B). Mean MMEs administered were 135.1 mg in Arm A, (SD = 86.0 mg) versus mean MME of 51.3 mg in Arm B (SD = 43.3 mg, (p < 0.05)). Given clear superiority results, the trial was prematurely terminated. Functional pain scores, LOS, and complications were similar between the arms (p > 0.05). Variability of mean MME was compared before and after implementation of the management protocols: SD in RCT#1 was 181.46 mg versus 124.6 mg in RCT#2. CONCLUSION Multimodal analgesia significantly reduced the need for opioids in patients undergoing major head and neck surgery. LEVEL OF EVIDENCE 1, Randomized Clinical Trial Laryngoscope, 133:S1-S11, 2023.
Collapse
Affiliation(s)
- Yelizaveta Shnayder
- Department of Otolaryngology‐Head & Neck Surgery University of Kansas School of Medicine Kansas City Kansas USA
| | - Maraya M. Baumanis
- Department of Otolaryngology‐Head & Neck Surgery University of Kansas School of Medicine Kansas City Kansas USA
| | - Adam Brown
- Department of Anesthesiology University of Kansas School of Medicine Kansas City Kansas USA
| | - Adam Reese
- Department of Anesthesiology University of Kansas School of Medicine Kansas City Kansas USA
| | - Andrés M. Bur
- Department of Otolaryngology‐Head & Neck Surgery University of Kansas School of Medicine Kansas City Kansas USA
| | - Kiran Kakarala
- Department of Otolaryngology‐Head & Neck Surgery University of Kansas School of Medicine Kansas City Kansas USA
| | - Kevin J. Sykes
- Department of Otolaryngology‐Head & Neck Surgery University of Kansas School of Medicine Kansas City Kansas USA
| |
Collapse
|
10
|
Weyh AM, Pucci R, Busby E, Kansal L, Joy R, Bunnell A, Valentini V, Dyalram D, Pattatheyill A, Figari M, Boccalatte L, Larrañaga J, Cassoni A, Fernandes R. Contrasting opioid use for pain management in microvascular head and neck reconstruction: an international study. Int J Oral Maxillofac Surg 2022; 51:1412-1419. [PMID: 35599083 DOI: 10.1016/j.ijom.2022.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 11/30/2022]
Abstract
Opioids are often the mainstay of postoperative pain management, despite strong evidence of their ill effects and potential for long-term addiction. The goal of this study was to quantify opioid use and contrast pain management strategies of multiple international institutions performing fibula free flap reconstruction. A retrospective multicenter cohort study was designed, including five international centers. For inclusion, the patients had to have undergone a primary fibula free flap reconstruction of the mandible. A total of 185 patients were included. The median opioid use across all centers at 72 hours was 133 oral morphine equivalents. The highest utilization was in the USA (P < 0.001), which was approximately six times that of Italy, four times that of Argentina, and twice that of India, despite all centers performing a similar procedure. Based on this study there are clear differences in prescribing practices and ideologies among surgeons from different countries.
Collapse
Affiliation(s)
- A M Weyh
- Department of Oral and Maxillofacial Surgery, University of Florida Jacksonville, Jacksonville, FL, USA.
| | - R Pucci
- Department of Maxillofacial Surgery, Sapienza University of Rome, Rome, Italy.
| | - E Busby
- Department of Oral and Maxillofacial Surgery, University of Florida Jacksonville, Jacksonville, FL, USA.
| | - L Kansal
- Department of Head and Neck Surgery, Tata Medical Center, Kolkata, India.
| | - R Joy
- Department of Oral and Maxillofacial Surgery, University of Maryland, Baltimore, MD, USA.
| | - A Bunnell
- Department of Oral and Maxillofacial Surgery, University of Florida Jacksonville, Jacksonville, FL, USA.
| | - V Valentini
- Department of Maxillofacial Surgery, Sapienza University of Rome, Rome, Italy.
| | - D Dyalram
- Department of Oral and Maxillofacial Surgery, University of Maryland, Baltimore, MD, USA.
| | - A Pattatheyill
- Department of Head and Neck Surgery, Tata Medical Center, Kolkata, India.
| | - M Figari
- Department of Head and Neck Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | - L Boccalatte
- Department of Head and Neck Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | - J Larrañaga
- Department of Head and Neck Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | - A Cassoni
- Department of Maxillofacial Surgery, Sapienza University of Rome, Rome, Italy.
| | - R Fernandes
- Department of Oral and Maxillofacial Surgery, University of Florida Jacksonville, Jacksonville, FL, USA.
| |
Collapse
|
11
|
Abstract
This paper is the forty-third consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2020 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).
Collapse
Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY, 11367, United States.
| |
Collapse
|
12
|
Mark M, Eggerstedt M, Urban MJ, Al‐Khudari S, Smith R, Revenaugh P. Designing an evidence‐based free‐flap pathway in head and neck reconstruction. World J Otorhinolaryngol Head Neck Surg 2022; 8:126-132. [PMID: 35782403 PMCID: PMC9242419 DOI: 10.1002/wjo2.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 11/05/2021] [Indexed: 11/24/2022] Open
Abstract
Background The use of autologous free‐tissue transfer is an increasingly utilized tool in the ladder of reconstructive options to preserve and restore function in patients with head and neck cancer. This article focuses on the evidence surrounding perioperative care that optimizes surgical outcomes and describes one tertiary center's approach to standardized free‐flap care. Data Sources This article examines English literature from PubMed and offers expert opinion on perioperative free‐flap care for head and neck oncology. Conclusion Free‐flap reconstruction for head and neck cancer is a process that, while individualized for each patient, is best supported by a comprehensive and standardized care pathway. Surgical optimization begins in the preoperative phase and a thoughtful approach to intraprofessional communication and evidence‐based practice is rewarded with improved outcomes.
Collapse
Affiliation(s)
- Michelle Mark
- Department of Otorhinolaryngology‐Head and Neck Surgery, Section of Facial Plastic and Reconstructive Surgery Rush University Medical Center Chicago Illinois USA
| | - Michael Eggerstedt
- Department of Otorhinolaryngology‐Head and Neck Surgery, Section of Facial Plastic and Reconstructive Surgery Rush University Medical Center Chicago Illinois USA
| | - Matthew J. Urban
- Department of Otorhinolaryngology‐Head and Neck Surgery, Section of Facial Plastic and Reconstructive Surgery Rush University Medical Center Chicago Illinois USA
| | - Samer Al‐Khudari
- Department of Otorhinolaryngology‐Head and Neck Surgery, Section of Facial Plastic and Reconstructive Surgery Rush University Medical Center Chicago Illinois USA
| | - Ryan Smith
- Department of Otorhinolaryngology‐Head and Neck Surgery, Section of Facial Plastic and Reconstructive Surgery Rush University Medical Center Chicago Illinois USA
| | - Peter Revenaugh
- Department of Otorhinolaryngology‐Head and Neck Surgery, Section of Facial Plastic and Reconstructive Surgery Rush University Medical Center Chicago Illinois USA
| |
Collapse
|
13
|
Chang MT, Lalakea ML, Shepard K, Saste M, Munoz A, Amoils M. Implementation of a Standardized Perioperative Pain Management Protocol to Reduce Opioid Prescriptions in Otolaryngologic Surgery. Otolaryngol Head Neck Surg 2022; 167:657-663. [PMID: 35015583 DOI: 10.1177/01945998211071116] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To evaluate the efficacy of implementing a standardized multimodal perioperative pain management protocol in reducing opioid prescriptions following otolaryngologic surgery. STUDY DESIGN Retrospective cohort study. SETTING County hospital otolaryngology practice. METHODS A perioperative pain management protocol was implemented in adults undergoing otolaryngologic surgery. This protocol included preoperative patient education and a postoperative multimodal pain regimen stratified by pain level: mild, intermediate, and high. Opioid prescriptions were compared between patient cohorts before and after protocol implementation. Patients in the pain protocol were surveyed regarding pain levels and opioid use. RESULTS We analyzed 210 patients (105 preprotocol and 105 postprotocol). Mean ± SD morphine milligram equivalents (MMEs) prescribed decreased from 132.5 ± 117.8 to 53.6 ± 63.9 (P < .05) following protocol implementation. Mean MMEs prescribed significantly decreased (P < .05) for each procedure pain tier: mild (107.4 to 40.5), intermediate (112.8 to 48.1), and high (240.4 to 105.0). Mean MMEs prescribed significantly decreased (P < .05) for each procedure type: endocrine (105.6 to 44.4), facial plastics (225.0 to 50.0), general (160.9 to 105.7), head and neck oncology (138.6 to 77.1), laryngology (53.8 to 12.5), otology (77.5 to 42.9), rhinology (142.2 to 44.4), and trauma (288.0 to 24.5). Protocol patients reported a mean 1-week postoperative pain score of 3.4, used opioids for a mean 3.1 days, and used only 39% of their prescribed opioids. CONCLUSION Preoperative counseling and standardization of a multimodal perioperative pain regimen for otolaryngology procedures can effectively lower amount of opioid prescriptions while maintaining low levels of postoperative pain.
Collapse
Affiliation(s)
- Michael T Chang
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Stanford University, Stanford, California, USA.,Division of Otolaryngology-Head and Neck Surgery, Santa Clara Valley Medical Center, San Jose, California, USA
| | - M Lauren Lalakea
- Division of Otolaryngology-Head and Neck Surgery, Santa Clara Valley Medical Center, San Jose, California, USA
| | - Kimberly Shepard
- Division of Otolaryngology-Head and Neck Surgery, Santa Clara Valley Medical Center, San Jose, California, USA
| | - Micah Saste
- Division of Otolaryngology-Head and Neck Surgery, Santa Clara Valley Medical Center, San Jose, California, USA
| | - Amanda Munoz
- Division of Otolaryngology-Head and Neck Surgery, Santa Clara Valley Medical Center, San Jose, California, USA
| | - Misha Amoils
- Division of Otolaryngology-Head and Neck Surgery, Santa Clara Valley Medical Center, San Jose, California, USA
| |
Collapse
|
14
|
Go BC, Go CC, Chorath K, Moreira A, Rajasekaran K. Multimodal Analgesia in Head and Neck Free Flap Reconstruction: A Systematic Review. Otolaryngol Head Neck Surg 2021; 166:820-831. [PMID: 34372726 DOI: 10.1177/01945998211032910] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Postoperative pain after head and neck cancer surgery is commonly treated with opioids, which are associated with considerable side effects. The objective of this study is to analyze the safety and efficacy of using multimodal analgesia (MMA) for patients undergoing head and neck cancer surgery with free flap reconstruction. DATA SOURCES A systematic search was conducted in PubMed, Cochrane, Embase, Scopus, and clinicaltrials.gov. REVIEW METHODS All studies comparing patients receiving MMA (gabapentin, corticosteroids, local anesthetic, acetaminophen, nonsteroidal anti-inflammatory drugs [NSAIDs]) vs patients receiving opioids for head and neck cancer surgery with free flap reconstruction were screened. The primary outcome was postoperative opioid usage. Secondary outcomes included length of stay, subjective pain scores, surgical/medical complications, adverse effects, and 30-day outcomes. RESULTS A total of 10 studies representing 1253 patients (MMA, n = 594; non-MMA, n = 659) met inclusion criteria. Gabapentinoids were the most commonly used intervention (72.9%) followed by NSAIDs (44.6%), acetaminophen (44.3%), corticosteroids (25.1%), ketamine (7.2%), and nerve block (3.4%). Eight studies reported a significant decrease in postoperative opioid usage in the MMA groups. Subjective pain had wider variation, with most studies citing significant pain improvement. There were no differences in surgical outcomes, medical complications, adverse effects, or 30-day mortality and readmission rates. CONCLUSION With the rise of the opioid epidemic, MMA may play an important role in the treatment of postoperative pain after head and neck cancer surgery. A growing body of literature demonstrates a variety of effective perioperative regimens.
Collapse
Affiliation(s)
- Beatrice C Go
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Cammille C Go
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kevin Chorath
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alvaro Moreira
- Department of Pediatrics, Division of Neonatology, University of Texas Health-San Antonio, San Antonio, Texas, USA
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
15
|
Healy DW, Cloyd BH, Straker T, Brenner MJ, Damrose EJ, Spector ME, Saxena A, Atkins JH, Ramamurthi RJ, Mehta A, Aziz MF, Cattano D, Levine AI, Schechtman SA, Cavallone LF, Abdelmalak BB. Expert Consensus Statement on the Perioperative Management of Adult Patients Undergoing Head and Neck Surgery and Free Tissue Reconstruction From the Society for Head and Neck Anesthesia. Anesth Analg 2021; 133:274-283. [PMID: 34127591 DOI: 10.1213/ane.0000000000005564] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The perioperative care of adult patients undergoing free tissue transfer during head and neck surgical (microvascular) reconstruction is inconsistent across practitioners and institutions. The executive board of the Society for Head and Neck Anesthesia (SHANA) nominated specialized anesthesiologists and head and neck surgeons to an expert group, to develop expert consensus statements. The group conducted an extensive review of the literature to identify evidence and gaps and to prioritize quality improvement opportunities. This report of expert consensus statements aims to improve and standardize perioperative care in this setting. The Modified Delphi method was used to evaluate the degree of agreement with draft consensus statements. Additional discussion and collaboration was performed via video conference and electronic communication to refine expert opinions and to achieve consensus on key statements. Thirty-one statements were initially formulated, 14 statements met criteria for consensus, 9 were near consensus, and 8 did not reach criteria for consensus. The expert statements reaching consensus described considerations for preoperative assessment and optimization, airway management, perioperative monitoring, fluid management, blood management, tracheal extubation, and postoperative care. This group also examined the role for vasopressors, communication, and other quality improvement efforts. This report provides the priorities and perspectives of a group of clinical experts to help guide perioperative care and provides actionable guidance for and opportunities for improvement in the care of patients undergoing free tissue transfer for head and neck reconstruction. The lack of consensus for some areas likely reflects differing clinical experiences and a limited available evidence base.
Collapse
Affiliation(s)
- David W Healy
- From the Department of Anesthesiology, The University of Michigan Medical School, Ann Arbor, Michigan
| | - Benjamin H Cloyd
- Department of Anesthesiology, Michigan Medicine - University of Michigan, Ann Arbor, Michigan
| | - Tracey Straker
- Department of Anesthesiology, Montefiore Medical Center, Bronx, New York
| | - Michael J Brenner
- Department of Otolaryngology, Michigan Medicine-University of Michigan, Ann Arbor, Michigan
| | - Edward J Damrose
- Department of Otolaryngology/Head & Neck Surgery & Anesthesiology/Perioperative Medicine (by courtesy)
| | - Matthew E Spector
- Department of Otolaryngology, Michigan Medicine-University of Michigan, Ann Arbor, Michigan
| | - Amit Saxena
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Joshua H Atkins
- Department of Anesthesiology & Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | - Arpan Mehta
- Department of Anesthesiology, Perioperative Medicine & Pain Management, The University of Miami, Miami, Florida
| | - Michael F Aziz
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, Oregon
| | - Davide Cattano
- Department of Anesthesiology, McGovern Medical School, UTHealth Houston, Houston, Texas
| | - Adam I Levine
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Samuel A Schechtman
- Department of Anesthesiology, Michigan Medicine - University of Michigan, Ann Arbor, Michigan
| | - Laura F Cavallone
- Department of Anesthesiology, University of Mississippi Medical Center, Jackson, Mississippi
| | - Basem B Abdelmalak
- Departments of General Anesthesiology and Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
16
|
Hinther A, Nakoneshny SC, Chandarana SP, Matthews TW, Hart R, Schrag C, Matthews J, McKenzie CD, Fick GH, Dort JC. Efficacy of Multimodal Analgesia for Postoperative Pain Management in Head and Neck Cancer Patients. Cancers (Basel) 2021; 13:cancers13061266. [PMID: 33809273 PMCID: PMC7999688 DOI: 10.3390/cancers13061266] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 03/03/2021] [Accepted: 03/10/2021] [Indexed: 12/16/2022] Open
Abstract
Simple Summary Chronic opioid use is a serious global health problem and surgery is often the point of initial exposure for many chronic opioid users. Multimodal analgesia (MMA) is an approach designed to reduce or eliminate opioid use in surgical patients, but it has not been studied in patients having major head and neck surgery. This study explores the impact of an MMA protocol on opioid prescribing practices in patients having major head and neck surgery with flap reconstruction. The results of this study will provide evidence to inform and guide pain management practice in this important patient population. The results of this study could also be applied to other areas of otorhinolaryngology. MMA is an important tool in the effort to reduce chronic opioid use. Abstract Postoperative opioid use has been linked to the subsequent development of opioid dependency. Multimodal analgesia (MMA) can reduce the use of opioids in the postoperative period, but MMA has not been well-studied after major head and neck surgery. Our goal is to explore the association between MMA and postoperative opioid use and pain control in patients undergoing major head and neck surgery. We performed a retrospective study in adult (age ≥ 18 years) patients undergoing primary head and neck cancer resection with free-flap reconstruction. All patients were treated using an established care pathway. The baseline group was treated between January 2015–December 2015 (n = 41), prior to the implementation of MMA, and were compared to an MMA-treated cohort treated between December 2017–June 2019 (n = 97). The primary outcome was the proportion of opioids prescribed and oral morphine equivalents (OMEs) consumed during the hospitalization. The secondary outcome was pain control. We found that the post-MMA group consumed fewer opioids in the postoperative period compared to the pre-MMA group. Prior to post-operative day (POD) 6, pain control was better in the post-MMA group; however, the pain control lines intersect on POD 6 and the pre-MMA group appeared to have better pain control from PODs 7–10. In conclusion, our data suggest MMA is an effective method of pain control and opioid reduction in patients undergoing surgery for head and neck cancer with free flap reconstruction. MMA use was associated with a significant decrease in the quantity of opioids consumed postoperatively. The MMA protocol was associated with improved pain management early in the postoperative course. Finally, the MMA protocol is a feasible method of pain control and may reduce the adverse side effects associated with opioid use.
Collapse
Affiliation(s)
- Ashley Hinther
- Section of Otolaryngology—Head and Neck Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada; (A.H.); (S.P.C.); (T.W.M.); (R.H.)
| | - Steven C. Nakoneshny
- Ohlson Research Initiative, Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada;
| | - Shamir P. Chandarana
- Section of Otolaryngology—Head and Neck Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada; (A.H.); (S.P.C.); (T.W.M.); (R.H.)
- Ohlson Research Initiative, Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada;
| | - T. Wayne Matthews
- Section of Otolaryngology—Head and Neck Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada; (A.H.); (S.P.C.); (T.W.M.); (R.H.)
- Ohlson Research Initiative, Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada;
| | - Robert Hart
- Section of Otolaryngology—Head and Neck Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada; (A.H.); (S.P.C.); (T.W.M.); (R.H.)
- Ohlson Research Initiative, Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada;
| | - Christiaan Schrag
- Section of Plastic and Reconstructive Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada; (C.S.); (J.M.); (C.D.M.)
| | - Jennifer Matthews
- Section of Plastic and Reconstructive Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada; (C.S.); (J.M.); (C.D.M.)
| | - C. David McKenzie
- Section of Plastic and Reconstructive Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada; (C.S.); (J.M.); (C.D.M.)
| | - Gordon H. Fick
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada;
| | - Joseph C. Dort
- Section of Otolaryngology—Head and Neck Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada; (A.H.); (S.P.C.); (T.W.M.); (R.H.)
- Ohlson Research Initiative, Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada;
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada;
- Correspondence: ; Tel.: +1-403-220-7268
| |
Collapse
|
17
|
Chorath K, Go B, Shinn JR, Mady LJ, Poonia S, Newman J, Cannady S, Revenaugh PC, Moreira A, Rajasekaran K. Enhanced recovery after surgery for head and neck free flap reconstruction: A systematic review and meta-analysis. Oral Oncol 2020; 113:105117. [PMID: 33360446 DOI: 10.1016/j.oraloncology.2020.105117] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 11/21/2020] [Accepted: 11/23/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Head and neck free flap reconstruction requires multidisciplinary and coordinated care in the perioperative setting to ensure safe recovery and success. Several institutions have introduced enhanced recovery after surgery (ERAS) protocols to attenuate the surgical stress response and improve postoperative recovery. With multiple studies demonstrating mixed results, the success of these interventions on clinical outcomes has yet to be determined. OBJECTIVE To evaluate the impact of ERAS protocols and clinical care pathways for head and neck free flap reconstruction. METHODS We searched PubMed, SCOPUS, EMBASE, and grey literature up to September 1st, 2020 to identify studies comparing patients enrolled in an ERAS protocol and control group. Our primary outcomes included hospital length of stay (LOS) and readmission. Mortality, reoperations, wound complication and ICU (intensive care unit) LOS comprised our secondary outcomes. RESULTS 18 studies met inclusion criteria, representing a total of 2630 patients. The specific components of ERAS protocols used by institutions varied. Nevertheless, patients enrolled in ERAS protocols had reduced hospital LOS (MD -4.36 days [-7.54, -1.18]), readmission rates (OR 0.64 [0.45;0.92]), and wound complications (RR 0.41 [0.21, 0.83]), without an increase in reoperations (RR 0.65 [0.41, 1.02]), mortality (RR 0.38 [0.05, 2.88]), or ICU LOS (MD -2.55 days [-5.84, 0.74]). CONCLUSION There is growing body of evidence supporting the role of ERAS protocols for the perioperative management of head and neck free flap patients. Our findings reveal that structured clinical algorithms for perioperative interventions improve clinically-meaningful outcomes in patients undergoing complex ablation and microvascular reconstruction procedures.
Collapse
Affiliation(s)
- Kevin Chorath
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Beatrice Go
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Justin R Shinn
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Leila J Mady
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Seerat Poonia
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Jason Newman
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Steven Cannady
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Peter C Revenaugh
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, IL, United States
| | - Alvaro Moreira
- Department of Pediatrics, University of Texas Health-San Antonio, San Antonio, TX, United States
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States.
| |
Collapse
|