Reduction of opioid use after implementation of enhanced recovery after bariatric surgery (ERABS)

Intraoperative Methadone in Spine Surgery ERAS Protocols: A Systematic Review of the Literature

STUDY DESIGN

Systematic review.

OBJECTIVE

To systematically review the use of intraoperative methadone in spine surgery and examine its effects on postoperative opioid use, pain, length of stay, and operative time.

SUMMARY OF BACKGROUND DATA

Spine surgery patients commonly have a history of chronic pain and opioid use, and as a result, they are at an increased risk of severe postoperative pain. While pure mu opioids remain the standard for acute surgical pain management, they are associated with significant short-term and long-term adverse events. Methadone presents an alternative to pure mu opioids which may improve postoperative management of pain following intraoperative use.

METHODS

A systematic review of MEDLINE, Embase, and Web of Science databases was conducted to review existing literature detailing operating time, postoperative pain, opioid usage, and hospital length of stay (LOS) following intraoperative methadone administration in spine surgery.

RESULTS

Following screening of 994 articles and application of inclusion criteria, 8 articles were included, 4 of which were retrospective. Conventional spine surgery intraoperative analgesic strategies used as comparators for intraoperative methadone included hydromorphone, ketamine, and sufentanil. Considering patient outcomes, included studies observed that patients treated with intraoperative methadone had statistically similar or significantly reduced pain scores, opioid usage, and LOS compared with comparator analgesics. However, one study observed that intraoperative methadone used in a multimodal analgesia regimen strategy with ketamine resulted in a shortened LOS compared with the use of intraoperative methadone alone. Differences in operating time between cases that used intraoperative methadone and cases that used comparator analgesics were not statistically significant among included studies.

CONCLUSION

Methadone may present an alternative option for both intraoperative and postoperative analgesia in spine surgery recovery protocols and may reduce postoperative pain, opioid use, and LOS while maintaining consistent operating time and reduced side effects of pure mu opioids.

LEVEL OF EVIDENCE

Level II.

Implementation of updated enhanced recovery after bariatric surgery guidelines: adapted protocol in a single tertiary center

The aim of this study is to evaluate the effects of an adapted protocol of enhanced recovery after bariatric surgery (ERABS) on outcomes. This is a single-center observational study comparing patients managed according to adapted ERABS protocol (March-May 2022) with a control group of old method (January 2021-February 2022). Totally, 253 bariatric patients were included in the study (n = 68) and control (n = 185) groups. Patients were mostly females (57.3% vs 70.2%; p = 0.053), of mean age 38.8 years and body mass index 41 ± 6.53 vs. 44.60 ± 7.37 kg/m2 (p = 0.007) in study and control groups, respectively. The majority (90.5%) underwent primary bariatric surgery. Adapted ERABS protocol compliance was 98.5%. The study group had shorter hospital stay (mean 2.86 ± 0.51 vs. 4.03 ± 0.28 days; p < 0.001), similar rates of total (3% vs. 2.7%, p = 0.92) and major complications (1.5% vs. 0, p = 0.10). Readmission rates were similar (1.5% vs 1.6%, p = 0.92). Applied only in the study group, early ambulation (p < 0.001), opioid restriction, and preventing postoperative nausea and vomiting (PONV), resulted in satisfactory scores (mean total visual analogue score 1.93 ± 0.80, morphine milligram equivalent 34.0 ± 14.5, and mean total PONV grade 0.17 ± 0.36). In conclusion, implementing adapted ERABS guidelines improved patients' postoperative care, raising awareness to pain management. Length of stay was shortened without safety compromise. Efforts to abandon old-school routines seem worthwhile, even if ERABS is partially implemented.

Bariatric surgery is as safe as other common operations: an analysis of the ACS-NSQIP

BACKGROUND

Metabolic and Bariatric Surgery (MBS) is the most effective management for patients with obesity and weight-related medical conditions. Nonetheless, some primary care physicians (PCPs) and surgeons from other specialties are reluctant to refer patients for MBS due to safety concerns.

OBJECTIVES

To compare the outcomes of patients who underwent MBS with those who underwent other common operations.

SETTING

American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP).

METHODS

Patients who underwent laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass (RYGB), classified as MBS, were compared to nine frequently performed procedures including hip arthroplasty and laparoscopic cholecystectomy, appendectomy, colectomy, hysterectomy, and hernia repairs, among others. A multivariable logistic regression was constructed to compare outcomes including readmission, reoperation, extended length of stay (ELOS) (>75th percentile or ≥3 days) and mortality.

RESULTS

A total of 1.6 million patients were included, with 11.1% undergoing MBS. The odds of readmission were marginally lower in the cholecystectomy (adjusted odds ratio [aOR] = .88, 95% confidence interval (CI) [.85, .90]) and appendectomy (aOR = .88, 95% CI [.85, .90]) cohorts. Similarly, odds of ELOS were among the lowest, surpassed only by same-day procedures such as cholecystectomies and appendectomies. The MBS group had significantly low odds of mortality, comparable to safe anatomical procedures such as hernia repairs. Infectious and thrombotic complications were exceedingly rare and amongst the lowest after MBS.

CONCLUSIONS

MBS demonstrates a remarkably promising safety profile and compares favorably to other common procedures in the short-term. PCPs and surgeons from other specialties can confidently refer patients for these low-risk, lifesaving operations.

Development and Implementation of an Enhanced Recovery Protocol for Bariatric Patients in a Third World Environment

Introduction: An applicable and reproducible enhanced recovery protocol was developed and implemented to improve our outcomes in a third-world environment. Methods: We compared the results obtained prospectively. The group treated before the application of the enhanced recovery protocol was called usual care (UC) and included all bariatric surgeries operated on between 2014 and 2017. The new protocol was applied between 2017 and 2019 including all operated patients, and this group was called Fast Track (FT). The variables analyzed were the length of stay, readmissions, and complications recorded during the first 30 days. We also analyzed the milligrams of morphine used by each patient, and a cost analysis was performed. Results: During the study period, 816 patients were studied. Of these, 385 (47.2%) belonged to the UC group and 431 (52.8%) to the FT group. The mean hospital stay was 58.5 hours (UC) versus 40.3 hours (FT) (P = .0001). When comparing the global morbidity of both groups, we did not find significant differences (P = .47). There was also no statistically significant difference when comparing major complications (P = .79). No mortality was recorded. Morphine indication reported a statistically significant difference that favored FT. Costs were significantly higher in UC than in FT (P < .0001). Conclusions: We believe that the implementation of an enhanced recovery protocol in bariatric surgery is a reliable measure and can be implemented even in an underdevelopment environment enlarging the benefit for patients.

Perioperative truncal peripheral nerve blocks for bariatric surgery: an opioid reduction strategy

BACKGROUND

Bariatric surgical patients are vulnerable to cardiopulmonary depressant effects of opioids. The enhanced recovery after surgery (ERAS) protocol to improve postoperative morbidity recommends regional anesthesia for postoperative pain management. However, there is limited evidence that peripheral nerve blocks (PNB) have added benefit.

OBJECTIVE

Study the effect of PNB on postoperative pain and opioid use following bariatric surgery.

SETTING

Academic medical center, United States.

METHODS

We conducted a cohort study of patients who underwent sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) surgery. A total of 44 patients received the control ERAS protocol with preoperative oral extended-release morphine sulfate (MS), while 45 patients underwent a PNB with either intrathecal morphine (IM) or oral MS per local ERAS protocol. The PNB group either underwent preoperative bilateral T7 paravertebral (PVT) PNBs (27 patients) with IM or postoperative transversus abdominis plane (TAP) PNBs (18 patients) with oral MS. The primary outcome compared total opioid consumption between the ERAS control group and the PNB group up to 48 hours postoperatively. Secondary outcomes included comparison by block type and postoperative pain scores.

RESULTS

PVT or TAP PNB patients had a reduction in mean postoperative oral morphine equivalent (OME) requirements compared with the ERAS protocol cohort at 24 hours (93.9 versus 42.8 mg), P < .0001; at 48 hours (72.6 versus 40.5 mg); and in pain scores at 24 hours (5.64/10 versus 4.46/10), P = .02. OME and pain scores were higher in the SG cohort.

CONCLUSION

Addition of truncal PNB to standard ERAS protocol for bariatric surgical patients reduces postoperative total opioid consumption.

Comparison of the Effects of Special Care Enhanced Recovery and Conventional Recovery Methods after Mini Omega Gastric Bypass

Background

Bariatric surgery is a surgical procedure for patients with extreme obesity. Enhanced Recovery after Surgery (ERAS) is a method that provides special peri- and post-operation care. Here, we aimed to compare the effects of ERAS and standard recovery cares.

Materials and Methods

This is a randomized clinical trial that was performed in 2020-2021 in Isfahan on 108 candidates for mini gastric bypass. Patients were then randomly divided into two equal groups receiving ERAS and standard recovery protocols. Patients were examined and visited after one month regarding the average number of hospitalization days, the average days required to return to normal activity or work, occurrence of pulmonary thromboemboli (PTE) and the rate of readmission.

Results

Patients that received ERAS had significantly lower frequencies of nausea and vomiting (P = 0.032). Patients that received ERAS had significantly lower hospitalization duration (P < 0.001) compared to controls. No other significant differences were observed between two groups regarding surgery complication, re-admission rate and occurrence of PTE (P > 0.99 for all).

Conclusion

Patients that received ERAS protocol after gastric bypass had significantly lower hospitalization duration and lower incidence of nausea and vomiting. They also had similar post-operative outcomes compared to the standard protocol.

Implementing novel modalities into an institutional enhanced recovery after bariatric surgery (ERABS) protocol

INTRODUCTION

Enhanced recovery after bariatric surgery pathways are associated with improved postoperative outcomes. This study aims to assess efficacy and safety of three novel protocol contributions (transversus abdominis plane blocks, ketamine and fosaprepitant), as well as their impact on length of stay (LOS) and on postoperative complications.

METHODS

Effectiveness and safety were retrospectively investigated in patients who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) over a 6-year period in a single institution. Group 1 patients were not exposed to any of our suggested interventions, whereas Group 2 were exposed to all of three.

RESULTS

Between January 2015 and August 2021, 1480 patients underwent primary SG (77.6%) or RYGB (22.4%); of those, 1132 (76.5%) and 348 (23.5%) were in Groups 1 and 2, respectively. Mean BMI and age were 45.87 versus 43.65 kg/m² and 45.53 versus 44.99 years in groups 1 and 2, respectively. Suggested interventions were associated with lower operative times (84.79 ± 24.21 vs. 80.78 ± 32.8 min, p = 0.025). In Group 2, the mean LOS decreased in 0.18 day (1.79 ± 1.04 vs. 1.60 ± 0.90; p = 0.004). Overall complication rates were 8% and 8.6% for groups 1 and 2, respectively; readmission rates were 5.7% (64 pts) vs. 7.2% (25 pts), p > 0.05. Reoperations were less prevalent in Group 2 (1.5% vs. 1.1%; p = 0.79).

CONCLUSION

Focus on optimized pain management, allied to a superior PONV control, may be relevant contributors for a lower LOS without negative impacts in complications rates.

Efficacy and safety of enhanced recovery after surgery protocol on minimally invasive bariatric surgery: a meta-analysis

BACKGROUND

Enhanced recovery after surgery (ERAS), a multidisciplinary and multimodal perioperative care protocol, has been widely used in several surgical fields. However, the effect of this care protocol on patients receiving minimally invasive bariatric surgery remains unclear. This meta-analysis compared the clinical outcomes of the ERAS protocol and standard care (SC) in patients who underwent minimally invasive bariatric surgery.

MATERIAL AND METHODS

PubMed, Web of Science, Cochrane Library, and Embase databases were systematically searched to identify literature reporting the effects of the ERAS protocol on clinical outcomes in patients undergoing minimally invasive bariatric surgery. All the articles published until 01 October 2022, were searched, followed by data extraction of the included literature and independent quality assessment. Then, pooled mean difference (MD) and odds ratio with a 95% CI were calculated by either a random-effects or fixed-effects model.

RESULTS

Overall, 21 studies involving 10 764 patients were included in the final analysis. With the ERAS protocol, the length of hospitalization (MD: -1.02, 95% CI: -1.41 to -0.64, P <0.00001), hospitalization costs (MD: -678.50, 95% CI: -1196.39 to -160.60, P =0.01), and the incidence of 30-day readmission (odds ratio =0.78, 95% CI: 0.63-0.97, P =0.02) were significantly reduced. The incidences of overall complications, major complications (Clavien-Dindo grade ≥3), postoperative nausea and vomiting, intra-abdominal bleeding, anastomotic leak, incisional infection, reoperation, and mortality did not differ significantly between the ERAS and SC groups.

CONCLUSIONS

The current meta-analysis indicated that the ERAS protocol could be safely and feasibly implemented in the perioperative management of patients receiving minimally invasive bariatric surgery. Compared with SC, this protocol leads to significantly shorter hospitalization lengths, lower 30-day readmission rate, and hospitalization costs. However, no differences were observed in postoperative complications and mortality.

Does Liposomal Bupivacaine Decrease Postoperative Opioid Use in Conjunction with an Enhanced Recovery After Bariatric Surgery Pathway? A Prospective, Double-blind, Randomized Controlled Trial

BACKGROUND

Minimization of opiate use is an important focus in the setting of the severe national opioid crisis. This study evaluated the role of liposomal bupivacaine (LB) in decreasing postoperative opioid use before and after implementation of a bariatric enhanced recovery after surgery (ERAS) program.

METHODS

We performed an IRB-approved, prospective, double-blind, randomized controlled trial of LB versus plain bupivacaine (PB) in patients undergoing elective, minimally invasive, weight loss surgery at a comprehensive metabolic and bariatric surgery program from November 2017 to December 2019. Primary outcomes were postoperative morphine milligram equivalents per day (MME/day) and average subjective inpatient pain level. Secondary outcomes were length of hospital stay (LOS) and adverse events (AEs).

RESULTS

Of the 100 patients enrolled, 78 were randomly assigned to LB (42) or PB (36). Thirty-four received the ERAS protocol, and 44 did not. The mean MME/day use did not differ significantly by the bupivacaine group [median, IQR PB: 20.3 (40.95); LB: 33.0 (42.9); p = .314], but it did differ by the ERAS group [median, IQR no ERAS 33.2 (47.1), ERAS 24.0 (34.0); p = .049]. Length of stay, inpatient pain score, and AEs did not differ significantly by either the bupivacaine or the ERAS group.

CONCLUSIONS

In our study, liposomal bupivacaine did not significantly decrease postoperative opioid use either before implementation of ERAS or as part of an enhanced recovery after surgery program for minimally invasive bariatric surgery procedures.

Enhanced Recovery After Surgery Promotes Recovery in Sleeve Gastrectomy: A Randomized Controlled Trial

Introduction: The most popular approach for treating obesity is laparoscopic sleeve gastrectomy (LSG). The enhanced recovery after surgery (ERAS) protocol aims to reduce the patient's surgical stress response, optimize their physiological function, and facilitate recovery. The purpose of this study was to investigate the efficacy and safety of the ERAS protocol in patients who have undergone LSG. Methods: Between January 2020 and March 2021, a single-center randomized controlled study with patients undergoing LSG was planned. Patient demographics, duration of surgery and anesthetic induction, postoperative nausea-vomiting (PONV) and pain scores, length of hospital stay, and emergency room readmissions within the first 30 days were also documented. Patients were divided into two groups: those who followed the ERAS protocol and those who did not. The senior surgeon was blinded for the preoperative and postoperative period, whereas the other surgeon was not. The groups were compared in terms of length of hospital stay, duration of surgery, visual analog scale (VAS) scores, PONV effect scores, and emergency service admissions within the first 30 days after surgery. Results: A total of 96 patients were included in this study. Of these, 49 were in the ERAS protocol group and 47 were in the traditional treatment group. The mean age of the patients in the ERAS and traditional treatment groups were 37.47 ± 10.11 years and 35.77 ± 9.62 years, respectively. While the ERAS group patients were hospitalized for a mean of 30.46 ± 11.26 hours, the traditional group patients were hospitalized for 52.02 ± 6.63 hours (P: .001). There was no difference between the groups in terms of the first 30-day readmission to the emergency department (P: .498). Both VAS and PONV effect scores at the 2nd and 12th hours of the ERAS group patients were lower (P: .001, .002, .001, .001, respectively). Conclusions: When compared with the conventional method, the ERAS protocol reduced patient hospitalization time, decreased postoperative nausea, vomiting, and pain scores, and did not vary in postoperative emergency department readmissions. In patients receiving LSG, the ERAS protocol can be employed safely and successfully. Clinical Trial Registration number: NCT04442568.

Enhanced recovery after bariatric surgery: an Italian consensus statement

Background

Enhanced recovery after bariatric surgery (ERABS) is an approach developed to improve outcomes in obese surgical patients. Unfortunately, it is not evenly implemented in Italy. The Italian Society for the Surgery of Obesity and Metabolic Diseases and the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care joined in drafting an official statement on ERABS.

Methods

To assess the effectiveness and safety of ERABS and to develop evidence-based recommendations with regard to pre-, intra-, and post-operative care for obese patients undergoing ERABS, a 13-member expert task force of surgeons and anesthesiologists from Italian certified IFSO center of excellence in bariatric surgery was established and a review of English-language papers conducted. Oxford 2011 Levels of Evidence and U.S. Preventive Services Task Force Grade Definitions were used to grade the level of evidence and the strength of recommendations, respectively. The supporting evidence and recommendations were reviewed and discussed by the entire group at meetings to achieve a final consensus.

Results

Compared to the conventional approach, ERABS reduces the length of hospital stay and does not heighten the risk of major post-operative complications, re-operations, and hospital re-admissions, nor does it increase the overall surgical costs. A total of 25 recommendations were proposed, covering pre-operative evaluation and care (7 items), intra-operative management (1 item, 11 sub-items), and post-operative care and discharge (6 items).

Conclusions

ERABS is an effective and safe approach. The recommendations allow the proper management of obese patients undergoing ERABS for a better outcome.

Implementation of a standardized multimodal pain regimen significantly reduces postoperative inpatient opioid utilization in patients undergoing bariatric surgery

BACKGROUND

Routine opioid use in surgical patients has received attention given the opioid epidemic and a renewed focus on the dangers and drawbacks of opioids in the postoperative setting. Little is known about opioid use in bariatric surgery, especially in the inpatient setting. We hypothesize that a standardized opioid-sparing protocol reduces postoperative inpatient opioid use in bariatric surgery patients.

METHODS

A retrospective cohort study was conducted of bariatric surgery patients at a single institution. From March to September 2019, a standardized intraoperative and postoperative opioid-sparing protocol was designed and implemented along with an educational program for patients regarding safe pain management. Inpatient opioid utilization in patients undergoing surgery in the preintervention phase between April and March 2019 was compared to patients from a postintervention phase of October 2019 to December 2020. Opioid utilization was measured in morphine milliequivalents (MME).

RESULTS

A total of 359 patients were included; 192 preintervention and 167 postintervention. Patients were similar demographically. For all patients, mean age was 44.1 years, mean BMI 49.2 kg/m2, and 80% were female. Laparoscopic sleeve gastrectomy was performed in 48%, laparoscopic gastric bypass in 34%, robotic sleeve gastrectomy in 17%, and robotic gastric bypass in 1%. In the postintervention phase inpatient opioid utilization was significantly lower [median 134.8 [79.0-240.8] MME preintervention vs. 61.5 [35.5-150.0] MME postintervention (p < 0.001)]. MME prescribed at discharge decreased from a median of 300 MME preintervention to 75 MME postintervention (p < 0.001). In the postintervention phase, 16% of patients did not receive an opioid prescription at discharge compared to 0% preintervention (p < 0.001). When examining by procedure, statistically significant reductions in opioid utilization were seen for each operation.

CONCLUSION

Implementation of a standardized intraoperative and postoperative multimodal pain regimen and educational program significantly reduces inpatient opioid utilization in patients undergoing bariatric surgery.

Impact of dedicated renal enhanced recovery after surgery (RERAS) program on postoperative opioid consumption and evaluation of surgeon-specific compliance to the program

INTRODUCTION AND OBJECTIVE

Enhanced Recovery After Surgery (ERAS) protocols have been increasingly applied to urologic surgeries such as cystectomy and prostatectomy, though research defining protocols and outcomes for renal ERAS programs (RERAS) for nephrectomy remains limited. We aim to assess perioperative outcomes following implementation of our RERAS protocol modified from ERAS society cystectomy guidelines, as well as describe compliance with protocol guidelines.

METHODS

We performed a retrospective cohort analysis of 400 patients who underwent partial or radical nephrectomy between October 2017 and August 2020. RERAS protocol was initiated September 30, 2018, and patients were categorized into pre- and post-RERAS implementation cohorts based on surgery date. Perioperative outcomes including complications, 30-day readmissions, length of stay, and opioid consumption were compared across pre- and post-RERAS cohorts. Protocol compliance was reported based on adherence to program recommendations.

RESULTS

Among 400 patients included in analysis, the pre-RERAS cohort included 133 patients and the post-RERAS cohort included 267 patients. There were no differences in overall complications (P = 0.354) and 30-day readmissions (P = 0.078). Length of stay (P < 0.001) and postoperative opioid consumption (P < 0.001) were significantly reduced post-RERAS. We observed an increase in compliance with RERAS recommendations over time (P< 0.001).

CONCLUSION

RERAS implementation was associated with decreased length of stay and opioid usage, underscoring the benefits of program adoption in an era of opioid dependence and strained hospital capacity. Successful initiation of a RERAS protocol requires intentional organization and buy in from all providers involved.

Utilization and evolving prescribing practice of opioid and non-opioid analgesics in patients undergoing lymphadenectomy for cutaneous malignancy

BACKGROUND AND OBJECTIVES

Opioids are commonly prescribed following surgery and can lead to persistent opioid use. We assessed changes in prescribing practices following an opioid education initiative for patients undergoing lymphadenectomy for cutaneous malignancy.

METHODS

A single-institution retrospective study of all eligible patients (3/2016-3/2020) was performed.

RESULTS

Indications for lymphadenectomy in 328 patients were metastatic melanoma (84%), squamous cell carcinoma (10%), and Merkel cell carcinoma (5%). At discharge, non-opioid analgesics were increasingly utilized over the 4-year study period, with dramatic increases after education initiatives (32%, 42%, 59%, and 79% of pts, respectively each year; p < 0.001). Median oral morphine equivalents (OMEs) prescribed also decreased dramatically starting in year 3 (250, 238, 150, and 100 mg, respectively; p < 0.001). Patients discharged with 200 mg OMEs were less likely to also be discharged with non-opioid analgesics (40% vs. 64%. respectively, p < 0.001).

CONCLUSIONS

Analgesic prescribing practices following lymphadenectomy for cutaneous malignancy improved significantly over a 4-year period, with use of non-opioids more than doubling and a 60% reduction in median OME. Opportunities exist to further increase non-opioid use and decrease opioid dissemination after lymphadenectomy for cutaneous malignancy.

Outcomes of Bariatric Surgery in Patients on Chronic Opioids: Can Bariatric Surgery Assist with Decreasing Long-term Opioid Utilization?

PURPOSE

The aim of our study was to assess long-term opioid use following bariatric surgery in patients on preoperative narcotics.

METHODS

We evaluated patients utilizing preoperative opioids (OP) who underwent primary laparoscopic Roux-en-Y gastric bypass (LRYGB) from 2013 to 2020. Patients were propensity-matched to those without preoperative opioid use (NOP) by demographics and comorbidities. Our objectives were to compare opioid use at 1 and 3 years after surgery and evaluate perioperative outcomes.

RESULTS

A total of 806 patients, matched 1:1 were evaluated, with 82.7% being females. Mean age was 46.5 years in the OP and 45.6 years in the NOP (p = 0.0018), preoperative BMI was 45.8 in the OP and 46.1 in the NOP (p = 0.695). All patients were followed up for 1 year. In the OP, 156 (38.7%) patients were taking opioids 1 year after surgery as opposed to 27 (6.7%) in the NOP (p < 0.0001). Three years after surgery, 74 (37.5%) patients in the OP and 27 (14.4%) in the NOP were taking outpatient opioids (p < 0.0001). There was no statistically significant difference between OP and NOP groups in terms of readmissions (9.4% vs. 5.7% p = 0.06), reinterventions (3.7 vs. 1.7% p = 0.13), reoperations (3.5% vs. 1.5% p = 0.11), or emergency room visits (8.9% vs. 7.2% p = 0.44). There were no mortalities.

CONCLUSION

Most patients requiring preoperative opioids can be weaned off after bariatric surgery. Enhanced recovery pathways are key to obtaining these results. Preoperative opioid use is not associated with increased complications compared to opioid-naïve patients.

Combined opioid free and loco-regional anaesthesia enhances the quality of recovery in sleeve gastrectomy done under ERAS protocol: a randomized controlled trial

Background

It is debatable whether opioid-free anaesthesia (OFA) is better suited than multimodal analgesia (MMA) to achieve the goals of enhanced recovery after surgery (ERAS) in patients undergoing laparoscopic sleeve gastrectomy.

Methods

In all patients, anaesthesia was conducted with an i.v. induction with propofol (2 mg. kg-1), myorelaxation with cisatracurium (0.15 mg.kg-1), in addition to an ultrasound-guided bilateral oblique subcostal transverse abdominis plane block. In addition, patients in the OFA group (n = 51) received i.v. dexmedetomidine 0.1 μg.kg-1 and ketamine (0.5 mg. kg-1) at induction, then dexmedetomidine 0.5 μg. kg-1.h-1, ketamine 0.5 mg.kg-1.h-1, and lidocaine 1 mg. kg-1.h-1 for maintenance, while patients in the MMA group (n = 52) had only i.v. fentanyl (1 μg. kg-1) at induction. The primary outcome was the quality of recovery assessed by QoR-40, at the 6th and the 24th postoperative hour. Secondary outcomes were postoperative opioid consumption, time to ambulate, time to tolerate oral fluid, and time to readiness for discharge.

Results

At the 6th hour, the QoR-40 was higher in the OFA than in the MMA group (respective median [IQR] values: 180 [173–195] vs. 185 [173–191], p < 0.0001), but no longer difference was found at the 24th hour (median values = 191 in both groups). OFA also significantly reduced postoperative pain and morphine consumption (20 mg [1–21] vs. 10 mg [1–11], p = 0.005), as well as time to oral fluid tolerance (238 [151–346] vs. 175 min [98–275], p = 0.022), and readiness for discharge (505 [439–626] vs. 444 min [356–529], p = 0.001), but did not influence time to ambulate.

Conclusion

While regional anaesthesia achieved most of the intraoperative analgesia, avoiding intraoperative opioids with the help of this OFA protocol was able to improve several sensible parameters of postoperative functional recovery, thus improving our knowledge on the OFA effects.

Clinical trial number

Registration number NCT04285255.

Prescriptions for pain medication before and after bariatric surgery

BACKGROUND

Significant and sustained weight loss resulting from bariatric surgery have demonstrated clinical reduction in severe obesity-related pain. Subsequentially, post-surgical pain reduction may reduce pain medication use. However, clear evidence regarding use of prescribed pain medications before and after bariatric surgery is absent.

METHODS

Linking two state-wide databases, patients who underwent bariatric surgery between July 1, 2013 and December 31, 2015 were identified. Proportion tests were used to compare percent of patients with pain medication prescriptions 1 year before and 1 year after bariatric surgery. Logistic regression was used to identify baseline factors that were associated with pain medication use 1-year following surgery.

RESULTS

A total of 3535 bariatric surgical patients aged 18-64 years at surgery were identified. Of these patients, 1339 patients met the following study criteria: covered by private insurance; known pre-surgical BMI; and continuous enrollment with health plan(s) from 12-month pre-surgery to 13-month post-surgery. While comparison of average number of overall pain medication prescriptions before and after surgery did not change, from 3.46 to 3.32 prescriptions (p value = 0.26), opioid prescription use increased from 1.62 vs. 2.05 (p value < 0.01). Patients prescribed more types of pain medications before surgery were more likely to have prescribed pain medications after surgery. Patients prescribed benzodiazepines at baseline had higher odds being prescribed post-surgery corticosteroids (OR = 1.89, p value < 0.01), muscle relaxants (OR = 2.18, p value < 0.01), and opioids (OR = 3.06, p value =  < 0.01) compared to patients without pre-surgery--prescribed benzodiazepine.

CONCLUSION

While comparison of average number of overall pain medication prescriptions before and after bariatric surgery did not decrease, opioid prescription increased post-surgery. Further studies are needed to examine whether post-surgery opioids are prescribed in lieu of or in tandem with other pain medication prescriptions.

Pain management after laparoscopic appendectomy: Comparative effectiveness of innovative pre-emptive analgesia using liposomal bupivacaine

BACKGROUND

Laparoscopic appendectomy is standard of care for appendicitis in the US. Pain control that limits opioids is an important area of research given the opioid epidemic. This study examined post-appendectomy inpatient opioid use and pain scores following intraoperative use of liposomal bupivacaine (LB) versus non-liposomal bupivacaine.

METHODS

This was a retrospective cohort study of 155 adults who underwent laparoscopic appendectomy for acute appendicitis. Patients were divided into four cohorts based on the analgesia administered: (i) bupivacaine hydrochloride (BH)± epinephrine; (ii) undiluted LB; (iii) LB diluted with normal saline; and (iv) LB diluted with BH.

RESULTS

Baseline demographic/clinical attributes, intra-operative findings, and post-operative pain scores were equivalent across cohorts. Post-operative pre-discharge opioid use was higher in the BH vs. LB cohorts (mean 60.4 vs. 46.0, 35.5, and 30.4 morphine milligram equivalents, respectively; p < 0.001).

CONCLUSIONS

Pre-emptive analgesia with LB during laparoscopic appendectomy can reduce inpatient opioid use without significantly increasing post-operative pain scores.

The Efficacy of Liposomal Bupivacaine for Opioid and Pain Reduction: A Systematic Review of Randomized Clinical Trials

Background The opioid crisis has prompted surgeons to search for alternative postoperative methods of analgesia. Liposomal bupivacaine is a long-acting local anesthetic formulation used for pain, potentially reducing opioid use. Evaluation of liposomal bupivacaine as a viable alternative for pain management is needed. The objective was to assess the efficacy of randomized clinical trials (RCTs) of liposomal bupivacaine in postoperative pain management and opioid consumption. Material and Methods The authors extracted RCTs comparing liposomal bupivacaine versus placebo or active comparators for postoperative pain or opioid reduction from PubMED/MEDLINE, Cochrane Library, and ClinicalTrials.gov. Exclusion criteria included nonhuman studies, non-RCTs, pooled studies, and inability to access full text. The following variables were abstracted: surgical specialty, number of subjects, pain and opioid outcomes, and authors' financial conflicts of interest. Results We identified 77 published RCTs, of which 63 studies with a total of 6770 subjects met inclusion criteria. Liposomal bupivacaine did not demonstrate significant pain relief compared to placebo or active agents in 74.58% of RCTs. Of the studies evaluating narcotic use, liposomal bupivacaine did not show a reduction in opioid consumption in 85.71% of RCTs. Liposomal bupivacaine, when compared to standard bupivacaine or another active agent, yielded no reduction in opioid use in 83.33% and 100.00% of studies, respectively. Clinical trials with a financial conflict of interest relating to the manufacturer of liposomal bupivacaine were significantly more likely to show pain relief (OR: 14.31 [95% CI, 2.8, 73.10], P = 0.0001) and decreased opioid consumption (OR: 12.35 [95% CI 1.40, 109.07], P = 0.0237). Of the 265 unpublished RCTs on ClinicalTrials.gov, 47.54% were withdrawn, terminated, suspended, or completed without study results available. Conclusions The efficacy of liposomal bupivacaine for providing superior postoperative pain control relative to placebo or another active agent is not supported by a majority of RCTs. Underreporting of trial results and bias due to underlying financial relationships amongst authors are two major concerns that should be considered when evaluating the available evidence.

Bariatric Enhanced Recovery Protocol: a Community Quality Perspective

INTRODUCTION

Bariatric enhanced recovery protocols can decrease length of stay (LOS) and hospital costs without compromising patient safety. Increased data is needed to compare patient outcomes before and after application of enhanced recovery pathways. We present a bariatric enhanced recovery protocol (BERP) at a community hospital. The objectives were to decrease hospital LOS and reduce schedule II substance use (medications with a high potential for abuse, potentially resulting in psychological or physical dependence), without compromising patient safety.

METHODS

This was a combined retrospective and prospective analysis of all patients undergoing bariatric surgery by two surgeons from September 2016 to April 2018. Mann-Whitney U, Pearson chi-square, and Fisher's exact tests were used to compare demographics, comorbidities, and outcomes.

RESULTS

Two hundred patients were evaluated. Overall median (interquartile range) age was 43.0 (36.0-54.0) years and body mass index (BMI) was 45.0 (40.6-50.3) kg/m². Pre-protocol mean hospital LOS was 2.3 days while enhanced recovery protocol patients mean LOS was 1.4 days (p < 0.001). Sixty-five percent of BERP patients were discharged on hospital day 1, while no patients prior to the protocol were discharged before hospital day 2. Only 9% of BERP patients were discharged with schedule II medications, compared to 100% of the pre-protocol patients (p < 0.001). Intraoperative, in-hospital, and 30-day complication rates were not statistically significant between the two groups.

CONCLUSION

Community hospitals can reduce length of stay and narcotic prescribing without compromising safety-related outcomes. Significant reductions in the amount of schedule II medications can be achieved when using multimodal enhanced recovery protocol approaches.

Optimizing Perioperative Use of Opioids: A Multimodal Approach

Purpose of Review

The main purpose of this article is to review recent literature regarding multimodal analgesia medications, citing their recommended doses, efficacy, and side effects. The second part of this report will provide a description of drugs in different stages of development which have novel mechanisms with less side effects such as tolerance and addiction.

Recent Findings

Multimodal analgesia is a technique that facilitates perioperative pain management by employing two or more systemic analgesics along with regional anesthesia, when possible. Even though opioids and non-opioid analgesics remain the most common medication used for acute pain management after surgery, they have many undesirable side effects including the potential for misuse. Newer analgesics including peripheral acting opioids, nitric oxide inhibitors, calcitonin gene-related peptide receptor antagonists, interleukin-6 receptor antagonists and gene therapy are under intensive investigation.

Summary

A patient's first exposure to opioids is often in the perioperative setting, a vulnerable time when multimodal therapy can play a large role in decreasing opioid exposure. Additionally, the current shift towards faster recovery times, fewer post-operative complications and improved cost-effectiveness during the perioperative period has made multimodal analgesia a central pillar of Enhanced Recovery After Surgery (ERAS) protocols.

A Nurse-Led Evidence-Based Practice Protocol to Reduce Postoperative Nausea and Vomiting in the Bariatric Surgery Patient

PURPOSE

To create and implement a standard care bundle to reduce postoperative nausea and vomiting (PONV) in the bariatric surgery patient.

DESIGN

Evidence-based quality improvement project.

METHODS

A pre- and postintervention chart review identified high-risk indicators for PONV in patients with longer lengths of stay (LOS), which led to the development of targeted care bundle components.

FINDINGS

A clinically significant difference was observed in predicted PONV for Apfel scores 3 and 4 in patients receiving the full bundle compared with those receiving a partial bundle. Decreased LOS after implementation of the antiemetic care bundle was found. Health care provider compliance with bundle administration was low (57%).

CONCLUSIONS

Clinically significant PONV scores were low after implementation of the antiemetic bundle for high-risk patients. The nurse-led creation and implementation of an antiemetic care bundle may have contributed to decreased LOS, reduced PONV, and reduced provider variability in care management.

Preoperative opioid use is associated with increased risk of postoperative complications within a colorectal-enhanced recovery protocol

BACKGROUND

As the opioid epidemic escalates, preoperative opioid use has become increasingly common. Recent studies associated preoperative opioid use with postoperative morbidity. However, limited study of its impact on patients within enhanced recovery protocols (ERP) exists. We assessed the impact of preoperative opioid use on postoperative complications among colorectal surgery patients within an ERP, hypothesizing that opioid-exposed patients would be at increased risk of complications.

METHODS

Elective colorectal cases from August 2013 to June 2017 were reviewed in a retrospective cohort study comparing preoperative opioid-exposed patients to opioid-naïve patients. Postoperative complications were defined as a composite of complications captured by the American College of Surgeons National Surgical Quality Improvement Program. Logistic regression identified risk factors for postoperative complications.

RESULTS

707 patients were identified, including 232 (32.8%) opioid-exposed patients. Opioid-exposed patients were younger (57.9 vs 61.9 years; p < 0.01) and more likely to smoke (27.6 vs 17.1%; p < 0.01). Laparoscopic procedures were less common among opioid-exposed patients (44.8 vs 58.1%; p < 0.01). Median morphine equivalents received were higher in opioid-exposed patients (65.0 vs 20.1 mg; p < 0.01), but compliance to ERP elements was otherwise equivalent. Postoperative complications were higher among opioid-exposed patients (28.5 vs 15.0%; p < 0.01), as was median length of stay (4.0 vs 3.0 days; p < 0.01). Logistic regression identified multiple patient- and procedure-related factors independently associated with postoperative complications, including preoperative opioid use (p = 0.001).

CONCLUSION

Preoperative opioid use is associated with increased risk of postoperative complications in elective colorectal surgery patients within an ERP. These results highlight the negative impact of opioid use, suggesting an opportunity to further reduce the risk of surgical complications through ERP expansion to include preoperative mitigation strategies for opioid-exposed patients.