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Ewing JK, Cassling KE, Hanneman MA, Broucek JR, Raymond BL, Pierce RA, Geiger TM, Bradley JF. Development of an Enhanced Recovery After Surgery Program in Ventral Hernia. Am Surg 2024; 90:2258-2264. [PMID: 39096287 DOI: 10.1177/00031348241268330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2024]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) programs have spread after initial success in colorectal surgery decreasing length of stay (LOS) and decreasing opioid consumption. Adoption of ERAS specifically for ventral hernia patients remains in evolution. This study presents the development and implementation of an ERAS pathway for ventral hernia. METHODS A multidisciplinary team met weekly over 6 months to develop an ERAS pathway specific to ventral hernia patients. 75 process components and outcome measures were included, spanning multiple phases of care: Preoperative-Clinic, Preoperative Day of Surgery (DOS), Intraoperative, and Postoperative. Preoperative components included education and physiologic optimization. Pain control across phases of care focuses on nonopioid, multimodal analgesia. Postoperatively, the pathway emphasizes early diet advancement, early mobilization, and minimization of IV fluids. We compared compliance and outcome measures between a Pre Go-Live (PGL) period (9/1/2020-8/30/2021) and After Go-live (AGL) period (5/12/2022-5/19/2023). RESULTS There were 125 patients in the PGL group and 169 patients in the AGL group. Overall, ERAS compliance increased from 73.9% to 82.9% after implementation. Length of stay decreased from an average of 2.27 days PGL to 1.92 days AGL. Finally, the average daily postoperative opioid usage decreased from 25.4 to 13.5 MME after the implementation. DISCUSSION Enhanced Recovery After Surgery can be successfully applied to the care of hernia patients with improvements in LOS and decreased opioid consumption. Institutional support and multidisciplinary cooperation were key for the development of such a program.
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Affiliation(s)
- John K Ewing
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kyle E Cassling
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Michael A Hanneman
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joseph R Broucek
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Britany L Raymond
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Richard A Pierce
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Timothy M Geiger
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joel F Bradley
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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2
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Crosier C, Hoffman K, Walker K, Blackhurst D, Warren JA. Continuing home opioid dose in chronic opioid users reduces total opioid use after ventral hernia repair. Am J Surg 2024; 238:115846. [PMID: 39059339 DOI: 10.1016/j.amjsurg.2024.115846] [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: 04/18/2024] [Revised: 07/03/2024] [Accepted: 07/11/2024] [Indexed: 07/28/2024]
Abstract
INTRODUCTION Managing acute postoperative pain in patients on chronic opioid therapy is challenging. There is little data regarding optimal perioperative chronic opioid management. We hypothesized that continuing the home dose of opioid while inpatient following ventral hernia repair (VHR) would reduce total opioid consumption postoperatively. METHODS Chronic opioid users were ordered their home opioid scheduled and our standard multimodal analgesia regimen. At time of discharge, we reviewed inpatient opioid use and prescribed opioids based on morphine milligram equivalent (MME) consumed per our established protocol. RESULTS VHR was performed in 658 patients with 117 utilizing chronic opioid medications from June 2017 through March 2022; 43 patients were managed on protocol and 74 were not. Inpatient daily MME consumption was similar between groups (34 vs 36 MME; p = 0.285). Patients treated according to protocol received significantly lower MME prescriptions at discharge (80 vs 225 MME; p < 0.001) with similar refills (21.4 vs 25.4 %; p = 0.820). CONCLUSION Continuing home opioids for chronic opioid users following VHR resulted in less opioid prescribing with no increase in refills.
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Affiliation(s)
| | | | | | | | - Jeremy A Warren
- Prisma Health Department of Surgery, USA; University of South Carolina School of Medicine Greenville, USA.
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3
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Coppersmith N, Sznol J, Esposito A, Flom E, Chiu A, Yoo P. The persistent benefits of decreasing default pill counts for postoperative narcotic prescriptions. PLoS One 2024; 19:e0304100. [PMID: 38833500 PMCID: PMC11149874 DOI: 10.1371/journal.pone.0304100] [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: 01/16/2024] [Accepted: 05/07/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND In 2017, a university-based academic healthcare system changed the opioid default pill count from 30 to 12 pills. Modifying the electronic default pill count influences short-term clinician prescribing practices. We sought to understand the long-term impact on postoperative opioid prescribing habits after an opioid default pill count reduction. MATERIALS AND METHODS A retrospective electronic medical record system (EMRS) review was conducted in a healthcare system comprised of seven affiliated hospitals. Patients who underwent a surgical procedure and were prescribed an opioid on discharge between 2017-2021 were evaluated. All prescriptions were converted into morphine equivalents (MME). Analyses were performed with the chi-square test and Bonferonni adjusted t-test. RESULTS 191,379 surgical procedures were studied. The average quantity of opioids prescribed decreased from 32 oxycodone 5 mg tablets in 2017 to 21 oxycodone 5 mg tablets in 2021 (236 MME to 154 MME, p<0.001). The percentage of patients obtaining a refill within 90 days of surgery varied between 18.3% and 19.9% (p<0.001). Patients with a pre-existing opioid prescription and opioid-naïve patients both had significant reductions in prescription quantities above the default MME (79.7% to 60.6% vs. 65.3% to 36.9%, p<0.001). There was no significant change in refills for both groups (pre-existing 36.7% to 38.3% (p = 0.1) vs naïve 15.0% to 15.3% (p = 0.29)). CONCLUSIONS The benefits of decreasing the default opioid pill count continue to accumulate long after the original change. Physician uptake of small changes to default EMRS practices represents a sustainable and effective intervention to reduce the quantities of postoperative opioids prescribed without deleterious effects on outpatient opiate requirements.
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Affiliation(s)
- Nathan Coppersmith
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Joshua Sznol
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Andrew Esposito
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Emily Flom
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Alexander Chiu
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Peter Yoo
- Academic Affairs, Hartford Healthcare, Hartford, Connecticut, United States of America
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Yun DH, Plymale MA, Oyler DR, Slavova SS, Davenport DL, Roth JS. Predictors of postoperative opioid use in ventral and incisional hernia repair. Surg Endosc 2024; 38:3052-3060. [PMID: 38609586 DOI: 10.1007/s00464-024-10808-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 03/21/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND One in two ventral and incisional hernia repair (VIHR) patients have preoperative opioid prescription within a year before procedure. The study's aim was to investigate risk factors of increased postoperative prescription filling in patients with or without preoperative opioid prescription. METHODS VIHR cases from 2013 to 2017 were reviewed. State prescription drug monitoring program data were linked to patient records. The primary endpoint was cumulative opioid dose dispensed through post-discharge day 45. Morphine milligram equivalent (MME) was used for uniform comparison. RESULTS 205 patients were included in the study (average age 53.5 years; 50.7% female). Over 35% met criteria for preoperative opioid use. Preoperative opioid tolerance, superficial wound infection, current smoking status, and any dispensed opioids within 45 days of admission were independent predictors for increased postoperative opioid utilization (p < 0.001). CONCLUSION Preoperative opioid use during 45-day pre-admission correlated strongly with postoperative prescription filling in VIHR patients, and several independent risk factors were identified.
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Affiliation(s)
- Do Hyun Yun
- College of Medicine, University of Kentucky, Lexington, KY, USA
| | - Margaret A Plymale
- Division of General, Endocrine and Metabolic Surgery, Department of Surgery, University of Kentucky, 800 Rose Street, C-240, Lexington, KY, 40536, USA
| | - Douglas R Oyler
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Svetla S Slavova
- Department of Biostatistics, University of Kentucky, Lexington, KY, USA
| | - Daniel L Davenport
- Department of Surgery, Division of Healthcare Outcomes and Optimal Patient Services, University of Kentucky, Lexington, KY, USA
| | - John Scott Roth
- Division of General, Endocrine and Metabolic Surgery, Department of Surgery, University of Kentucky, 800 Rose Street, C-240, Lexington, KY, 40536, USA.
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Desai S, Carbonell C, Hoffman K, Hammond B, Crosier C, Blackhurst D, Carbonell AM, Love MW, Cobb WS, Warren JA. Impact of methocarbamol on opioid use after ventral incisional hernia repair. Am J Surg 2023; 226:858-863. [PMID: 37481407 DOI: 10.1016/j.amjsurg.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 06/12/2023] [Accepted: 07/05/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND Alternatives to opioid analgesia are needed to reduce the risk of abuse, misuse, and diversion. Musculoskeletal pain is a significant contributor to postoperative pain after ventral hernia repair (VHR). We report the impact of methocarbamol on opioid prescribing after VHR. METHODS Review of all robotic and open VHR, Jan 2020-July 2022. Data was collected in the Abdominal Core Health Quality Collaborative (ACHQC) with additional chart review to assess for opioid refills. A 2:1 propensity score match was performed comparing opioid prescribing in patients prescribed vs not prescribed methocarbamol. RESULTS 101 patients received methocarbamol compared with 202 without. Similar number of patients received an opioid prescription (87.1 vs 86.6%; p = 0.904). Study patients received significantly lower MME prescription at discharge (60 v 75; p = 0.021) with no difference in refills (12.5 vs 16.6%; p = 0.386). CONCLUSION Addition of methocarbamol to a multimodal analgesic regimen after VHR facilitates reduction in prescribed opioid with no increase in refills.
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Affiliation(s)
| | - Cecilia Carbonell
- Prisma Health Department of Surgery, Summer Program for Undergraduate Research in Surgery, USA
| | | | - Brooke Hammond
- Prisma Health Department of Surgery, Summer Program for Undergraduate Research in Surgery, USA
| | | | | | - Alfredo M Carbonell
- Prisma Health Department of Surgery, USA; University of South Carolina School of Medicine Greenville, USA
| | | | - William S Cobb
- Prisma Health Department of Surgery, USA; University of South Carolina School of Medicine Greenville, USA
| | - Jeremy A Warren
- Prisma Health Department of Surgery, USA; University of South Carolina School of Medicine Greenville, USA.
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Hennessey RQL, Yang Y, Meneghetti AT, Panton ONM, Chiu CJ. A cost-conscious establishment of a robotic abdominal wall reconstruction program in a publicly funded healthcare system. Hernia 2023; 27:1115-1122. [PMID: 37347343 DOI: 10.1007/s10029-023-02823-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 06/11/2023] [Indexed: 06/23/2023]
Abstract
PURPOSE Despite reports of better short-term outcomes, the main criticism for the adoption of the robotic surgery platform for abdominal wall reconstruction (AWR) has been the associated cost, especially in countries with a publicly funded healthcare system such as Canada. We describe our experience in implementation of robotic AWR while ensuring cost-effectiveness. METHODS This is a retrospective cohort analysis of all patients with ventral hernias ranging between 5 to 15 cm who underwent either open or robotic AWR between January 2020 to August 2022. We reviewed patient characteristics, operative time, post-operative length of stay (LOS), and average cost of surgery. RESULTS 45 patients underwent open repair and 28 underwent robotic repair in the study period. There was no difference in major patient characteristics between the two groups. Operative time was shorter for open repairs (233.2 ± 96.6 min vs. 299.3 ± 71.8 min, p < 0.001). LOS was significantly longer for open repairs (5 days (interquartile range = 4-6) vs. 2 days (IQR = 1.75-3), p < 0.001) and there were significantly more patients who underwent robotic repair who left hospital in less than 3 days (13.3 vs. 64.3%, p < 0.001). The average overall hospital-based cost for each open repair was $26,952.18 when the cost for equipment, operative time, inpatient hospital stay, and epidural use are accounted for, compared to $17,447.40 for robotic repair ($9,504.78 saving per case). CONCLUSION With proper selection of patients based on size of hernia, we demonstrate cost conscious adaptation of the robotic technology to AWR. Our future studies will continue to explore the benefits and limits of this approach in complex hernia repair.
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Affiliation(s)
- Rachel Q Liu Hennessey
- Division of General Surgery, Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada.
| | - Yuwei Yang
- Division of General Surgery, Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Adam T Meneghetti
- Division of General Surgery, Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - O Neely M Panton
- Division of General Surgery, Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Chieh Jack Chiu
- Division of General Surgery, Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
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Millard JL, Hahn EA, Schumann E, Register L, Blackhurst D, Carbonell AM, Cobb WS, Warren JA. A Standardized Protocol for Opioid Prescribing After Surgery Decreases Total Morphine Equivalents Prescribed. Am Surg 2023; 89:3771-3777. [PMID: 37195287 DOI: 10.1177/00031348231175494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
INTRODUCTION Perioperative opioid analgesia has been extensively reexamined during the opioid epidemic. Multiple studies have demonstrated over prescription of opioids, demonstrating the need for change in prescribing practices. A standard opioid prescribing protocol was implemented to evaluate opioid prescribing trends and practices. OBJECTIVES To evaluate opioid use after primary ventral, inguinal, and incisional hernia repair and to assess clinical factors that may impact opioid prescribing and consumption. Secondary outcomes include the number of refills, patients without opioid requirement, difference in opioid use based on patient characteristics and adherence to prescribing protocol. METHODS This is a prospective observational study examining patients undergoing inguinal, primary ventral and incisional hernias between February and November 2019. A standardized prescribing protocol was implemented and utilized for postoperative prescribing. All data was captured in the abdominal core health quality collaborative (ACHQC) and opioid use was standardized via morphine milligram equivalents (MME). RESULTS 389 patients underwent primary ventral, incisional, and inguinal hernia repair, with a total of 285 included in the final analysis. 170 (59.6%) of patients reported zero opioid use postoperatively. Total opioid MME prescribed and high MME consumption were significantly higher after incisional hernia repair with a greater number of refills were required. Compliance with prescribing protocol resulted in lower MME prescription, but not actual lower MME consumption. CONCLUSIONS Implementation of a standardized protocol for opioid prescribing after surgery decreases the total MME prescribed. Compliance with our protocol significantly reduced this disparity, which has the potential for decreasing abuse, misuse, and diversion of opioids by better estimating actual postoperative analgesic requirements.
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Affiliation(s)
- Jessica L Millard
- Prisma Health- Upstate, Department of General Surgery, Greenville Memorial, Greenville, SC, USA
| | - Elizabeth A Hahn
- University of South Carolina School of Medicine-Greenville, Greenville, SC, USA
| | - Emily Schumann
- University of South Carolina School of Medicine-Greenville, Greenville, SC, USA
| | - Lindsey Register
- University of South Carolina School of Medicine-Greenville, Greenville, SC, USA
| | - Dawn Blackhurst
- Prisma Health- Upstate, Department of General Surgery, Greenville Memorial, Greenville, SC, USA
| | - Alfredo M Carbonell
- Prisma Health- Upstate, Department of General Surgery, Greenville Memorial, Greenville, SC, USA
- University of South Carolina School of Medicine-Greenville, Greenville, SC, USA
| | - William S Cobb
- Prisma Health- Upstate, Department of General Surgery, Greenville Memorial, Greenville, SC, USA
- University of South Carolina School of Medicine-Greenville, Greenville, SC, USA
| | - Jeremy A Warren
- Prisma Health- Upstate, Department of General Surgery, Greenville Memorial, Greenville, SC, USA
- University of South Carolina School of Medicine-Greenville, Greenville, SC, USA
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8
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Reinhorn M, Dews T, Warren JA. Utilization of a National Registry to influence opioid prescribing behavior after hernia repair. Hernia 2022; 26:847-853. [PMID: 34480659 DOI: 10.1007/s10029-021-02495-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 08/25/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Despite progress toward curtailing opioid prescribing, physicians are often slow to adopt new prescribing practices. Using the Abdominal Core Health Quality Collaborative (ACHQC), we aimed to demonstrate the ability of a national, disease-specific, personalized registry to impact opioid prescribing. METHODS Using a collaborative and iterative process, a module was developed to capture surgeon opioid prescribing, patient-reported consumption, and risk factors for opioid use. Study reported according to the Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0 guidelines. RESULTS Six months after implementation of the ACHQC opioid module, we assessed participation, prescribing and patient consumption patterns. For ventral hernia repair (VHR; n = 398), 23 surgeons reported prescribing > 20 pills (43%), 11-20 (40%), and < 10 (18%). In contrast, patients (n = 217) reported taking < 10 pills in 65% and only 20% reported taking > 15. For inguinal hernia repair (IHR; n = 443) 37 surgeons reported prescribing > 20 tablets (22%), 11-20 (32%), and < 10 (44%). Patients (n = 277) reported taking < 10 pills in 81% of cases, including 50% reporting zero, and only 13% taking > 15. We identified barriers to practice change and developed a strategy for education, provision of individualized data, and encouraging participation. Surgeon participation has since increased significantly (n = 65 for VHR; n = 53 for IHR), and analysis of the impact of this process is ongoing. CONCLUSION Quality improvement requires physician engagement, which can be facilitated by meaningful and actionable data. The specificity of the ACHQC and the ability to provide surgeons with individualized data is a model method to incite change in physician behavior and improve patient outcomes.
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Affiliation(s)
- M Reinhorn
- Boston Hernia & Pilonidal Center, Tufts University School of Medicine, Newton-Wellesley Hospital, 201 Walnut St, Ste 100, Wellesley, MD, 02481, USA
| | - T Dews
- Cleveland Clinic Pain Management, Anesthesiology Institute, Cleveland Clinic Euclid Hospital, Case Western Reserve University, Cleveland Clinic Lerner College of Medicine, Cleveland, USA
| | - J A Warren
- Department of Surgery, Prisma Health Upstate, University of South Carolina School of Medicine Greenville, 701 Grove Rd, ST 3, Greenville, SC, 29605, USA.
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Higgins RM, Petro CC, Warren J, Perez AJ, Dews T, Phillips S, Reinhorn M. The opioid reduction task force: using the ACHQC Data Registry to combat an epidemic in hernia patients. Hernia 2022; 26:855-864. [PMID: 35039950 DOI: 10.1007/s10029-021-02556-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 12/27/2021] [Indexed: 11/04/2022]
Abstract
PURPOSE Post-operative opioid prescriptions contribute to prolonged opioid misuse and abuse. Using a national hernia registry, we aimed to evaluate the effectiveness of a data-driven educational intervention on surgeon prescribing behavior. METHODS After collecting opioid prescribing and patient consumption data from March 2019-December 2019 in inguinal and umbilical hernia repair, the Abdominal Core Health Quality Collaborative (ACHQC) Opioid Reduction Task Force presented data at a Quality Improvement (QI) Summit to educate surgeons on strategies to minimize opioid prescribing. Surgeons were asked to implement a multimodal pain management approach and were supported with educational tools created by the task force. Prescribing and consumption data after the summit, December 2019-March 2021, were then collected to assess the effectiveness of the QI effort. RESULTS Registry participation before and after the QI summit increased from 52 to 91 surgeons, with an increase of 353-830 umbilical hernia patients and 976-2447 inguinal hernia patients. After the summit, high (> 10 tablets) surgeon prescribers shifted toward low (≤ 10 tablets) prescribing. Yet, patients consumed less than what was prescribed, with a significant increase in patients consuming ≤ 10 tablets before and after the summit: 79-88% in umbilical hernia (p = 0.01) and 85-94% in inguinal hernia (p < 0.001). CONCLUSIONS Following an educational QI summit by the ACHQC Opioid Reduction Task Force, high opioid prescribing has shifted toward low. However, patients consume less than prescribed, highlighting the importance of continuing this effort to reduce opioid prescribing.
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Affiliation(s)
- R M Higgins
- Division of Minimally Invasive Gastrointestinal Surgery, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA.
| | - C C Petro
- Center for Abdominal Core Health, Cleveland Clinic, Cleveland, OH, USA
| | - J Warren
- The University of South Carolina School of Medicine Greenville, Greenville, SC, USA
| | - A J Perez
- Division of General, Acute Care and Trauma Surgery, The University of North Carolina, Chapel Hill, NC, USA
| | - T Dews
- Pain Management Department, Cleveland Clinic Euclid Hospital, Cleveland, OH, USA
| | - S Phillips
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - M Reinhorn
- Mass General Brigham-Newton Wellesley Hospital, Boston Hernia and Pilonidal Center, Newton, MA, USA
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Jensen KK, East B, Jisova B, Cano ML, Cavallaro G, Jørgensen LN, Rodrigues V, Stabilini C, Wouters D, Berrevoet F. The European Hernia Society Prehabilitation Project: a systematic review of patient prehabilitation prior to ventral hernia surgery. Hernia 2022; 26:715-726. [PMID: 35212807 DOI: 10.1007/s10029-022-02573-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 01/23/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND Ventral hernia repair is one of the most commonly performed surgical procedures worldwide. To reduce the risk of complications, patient prehabilitation has received increasing focus in recent years. To assess prehabilitation measures, this European Hernia Society endorsed project was launched. The aim of this systematic review was to evaluate the current literature on patient prehabilitation prior to ventral hernia repair. METHODS The strategies examined were optimization of renal disease, obesity, nutrition, physical exercise, COPD, diabetes and smoking cessation. For each topic, a separate literature search was conducted, allowing for seven different sub-reviews. RESULTS A limited amount of well-conducted research studies evaluating prehabilitation prior to ventral hernia surgery was found. The primary findings showed that smoking cessation and weight loss for obese patients led to reduced risks of complications after abdominal wall reconstruction. CONCLUSION Prehabilitation prior to ventral hernia repair may be widely used; however, the literature supporting its use is limited. Future studies evaluating the impact of prehabilitation before ventral hernia surgery are warranted.
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Affiliation(s)
- K K Jensen
- Digestive Disease Center, Bispebjerg University Hospital, Bispebjerg Bakke 23, 2400, Copenhagen, NV, Denmark.
| | - B East
- 3rd Department of Surgery and 1st Medical Faculty of Charles University, Motol University Hospital, Prague, Czech Republic
| | - B Jisova
- 3rd Department of Surgery and 1st Medical Faculty of Charles University, Motol University Hospital, Prague, Czech Republic
| | - M López Cano
- Abdominal Wall Surgery Unit, Department of General Surgery, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - G Cavallaro
- Department of Surgery "P. Valdoni", Sapienza University, Rome, Italy
| | - L N Jørgensen
- Digestive Disease Center, Bispebjerg University Hospital, Bispebjerg Bakke 23, 2400, Copenhagen, NV, Denmark
| | - V Rodrigues
- Abdominal Wall Surgery Unit, Department of General Surgery, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - C Stabilini
- Department of Surgery, University of Genoa, Genoa, Italy
- Ospedale Policlinico San Martino IRCCS, Genoa, Italy
| | - D Wouters
- Department for General and HPB Surgery and Liver Transplantation, University Hospital Gent, Gent, Belgium
| | - F Berrevoet
- Department for General and HPB Surgery and Liver Transplantation, University Hospital Gent, Gent, Belgium
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Tavernier JR. Original Research: Combating the Opioid Epidemic Through Nurse Use of Multimodal Analgesia: An Integrative Literature Review. Am J Nurs 2022; 122:20-32. [PMID: 35394962 DOI: 10.1097/01.naj.0000829772.68328.d5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Opioid misuse and addiction have become a national crisis. New pain management guidelines call for the use of multimodal analgesia to manage acute pain. In hospital settings, a clinical decision aid that emphasizes multimodal analgesia may improve nurses' use of this opioid-sparing strategy. PURPOSE This integrative review was conducted to provide nurses with evidence-based information on the opioid-sparing benefits of multimodal analgesia. METHODS A literature search was conducted using several electronic databases and Google Scholar. These initial searches yielded 136 articles of interest. Twenty-eight were selected for retrieval and in-depth appraisal; of these, 13 met all inclusion criteria. RESULTS Of the 13 reviewed studies, six were randomized controlled trials, six were retrospective cohort or population-based studies, and one was a qualitative study. Overall, the findings provided strong evidence that multimodal analgesia is effective in managing acute pain in surgical patients while reducing opioid requirements. Several studies also found that multimodal analgesia was associated with shorter hospital lengths of stay. CONCLUSIONS With the appropriate tools and education, nurses can make the transition from traditional opioids to multimodal analgesia strategies. In so doing, they can have a significant positive impact on the opioid epidemic. Hospital leaders must address nursing practice regarding the use of opioids alone versus multimodal analgesia for the management of acute pain. Clinical decision tools such as the Michigan Opioid Safety Score may help nurses adopt new acute pain management guidelines. Further research regarding nursing practice and the opioid epidemic is needed.
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Affiliation(s)
- Jennifer René Tavernier
- Jennifer René Tavernier is nursing faculty in the Health Professions Division at Lane Community College, Eugene, OR. Contact author: . The author has disclosed no potential conflicts of interest, financial or otherwise
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Cheung CK, Adeola JO, Beutler SS, Urman RD. Postoperative Pain Management in Enhanced Recovery Pathways. J Pain Res 2022; 15:123-135. [PMID: 35058714 PMCID: PMC8765537 DOI: 10.2147/jpr.s231774] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 12/30/2021] [Indexed: 12/05/2022] Open
Abstract
Postoperative pain is a common but often inadequately treated condition. Enhanced recovery pathways (ERPs) are increasingly being utilized to standardize perioperative care and improve outcomes. ERPs employ multimodal postoperative pain management strategies that minimize opioid use and promote recovery. While traditional opioid medications continue to play an important role in the treatment of postoperative pain, ERPs also rely on a wide range of non-opioid pharmacologic therapies as well as regional anesthesia techniques to manage pain in the postoperative setting. The evidence for the use of these interventions continues to evolve rapidly given the increasing focus on enhanced postoperative recovery. This article reviews the current evidence and knowledge gaps pertaining to commonly utilized modalities for postoperative pain management in ERPs.
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Affiliation(s)
- Christopher K Cheung
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Janet O Adeola
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Sascha S Beutler
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Al-Mansour M, Neal D, Crippen C, Loftus T, Read T, Tighe P. Outcomes of transversus abdominis plane block in ventral hernia repair: A propensity score matching analysis using a national database. INTERNATIONAL JOURNAL OF ABDOMINAL WALL AND HERNIA SURGERY 2022. [DOI: 10.4103/ijawhs.ijawhs_37_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
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Morrell DJ, Doble JA, Hendriksen BS, Horne CM, Hollenbeak CS, Pauli EM. Comparative effectiveness of surgeon-performed transversus abdominis plane blocks and epidural catheters following open hernia repair with transversus abdominis release. Hernia 2021; 25:1611-1620. [PMID: 34319465 DOI: 10.1007/s10029-021-02454-0] [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: 05/26/2021] [Accepted: 06/27/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE Recovery protocols aim to limit narcotic administration following ventral hernia repair (VHR). However, little is known about the contribution of a protocol's individual components on patient outcomes. We previously reported that surgeon-performed transversus abdominis plane block (TAP-block) is more effective than ultrasound-guided TAP-block following VHR. This study evaluates the effectiveness of two postoperative analgesia modalities: epidural catheter and surgeon-performed TAP-block following VHR performed with transversus abdominis release (TAR). METHODS A retrospective analysis was performed on data prospectively collected between 2012 and 2019. All patients undergoing open VHR with TAR performed by a single surgeon were identified. Parastomal hernia repairs and any patients receiving ultrasound-guided TAP blocks or paraspinal blocks were excluded. Primary outcome was length of stay (LOS) with secondary outcomes including pain scores, opioid requirements, and 30-day morbidity. Linear regression was used to model LOS. RESULTS One hundred thirty-five patients met inclusion criteria (63 epidural, 72 TAP-block). The majority (67.4%) of patients were modified ventral hernia working group grade 2. The only statistically significant difference in postoperative pain scores between the groups was on postoperative day 2 (TAP block 3.19 versus epidural 4.11, p = 0.0126). LOS was significantly shorter in the TAP block group (4.7 versus 6.2 days, p = 0.0023) as was time to regular diet (3.2 versus 4.7 days, p < 0.0001). After controlling for confounders, epidural was associated with increased LOS by 1.3 days (p = 0.0004). CONCLUSION Epidural use following VHR with TAR is associated with increased LOS and increased time to regular diet without reducing pain or opioid use when compared to surgeon-performed TAP block.
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Affiliation(s)
- D J Morrell
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA
| | - J A Doble
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA
| | - B S Hendriksen
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA
| | - C M Horne
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA
| | - C S Hollenbeak
- Department of Health Policy and Administration, The Pennsylvania State University, University Park, PA, USA
| | - E M Pauli
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA.
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White B, Dahdaleh F, Naffouje SA, Kothari N, Berg J, Wiemann W, Salti GI. Impact of Enhanced Recovery After Surgery on Postoperative Outcomes for Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol 2021; 28:5265-5272. [PMID: 33469794 DOI: 10.1245/s10434-020-09476-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 12/01/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have been associated with significant morbidity and increased hospital length of stay (LOS). The authors report their experience after implementation of an enhanced recovery after surgery (ERAS) program for CRS-HIPEC. METHODS Outcomes were analyzed before and after ERAS implementation. The components of ERAS included preoperative carbohydrate loading, goal-directed fluid management, multimodal pain management, minimization of narcotic use, avoidance of nasogastric tubes, and early mobilization and feeding. RESULTS Of 168 procedures, 88 (52%) were in the pre-ERAS group and 80 (48%) were in the post-ERAS group. The two groups did not differ in terms of age, sex, comorbidities, peritoneal carcinomatosis index scores, completeness of cytoreduction, or operative time. The ERAS patients received fewer fluids intraoperatively (mean, 4.2 vs 6.4 L; p < 0.01). The mean LOS was 7.9 days post-ERAS compared with 10.0 days pre-ERAS (p = 0.015). Clavien-Dindo complications classified as grade ≥ 3 were lower after ERAS (23.7% vs 38.6%; p = 0.04). Moreover, the readmission rates remained the same (16.2% vs 13.6%; p = 0.635). CONCLUSIONS Implementation of an ERAS program for patients undergoing CRS-HIPEC is feasible and not associated with an increase in overall major complications or readmissions. These data support incorporation of ERAS protocols for CRS-HIPEC procedures.
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Affiliation(s)
- Bradley White
- Department of General Surgery, Division of Surgical Oncology, The University of Illinois at Chicago, 840 South Wood Street, M/C 820, Chicago, IL, 60612, USA
| | - Fadi Dahdaleh
- Department of Surgical Oncology, Edward-Elmhurst Health, Naperville, IL, USA
| | - Samer A Naffouje
- Department of Surgical Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Neerav Kothari
- Department of Anesthesia, University of Illinois Hospital and Health Sciences System, Chicago, IL, USA
| | - Jessica Berg
- Department of Surgical Oncology, Edward-Elmhurst Health, Naperville, IL, USA
| | - Wendy Wiemann
- Department of Surgical Oncology, Edward-Elmhurst Health, Naperville, IL, USA
| | - George I Salti
- Department of General Surgery, Division of Surgical Oncology, The University of Illinois at Chicago, 840 South Wood Street, M/C 820, Chicago, IL, 60612, USA. .,Department of Surgical Oncology, Edward-Elmhurst Health, Naperville, IL, USA.
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Said ET, Drueding RE, Martin EI, Furnish TJ, Meineke MN, Sztain JF, Abramson WB, Swisher MW, Jacobsen GR, Gosman AA, Gabriel RA. The Implementation of an Acute Pain Service for Patients Undergoing Open Ventral Hernia Repair with Mesh and Abdominal Wall Reconstruction. World J Surg 2021; 45:1102-1108. [PMID: 33454790 DOI: 10.1007/s00268-020-05915-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION In this retrospective cohort single-institutional study, we report the outcomes of implementing a standardized protocol of multimodal pain management with thoracic epidural analgesia via the acute pain service (APS) for patients undergoing ventral hernia repair with mesh placement and abdominal wall reconstruction. METHODS The primary outcome evaluated was postoperative 72-h opioid consumption, measured in intravenous morphine equivalents (MEQ). Secondary outcomes included hospital length of stay (LOS) among other outcomes. The two cohorts were the APS versus non-APS group, in which the former cohort had an APS providing epidural and multimodal analgesia and the latter utilized pain management per surgical team, which mostly consisted of opioid therapy. Using1:1 propensity-score-matched cohorts, Wilcoxon signed-rank test was used to calculate the differences in outcomes. A p < 0.05 was considered statistically significant. RESULTS There were 83 patients, wherein 51 (61.4%) were in the APS group. Between matched cohorts, the non-APS cohort's median [quartiles] total opioid consumption during the first three days was 85.6 mg MEQs [58.9, 112.8 mg MEQs]. The APS cohort was 31.7 mg MEQs [16.0, 55.3 mg MEQs] (p < 0.0001). The non-APS hospital LOS median [quartiles] was 5 days [4, 7 days] versus 4 days [4, 5 days] in the APS group (p = 0.01). DISCUSSION A dedicated APS was associated with decreased opioid consumption by 75%, as well as a decreased hospital LOS. We report no differences in ICU length of stay, time to oral intake, time to ambulation or time to urinary catheter removal.
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Affiliation(s)
- Engy T Said
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain Medicine, University of California, 9400 Campus Point Dr, MC 7770, La Jolla, San Diego, CA, 92037, USA
| | - Ross E Drueding
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain Medicine, University of California, 9400 Campus Point Dr, MC 7770, La Jolla, San Diego, CA, 92037, USA
| | - Erin I Martin
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain Medicine, University of California, 9400 Campus Point Dr, MC 7770, La Jolla, San Diego, CA, 92037, USA
| | - Timothy J Furnish
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain Medicine, University of California, 9400 Campus Point Dr, MC 7770, La Jolla, San Diego, CA, 92037, USA
| | - Minhthy N Meineke
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain Medicine, University of California, 9400 Campus Point Dr, MC 7770, La Jolla, San Diego, CA, 92037, USA
| | - Jacklynn F Sztain
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain Medicine, University of California, 9400 Campus Point Dr, MC 7770, La Jolla, San Diego, CA, 92037, USA
| | - Wendy B Abramson
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain Medicine, University of California, 9400 Campus Point Dr, MC 7770, La Jolla, San Diego, CA, 92037, USA
| | - Matthew W Swisher
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain Medicine, University of California, 9400 Campus Point Dr, MC 7770, La Jolla, San Diego, CA, 92037, USA
| | - Garth R Jacobsen
- Department of Surgery, Division of Minimally Invasive Surgery, University of California, La Jolla, San Diego, CA, USA
| | - Amanda A Gosman
- Department of Surgery, Division of Plastic Surgery, University of California, La Jolla, San Diego, CA, USA
| | - Rodney A Gabriel
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain Medicine, University of California, 9400 Campus Point Dr, MC 7770, La Jolla, San Diego, CA, 92037, USA.
- Department of Medicine, Division of Biomedical Informatics, University of California, 9400 Campus Point Dr, MC 7770, La Jolla, San Diego, CA, 92037, USA.
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Ueland W, Walsh-Blackmore S, Nisiewicz M, Davenport DL, Plymale MA, Plymale M, Roth JS. The contribution of specific enhanced recovery after surgery (ERAS) protocol elements to reduced length of hospital stay after ventral hernia repair. Surg Endosc 2020; 34:4638-4644. [PMID: 31705287 DOI: 10.1007/s00464-019-07233-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 10/28/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND Ventral hernia repair (VHR) is a commonly performed procedure that may be associated with prolonged hospitalization. Enhanced recovery after surgery (ERAS) protocols are intended to decrease hospital length of stay (LOS) and improve outcomes. This study evaluated the impact of compliance with individual VHR ERAS elements on LOS. METHODS With IRB approval, a medical record review (perioperative characteristics, clinical outcomes, compliance with ERAS elements) was conducted of open VHR consecutive cases performed in August 2013-July 2017. The ERAS protocol was implemented in August 2015; elements in place prior to implementation were accounted for in compliance review. Clinical predictors of LOS were determined through forward regression of log-transformed LOS. The effects of specific ERAS elements on LOS were assessed by adding them to the model in the presence of the clinical predictors. RESULTS Two-hundred and thirty-four patients underwent VHR (109 ERAS, 125 pre-ERAS). Across all patients, the mean LOS was 5.4 days (SD = 3.3). Independent perioperative predictors (P's < 0.05) of increased LOS were CDC Wound Class III/IV (38% increase above the mean), COPD (35%), prior infected mesh (21%), concomitant procedure (14%), mesh size (3% per 100 cm2), and age (8% increase per 10 years from mean age). Formal ERAS implementation was associated with a 15% or about 0.7 days (95% CI 6%-24%) reduction in mean LOS after adjustment. Compliance with acceleration of intestinal recovery was low (25.6%) as many patients were not eligible for alvimopan use due to preoperative opioids, yet when achieved, provided the greatest reduction in LOS (- 36%). CONCLUSIONS Implementation of an ERAS protocol for VHR results in decreased hospital LOS. Evaluation of the impact of specific ERAS element compliance to LOS is unique to this study. Compliance with acceleration of intestinal recovery, early postoperative mobilization, and multimodal pain management standards provided the greatest LOS reduction.
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Affiliation(s)
- Walker Ueland
- University of Kentucky College of Medicine, Lexington, KY, USA
| | | | | | | | | | | | - John S Roth
- Division of General Surgery, University of Kentucky, Lexington, KY, USA. .,Division of General Surgery, Department of Surgery, University of Kentucky, C 222, Chandler Medical Center, 800 Rose Street, Lexington, KY, 40536, USA.
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18
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Lode L, Oma E, Henriksen NA, Jensen KK. Enhanced recovery after abdominal wall reconstruction: a systematic review and meta-analysis. Surg Endosc 2020; 35:514-523. [PMID: 32974781 DOI: 10.1007/s00464-020-07995-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 09/14/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) are evidence-based protocols associated with improved patient outcomes. The use of ERAS pathways is well documented in various surgical specialties. The aim of this systematic review and meta-analysis was to examine the efficacy of ERAS protocols in patients undergoing abdominal wall reconstruction (AWR). METHODS This systematic review and meta-analysis were reported according to PRISMA and MOOSE guidelines. The databases PubMed, EMBASE, CINAHL, Web of Science and Cochrane Library were searched for original studies comparing ERAS with standard care in patients undergoing AWR. The primary outcome was length of stay (LOS) and secondary outcomes were readmission and surgical site infection (SSI) and/or surgical site occurrences (SSO). RESULTS Five studies were included in the meta-analysis. All were retrospective cohort studies including 453 patients treated according to ERAS protocols, and 494 patients treated according to standard care. The meta-analysis demonstrated that patients undergoing AWR managed with ERAS had a mean 0.89 days reduction in LOS compared with patients treated with standard care (95% CI - 1.70 to - 0.07 days, p = 0.03). There was no statistically significant difference in readmission rate (OR 1.00, 95% CI 0.53 to 1.87, p = 1.00) or SSI/SSO (OR 1.19, 95% CI 0.67 to 2.11, p = 0.56) between groups. CONCLUSIONS The use of ERAS in patients undergoing AWR was found to significantly reduce LOS without increasing the readmission rate or SSI/SSO. Based on the existing literature, ERAS protocols should be implemented for patients undergoing AWR.
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Affiliation(s)
- Lise Lode
- Department of Surgery, Herlev and Gentofte Hospital, Herlev Ringvej 75, 2730, Herlev, Denmark.
| | - Erling Oma
- Digestive Disease Center, Bispebjerg Hospital, Copenhagen, Denmark
| | - Nadia A Henriksen
- Department of Surgery, Herlev and Gentofte Hospital, Herlev Ringvej 75, 2730, Herlev, Denmark
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Peterman DE, Knoedler BP, Ewing JA, Carbonell AM, Cobb WS, Warren JA. Implementation of an Evidence-Based Protocol Significantly Reduces Opioid Prescribing After Ventral Hernia Repair. Am Surg 2020; 86:1602-1606. [PMID: 32833492 DOI: 10.1177/0003134820942207] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Increased recognition of the dangers of opioid analgesia has led to significant focus on strategies for reducing use through multimodal analgesia, enhanced recovery protocols, and standardized guidelines for prescribing. Our institution implemented a standard protocol for prescribing analgesics at discharge after ventral hernia repair (VHR). We hypothesize that this strategy significantly reduces opioid use. METHODS A standardized protocol for discharge prescribing was implemented in March 2018. Patients were prescribed ibuprofen, acetaminophen, and opioids based on milligram morphine equivalent (MME) use the 24 hours prior to discharge. We retrospectively reviewed prescriptions of opioids for two 6-month periods-July-December 2017 (PRE) and July-December 2018 (POST)-for comparison using EPIC report and the South Carolina Prescription Monitoring Program. Analysis performed included Mann-Kendall linear trend test and Student's t-test for continuous variables. RESULTS VHR was performed in 105 patients in the PRE and 75 patients in the POST group. Total MME prescribed decreased significantly from mean 322.7 + 261.3/median 225 (IQR 150-400) MME to 141.6 + 150.4/median 100 (50-184) MME (P < .001). This represents a 57% reduction in mean opioid MME prescriptions. Acetaminophen prescribing increased from 10% to 65%, and ibuprofen from 7.6% to 61.3%. Refills were prescribed in 21 patients (20%) during the PRE period, which decreased to 10.7% during the POST group (P = .141). Implementation of an evidence-based protocol significantly reduces opioid prescribing after VHR. DISCUSSION A multimodal approach to postoperative pain management decreases the need for opioids. The additional implementation of an evidence-based prescribing protocol results in significant reduction of opioid use following VHR.
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Affiliation(s)
- Diana E Peterman
- Department of Surgery, Prisma Health-Upstate, Greenville, SC, USA
| | - Bryan P Knoedler
- Department of Surgery, Division of Minimal Access, University of South Carolina School of Medicine, Greenville, SC, USA
| | - Joseph A Ewing
- Department of Surgery, Prisma Health-Upstate, Greenville, SC, USA
| | - Alfredo M Carbonell
- Department of Surgery, Division of Minimal Access, University of South Carolina School of Medicine, Greenville, SC, USA
| | - William S Cobb
- Department of Surgery, Division of Minimal Access, University of South Carolina School of Medicine, Greenville, SC, USA
| | - Jeremy A Warren
- Department of Surgery, Division of Minimal Access, University of South Carolina School of Medicine, Greenville, SC, USA
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Millard JL, Moraney R, Childs JC, Ewing JA, Carbonell AM, Cobb WS, Warren JA. Opioid Use After Inguinal and Ventral Hernia Repair. Am Surg 2020; 86:965-970. [PMID: 32779472 DOI: 10.1177/0003134820942179] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Recent data on opioid consumption indicate that patients typically require far less than is prescribed. Prisma Health Upstate Hernia Center adopted standardized postoperative prescribing after hernia repair and began tracking patient-reported opioid utilization. The aim of this study is to evaluate patient opioid use after hernia repair in order to guide future prescribing. METHODS All patients who underwent primary ventral (umbilical and epigastric), incisional, and inguinal hernia repair between February and May 2019 were reviewed. Patients reported the number of opioid pills taken at their first postoperative visit and documented either in the progress note or in the Americas Hernia Society Quality Collaborative (AHSQC) patient-reported outcomes (PRO) questionnaire. All demographic, operative, and outcomes data were captured prospectively in the AHSQC. Opioid use reported as milligram morphine equivalents (MME). RESULTS A total of 162 surgeries were performed during the study period, and 107 had patient-reported opioid use for analysis. Inguinal hernia repair was performed in 36 patients, 10 primary ventral hernia repairs, and 61 incisional hernia repairs. No opioid use was reported in 63.9% of inguinal hernias, 60% of primary ventral hernias, and 20% of incisional hernias. Inguinal hernia patients consumed a mean of 10.5 MME, primary ventral patients 11 MME, and incisional hernia patients 78.5 MME. CONCLUSION Patients require little to no opioid after primary ventral or inguinal hernia repair and opioid-free surgery is feasible. Incisional hernia is more heterogenous, but the majority of patients still required less opioid than previously thought.
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Affiliation(s)
- Jessica L Millard
- Department of Surgery, Prisma Health Upstate-Greenville Memorial, Greenville, SC, USA
| | - Robyn Moraney
- University of South Carolina School of Medicine-Greenville, Greenville, SC, USA
| | - Jordan C Childs
- Department of Surgery, Prisma Health Upstate: Summer Program for Undergraduate Research in Surgery, Greenville, SC, USA
| | - Joseph A Ewing
- Department of Surgery, Prisma Health Upstate-Greenville Memorial, Greenville, SC, USA
| | - Alfredo M Carbonell
- University of South Carolina School of Medicine-Greenville, Greenville, SC, USA
| | - William S Cobb
- University of South Carolina School of Medicine-Greenville, Greenville, SC, USA
| | - Jeremy A Warren
- University of South Carolina School of Medicine-Greenville, Greenville, SC, USA
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Sartori A, Botteri E, Agresta F, Gerardi C, Vettoretto N, Arezzo A, Pisanu A, Di Saverio S, Campanelli G, Podda M. Should enhanced recovery after surgery (ERAS) pathways be preferred over standard practice for patients undergoing abdominal wall reconstruction? A systematic review and meta-analysis. Hernia 2020; 25:501-521. [PMID: 32683579 DOI: 10.1007/s10029-020-02262-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/09/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE Although many studies assessing enhanced recovery after surgery (ERAS) pathways in abdominal wall reconstruction (AWR) have recently demonstrated lower rates of postoperative morbidity and a decrease in postoperative length of stay compared to standard practice, the utility of ERAS in AWR remains largely unknown. METHODS A systematic literature search for randomized and non-randomized studies comparing ERAS (ERAS +) pathways and standard protocols (Control) as an adopted practice for patients undergoing AWR was performed using MEDLINE, the Cochrane Central Register of Controlled Trials, Scopus, Web of Science, and EMBASE databases. A predefined search strategy was implemented. The included studies were reviewed for primary outcomes: overall postoperative morbidity, abdominal wall morbidity, surgical site infection (SSI), and length of hospital stay; and for secondary outcome: operative time, estimated blood loss, time to discontinuation of narcotics, time to urinary catheter removal, time to return to bowel function, time to return to regular diet, and readmission rate. Standardized mean difference (SMD) was calculated for continuous variables and Odds Ratio for dichotomous variables. RESULTS Five non-randomized studies were included for qualitative and quantitative synthesis. 840 patients were allocated to either ERAS + (382) or Control (458). ERAS + and Control groups showed equivalent results with regard to the incidence of postoperative morbidity (OR 0.73, 95% CI 0.32-1.63; I2= 76%), SSI (OR 1.17, 95% CI 0.43-3.22; I2= 54%), time to return to bowel function (SMD - 2.57, 95% CI - 5.32 to 0.17; I2= 99%), time to discontinuation of narcotics (SMD - 0.61, 95% CI - 1.81 to 0.59; I2= 97%), time to urinary catheter removal (SMD - 2.77, 95% CI - 6.05 to 0.51; I2= 99%), time to return to regular diet (SMD - 0.77, 95% CI - 2.29 to 0.74; I2= 98%), and readmission rate (OR 0.82, 95% CI 0.52-1.27; I2= 49%). Length of hospital stay was significantly shorter in the ERAS + compared to the Control group (SMD - 0.93, 95% CI - 1.84 to - 0.02; I2= 97%). CONCLUSIONS The introduction of an ERAS pathway into the clinical practice for patients undergoing AWR may cause a decreased length of hospitalization. These results should be interpreted with caution, due to the low level of evidence and the high heterogeneity.
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Affiliation(s)
- A Sartori
- Department of General Surgery, Montebelluna Civil Hospital, ULSS 2 Marca Trevigiana, Montebelluna, Italy.
| | - E Botteri
- Department of General Surgery, Montichiari Hospital, Montichiari, Italy
| | - F Agresta
- Department of General Surgery, Adria and Trecenta Civil Hospitals, ULSS 19, Adria, Italy
| | - C Gerardi
- Istituto di Ricerche Farmacologiche "Mario Negri" IRCCS, Milan, Italy
| | - N Vettoretto
- Department of General Surgery, Montichiari Hospital, Montichiari, Italy
| | - A Arezzo
- Department of Surgical Sciences, Università di Torino, Turin, Italy
| | - A Pisanu
- Department of Surgery, General and Emergency Surgery Unit, Azienda Ospedaliero-Universitaria, Cagliari University Hospital "Duilio Casula" University of Cagliari, Cagliari, Italy
| | - S Di Saverio
- Department of Surgery, University of Insubria, Varese, Italy
| | - G Campanelli
- Department of Medicine and Surgery, Istituto Clinico Sant'Ambrogio, University of Insubria, Milan, Italy
| | - M Podda
- Department of Surgery, General and Emergency Surgery Unit, Azienda Ospedaliero-Universitaria, Cagliari University Hospital "Duilio Casula" University of Cagliari, Cagliari, Italy
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Ebbehøj AL, Sparre P, Jensen KK. Recovery after laparoscopic parastomal hernia repair. Surg Endosc 2020; 35:2178-2185. [PMID: 32399941 DOI: 10.1007/s00464-020-07623-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 05/02/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The perioperative care and postoperative period after laparoscopic hernia repair have not been well described. The aim of this study was to describe the postoperative course after laparoscopic parastomal hernia repair. METHODS This was a prospective cohort study including consecutive patients undergoing laparoscopic parastomal hernia repair. The outcomes of interest were patient-reported pain, nausea and fatigue, time to stoma function, length of stay (LOS), use of transversus abdominis plane (TAP) block and epidural analgesia, the cumulative dose of morphine equivalent analgesics during the first 5 postoperative days, and postoperative complications. RESULTS Forty patients were included, 20% had ileostomy and 80% colostomy. The mesh was placed according to Sugarbaker (87.5%) and keyhole (12.5%) technique. Twenty-two patients (55%) required peripheral nervous blockades postoperatively. The median number of days to stoma function was 3 days (range 2-3.8). The mean cumulative dose of morphine equivalent analgesics was 21.9 mg on the day of surgery, 27.8 mg on the first postoperative day (POD1), 23.9 on POD2, 17.3 mg on POD3, 15.3 mg on POD4, 8.9 mg on POD5, and 115.2 mg in total. The median LOS was 4 days (range 3-6). The incidence of postoperative complications was 25%. CONCLUSION Laparoscopic parastomal hernia repair carried a high risk of complications. Further, analgesic treatment after surgery was insufficient, with high opioid requirements postoperatively, and more than half of the patients required peripheral nervous blockades, indicating that postoperative pain is a major issue in this patient group. Improved postoperative care for these patients is required.
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Affiliation(s)
- Anders L Ebbehøj
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark. .,Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Nielsine Nielsens Vej 41A, 2400, Copenhagen, NV, Denmark.
| | - Peter Sparre
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Kristian K Jensen
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
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Ndon S, Spock T, Torabi SJ, Manes RP. Patterns in Pain and Opiate Use after Endoscopic Sinus Surgery. Otolaryngol Head Neck Surg 2020; 162:969-978. [PMID: 32284006 DOI: 10.1177/0194599820915472] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To evaluate postoperative opiate use and patients' opinions regarding pain management after endoscopic sinus surgery (ESS). STUDY DESIGN Case series with planned data collection. SETTING Tertiary referral medical center. SUBJECTS AND METHODS We prospectively evaluated postoperative opiate utilization in adults undergoing ESS over a 2-year period at an academic medical facility. Exclusion criteria included use of nasal packing, intracranial or orbital procedures, tumor surgery, and any use of endoscopic drills. All patients underwent bilateral maxillary antrostomy, total ethmoidectomy, sphenoidotomy, and frontal sinusotomy with or without septoplasty. Patients were discharged with 30 oxycodone-acetaminophen (5-325 mg) and a survey assessing pain and narcotic/nonnarcotic use on postoperative days 0 to 7. RESULTS A total of 64 patients completed surveys. Mean ± SD narcotic use over the 7-day postoperative period was 7.7 ± 7.6 pills. Patients with high narcotic use (>6 pills total) had no differences in demographic or surgical factors from those with low use (≤6 pills) but did report a higher level of postoperative day 1 pain (4.8 ± 1.1 vs 2.0 ± 1.4, P < .001). Narcotic use declined during this period, with <30% of patients requiring narcotics by postoperative day 3. CONCLUSION Our results support reduced opiate prescription and encouragement of nonnarcotic use after ESS without compromising effective pain management.
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Affiliation(s)
- Sifon Ndon
- Department of Otolaryngology, UCSF School of Medicine, San Francisco, California, USA
| | - Todd Spock
- Department of Otolaryngology, Mount Sinai Health, New York, New York, USA
| | - Sina J Torabi
- Section of Otolaryngology, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - R Peter Manes
- Section of Otolaryngology, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
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Jensen KK, Brøndum TL, Leerhøy B, Belhage B, Hensler M, Arnesen RB, Kehlet H, Jørgensen LN. Preoperative, single, high-dose glucocorticoid administration in abdominal wall reconstruction: A randomized, double-blinded clinical trial. Surgery 2020; 167:757-764. [DOI: 10.1016/j.surg.2019.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 11/26/2019] [Accepted: 12/06/2019] [Indexed: 10/25/2022]
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BİRİCİK E, GÜNEŞ Y. Nörocerrahi ve Eras (Enhanced Recovery After Surgery). ARŞIV KAYNAK TARAMA DERGISI 2020. [DOI: 10.17827/aktd.604717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Enhanced recovery after surgery: A clinical review of implementation across multiple surgical subspecialties. Am J Surg 2020; 219:530-534. [DOI: 10.1016/j.amjsurg.2019.11.009] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 11/06/2019] [Accepted: 11/07/2019] [Indexed: 01/15/2023]
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Nassif GJ, Miller TE. Evolving the management of acute perioperative pain towards opioid free protocols: a narrative review. Curr Med Res Opin 2019; 35:2129-2136. [PMID: 31315466 DOI: 10.1080/03007995.2019.1646001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objective: Identification of pain as the fifth vital sign has resulted in over-prescription and overuse of opioids in the US, with addiction reaching epidemic proportions. In Europe, and more recently in the US, a shift has occurred with the global adoption of multimodal analgesia (MMA), which seeks to minimize perioperative opioid use. Improved functional outcomes and reduced healthcare utilization costs have been demonstrated with MMA, but wide scale use of opioids in pain management protocols continues. As a next step in the pain management evolution, opioid-free analgesia (OFA) MMA strategies have emerged as feasible in many surgical settings.Methods: Articles were limited to clinical studies and meta-analyses focusing on comparisons between opioid-intensive and opioid-free/opioid-sparing strategies published in English.Results: In this review, elimination or substantial reduction in opioid use with OFA strategies for perioperative acute pain are discussed, with an emphasis on improved pain control and patient satisfaction. Improved functional outcomes and patient recovery, as well as reduced healthcare utilization costs, are also discussed, along with challenges facing the implementation of such strategies.Conclusions: Effective MMA strategies have paved the way for OFA approaches to postoperative pain management, with goals to reduce opioid prescriptions, improve patient recovery, and reduce overall healthcare resource utilization and costs. However, institution-wide deployment and adoption of OFA is still in early stages and will require personalization and better management of patient expectations.
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Affiliation(s)
- George J Nassif
- AdventHealth Center of Colon and Rectal Surgery, Associate Professor of Surgery, University of Central Florida, Orlando, FL, USA
| | - Timothy E Miller
- Vascular and Transplant Anesthesia, Duke University School of Medicine, Durham, NC, USA
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Colvin J, Rosen M, Prabhu A, Rosenblatt S, Petro C, Zolin S, Krpata D. Enhanced recovery after surgery pathway for patients undergoing abdominal wall reconstruction. Surgery 2019; 166:849-853. [DOI: 10.1016/j.surg.2019.05.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/27/2019] [Accepted: 05/19/2019] [Indexed: 12/14/2022]
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Floriano D, Sahagian MJ, Chiavaccini L. Impact of epidural bupivacaine on perioperative opioid requirements, recovery characteristics, and duration of hospitalization in dogs undergoing cystotomy: A retrospective study of 56 cases. Vet Surg 2019; 48:1330-1337. [PMID: 31328291 DOI: 10.1111/vsu.13290] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 06/03/2019] [Accepted: 06/22/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To compare perioperative opioid consumption and duration of hospitalization (DOH) in anesthetized dogs receiving opioid-based analgesia (OBA) vs those receiving bupivacaine epidural-based analgesia (EPID) during cystotomy. STUDY DESIGN Retrospective cross-sectional study. ANIMALS Fifty-six client-owned dogs undergoing cystotomy. METHODS Clinical records of dogs undergoing cystotomy between January 2015 and December 2017 were reviewed. Demographic data, duration of anesthesia and surgery, anesthetic management, perioperative opioid consumption expressed in morphine equivalents (ME), perioperative use of adjuvant analgesics, time to first micturition, time to eat, time to ambulate, and DOH were recorded. Opioid consumption and DOH were compared with a Wilcoxon rank-sum test, followed by linear regression analysis as appropriate. Time to first micturition, time to eat, and time to walk unassisted were modeled with Cox-proportional hazard models. RESULTS Dogs treated with EPID during surgery required 1.5 mg/kg ME less compared with those treated with OBA (P = .04) during surgery. Three of 19 dogs treated with EPID vs 15 of 37 dogs receiving OBA required intraoperative adjuvant analgesics (P = .06). Dogs treated with EPID regained motor function slower than dogs treated with OBA (P = .01); however, there was no difference in time to urinate, time to eat, or DOH between treatments. CONCLUSION Perioperative lumbosacral epidural with bupivacaine reduced intraoperative opioid consumption in dogs anesthetized for cystotomy. CLINICAL SIGNIFICANCE The use of epidural bupivacaine in dogs undergoing cystotomy may reduce intraoperative opioid requirements without affecting return of bladder function or DOH.
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Affiliation(s)
- Dario Floriano
- Department of Clinical Studies, Matthew J. Ryan Veterinary Hospital, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael J Sahagian
- Department of Clinical Studies, Matthew J. Ryan Veterinary Hospital, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ludovica Chiavaccini
- Department of Molecular and Biomedical Sciences, North Carolina State University, Raleigh, North Carolina
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Enhanced recovery after surgical repair of incisional hernias. Hernia 2019; 24:3-8. [PMID: 31177341 DOI: 10.1007/s10029-019-01992-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 06/02/2019] [Indexed: 12/25/2022]
Abstract
AIM Enhanced recovery programmes (ERPs) were developed to improve the patient's post-operative comfort and reduce post-operative morbidity after several types of major surgery including the incisional hernia repair. The aim of this review was to describe the features of ERPs in the setting for incisional hernia repair. METHODS The literature review was conducted until March 2019, but retrieved very few papers (n = 4) on this topic. All studies were retrospective. RESULTS Setting and comorbidities of incisional hernia patients are of such importance in many cases that prehabilitation (including tobacco use cessation, management of obesity, diabetes or malnutrition) should play a greater role compared with other specialties. The other peri-operative measures are similar to other specialties but their implementation was very heterogeneous in the published studies. CONCLUSIONS Like in other surgeries, ERPs were feasible and probably efficient to improve the post-operative course of incisional hernia patients. But the level of evidence remains low.
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Nielsen MØ, Bjerg J, Dorfelt A, Jørgensen LN, Jensen KK. Short-term safety of preoperative administration of botulinum toxin A for the treatment of large ventral hernia with loss of domain. Hernia 2019; 24:295-299. [PMID: 31041556 DOI: 10.1007/s10029-019-01957-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 04/16/2019] [Indexed: 12/22/2022]
Abstract
PURPOSE Preoperative intramuscular-administered botulinum toxin A (BTA) in the lateral abdominal muscles prior to abdominal wall reconstruction has been reported to produce a flaccid paralysis and improve the primary closure rate of large ventral hernias with loss of domain. Complications to this treatment remain sparsely described. The aim of the current study was to report safety and short-term outcome of abdominal wall reconstruction aided by BTA administration. METHODS This was a retrospective two-center study including all patients undergoing abdominal wall reconstruction for ventral hernia aided by preoperative BTA administration to the lateral abdominal muscles. Data were retrieved from patient charts and included preoperative demographic and perioperative information as well as postoperative 30-day complications and readmissions. RESULTS A total of 37 patients underwent BTA administration prior to hernia repair. The mean age and body mass index were 59.5 (SD 10.1) years and 31.1 (SD 5.2) kg/m2. The BTA injections were administered mean 31.6 days (SD 10.0) prior to the hernia repair. One (2.7%) patient reported pain as a complication immediately after the BTA administration. Subsequent to the hernia repair, six (16.2%) patients were readmitted within 30 days. Nine patients (24.3%) had wound complications and medical complications occurred in seven (18.9%) patients. CONCLUSIONS We found early preoperative administration of BTA a safe adjunct to large ventral hernia repair, without adverse events related to the administration preoperative. Future studies should further highlight the efficacy of preoperative BTA for reconstruction of otherwise untreatable hernias.
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Affiliation(s)
- M Ø Nielsen
- Digestive Disease Center, Bispebjerg University Hospital, Bispebjerg Bakke 23, 2400, Copenhagen NV, Denmark.
| | - J Bjerg
- Department of Surgery, Odense University Hospital, Baagøes Alle 15, 5700, Svendborg, Denmark
| | - A Dorfelt
- Department of Surgery, Odense University Hospital, Baagøes Alle 15, 5700, Svendborg, Denmark
| | - L N Jørgensen
- Digestive Disease Center, Bispebjerg University Hospital, Bispebjerg Bakke 23, 2400, Copenhagen NV, Denmark
| | - K K Jensen
- Digestive Disease Center, Bispebjerg University Hospital, Bispebjerg Bakke 23, 2400, Copenhagen NV, Denmark
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Halawi MJ, Lieberman JR. Battling the opioid epidemic: lessons learned and management strategies. Arthroplast Today 2019; 5:2-4. [PMID: 31020012 PMCID: PMC6470326 DOI: 10.1016/j.artd.2018.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 10/01/2018] [Accepted: 10/04/2018] [Indexed: 11/28/2022] Open
Affiliation(s)
- Mohamad J Halawi
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, CT, USA
| | - Jay R Lieberman
- Department of Orthopaedic Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA.,American Association of Hip and Knee Surgeons, Rosemont, IL, USA
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Warren JA, Carbonell AM, Jones LK, Mcguire A, Hand WR, Cancellaro VA, Ewing JA, Cobb WS. Length of Stay and Opioid Dose Requirement with Transversus Abdominis Plane Block vs Epidural Analgesia for Ventral Hernia Repair. J Am Coll Surg 2019; 228:680-686. [DOI: 10.1016/j.jamcollsurg.2018.12.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 12/17/2018] [Indexed: 12/12/2022]
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Ueland W, Plymale MA, Davenport DL, Roth JS. Perioperative factors associated with pain following open ventral hernia repair. Surg Endosc 2019; 33:4102-4108. [PMID: 30805787 DOI: 10.1007/s00464-019-06713-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 02/19/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Effective pain control following open ventral and incisional hernia repair (VHR) impacts all aspects of patient recovery. To reduce opioid use and enhance pain management, multimodal therapy is thought to be beneficial. The purpose of this study was to identify patient characteristics associated with perioperative patient-reported pain scores. METHODS With IRB approval, surgical databases were searched for cases of open VHR performed over 3 years. Based on a retrospective chart review, modes of pain management and visual analog scale (VAS) pain scores were recorded in 12-h intervals to hospital discharge or to 8 days post-operation. Forward stepwise multivariable regression assessed the independent contribution of the perioperative factors to VAS pain scores. RESULTS Included in the analyses were 175 patients that underwent VHR. Average age was 55 years (+/- 12.8), and half were female (50.9%). Factors independently associated with increased preoperative VAS pain scores included preoperative opioid use, preoperative open wound, CDC Wound Class II, and prior hernia repair(s). Patients with epidural for postoperative pain had significantly decreased VAS pain scores across the time continuum. Operative factors significantly associated with increased preoperative VAS pain score included median hernia defect size, concomitantly performed procedure(s), duration of operation, and estimated blood loss. Greater preoperative VAS pain score predicted increased pain at each postoperative time point (all p < .05). CONCLUSIONS Preoperative pain and opioid use are associated with increased pain postoperatively. Epidural analgesia effectively results in decreased patient-reported pain. Increased operative complexity is associated with increased preoperative pain scores.
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Affiliation(s)
- Walker Ueland
- University of Kentucky College of Medicine, Lexington, KY, USA
| | - Margaret A Plymale
- Division of General Surgery, Department of Surgery, University of Kentucky College of Medicine, C 225, 800 Rose Street, Lexington, KY, 40536, USA.
| | - Daniel L Davenport
- Department of Surgery, University of Kentucky College of Medicine, Lexington, KY, USA
| | - John Scott Roth
- Division of General Surgery, Department of Surgery, University of Kentucky College of Medicine, C 225, 800 Rose Street, Lexington, KY, 40536, USA
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Abstract
Lack of physician familiarity with alternative pain control strategies is a major reason why opioids remain the most commonly used first-line treatment for pain after surgery. This is perhaps most problematic in abdominal wall reconstruction, where opioids may delay ambulation and return of bowel function, while negatively affecting mental status. In this article, we discuss multimodal strategies for optimal pain control in abdominal wall reconstruction. These strategies are straightforward and are proven to improve pain control while minimizing opioid-associated side effects.
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Persistent Opioid Use Among Children, Adolescents, and Young Adults After Common Cleft Operations. J Craniofac Surg 2018; 29:1697-1701. [PMID: 30059422 DOI: 10.1097/scs.0000000000004762] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Surgical care represents an important source of opioid prescribing and chronic use, but rates of prolonged opioid use following pediatric procedures remain unclear. The authors describe the rates and risk factors for new persistent opioid use in patients after common cleft operations. METHODS The authors examined claims from the Truven Marketscan databases from January 1, 2010 to December 31, 2014. The authors included opioid-naive patients ages 8 to 25, who underwent 1 of 10 cleft-related procedures. Patients were considered opioid-naïve if they had no opioid prescription fills in the 11 months prior to the perioperative period. The authors obtained a random sample of age-matched, nonsurgical patients from the same dataset to be used as a control group. Included cleft patients had no procedural codes in the 6 months following surgery. All included patients filled an opioid prescription during the perioperative period, defined as 30 days before and 14 days after surgery. The primary outcome was new persistent opioid use, which is defined as continued opioid prescription fills between 90 and 180 days after the procedure. RESULTS This cohort included 2039 cleft patients and 2100 control patients. The incidence of new persistent opioid use following surgery was 4.4% and 0.1% in the control group. Higher odds of opioid use 3 months beyond surgery were associated with distractor placement (OR 5.34, CI 2.00-14.24, P = 0.001). Increasing age (OR 1.11, CI 1.04-1.17, P = 0.001) and presence of a gastrointestinal comorbidity (OR 7.37, CI 1.49-36.54, P = 0.014) were also associated with new persistent use. CONCLUSIONS New persistent opioid use occurs after cleft-related procedures and could lead to chronic use in children, adolescents, and young adults.
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Hernandez MC, Panchamia J, Finnesgard EJ, Leiting JL, Franssen B, Saleem H, Kendrick ML, Nagorney DM, Truty MJ, Smoot RL. Transversus abdominis plane blocks with liposomal bupivacaine after open major hepatectomy is associated with reduced early patient-reported pain scores and opioid administration. Surgery 2018; 164:1251-1258. [PMID: 30201232 DOI: 10.1016/j.surg.2018.07.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 07/05/2018] [Accepted: 07/11/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Opioid overprescription can contribute to suboptimal patient outcomes. Surgeon-performed transversus abdominis plane blocks appear to be associated with pain reduction. We compared the analgesic efficacy of surgeon-performed transversus abdominis plane blocks for major hepatectomy with or without concurrent neuraxial analgesia. METHODS We performed a single-institution review, assessing surgeon-performed transversus abdominis plane blocks for major hepatectomy during 2013-2016. The primary outcome was patient-reported pain (11-point numeric pain-rating scale) and the secondary outcome was opioid consumption. Independent factors predictive of pain control were identified using logistic regression and reported as odds ratios with 95% confidence intervals. RESULTS A total of 232 patients with a mean (± SD) age of 56.5 (±13.9) years; 51.7% were female. Operative duration, incision type, and American Society of Anesthesiologists score were similar between groups. The 24-hour pain score was decreased substantially in patients who received a transversus abdominis plane block compared with those who did not (3 [2-4] versus 5 [4-6], P = .001) and this decrease in pain sscore persisted at 48 hours (2 [1-2] versus 4 [4-5], P = .001). In patients who received a transversus abdominis plane block, there were decreasess in consumption of oral morphine equivalents at 24 hours (322 [± 18] versus 183 [± 15], P = .0001) and 48 hours (100 [± 11] versus 33 [± 9.4], P = .03) compared with those without transversus abdominis plane block respectively. CONCLUSION In patients receiving a transversus abdominis plane block, early patient opioid consumption was decreased and utilization was predictive for improved pain control. Routine transversus abdominis plane block administration should be considered during major hepatectomy as a step toward curbing systematic reliance on opioids for pain management. A prospective study on the utility of transversus abdominis plane block in hepatectomy is warranted.
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Affiliation(s)
- Matthew C Hernandez
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jason Panchamia
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | - Eric J Finnesgard
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jennifer L Leiting
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Bernardo Franssen
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Humza Saleem
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Michael L Kendrick
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - David M Nagorney
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Mark J Truty
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Rory L Smoot
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA.
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Postoperative opioid prescribing: Getting it RIGHTT. Am J Surg 2018; 215:707-711. [DOI: 10.1016/j.amjsurg.2018.02.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 01/03/2018] [Accepted: 02/01/2018] [Indexed: 11/23/2022]
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