1
|
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.
Collapse
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
| |
Collapse
|
2
|
Lee L, Kelly J, Nassif GJ, deBeche-Adams TC, Albert MR, Monson JRT. Defining the learning curve for transanal total mesorectal excision for rectal adenocarcinoma. Surg Endosc 2018; 34:1534-1542. [PMID: 29998391 DOI: 10.1007/s00464-018-6360-4] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 07/06/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Early observational data suggest that this approach is safe and feasible, but it is technically challenging and the learning curve has not yet been determined. The objective of this study was to determine the number of cases required achieve proficiency in transanal total mesorectal excision (TA-TME) for rectal adenocarcinoma. METHODS All TA-TME cases performed from 03/2012-01/2017 at a single high-volume tertiary care institution for rectal adenocarcinoma were included. A cumulative summation (CUSUM) analysis was performed to determine the number of cases required to reach proficiency, defined as high-quality TME (complete or near-complete mesorectal envelope, negative distal (DRM), and circumferential resection (> 1 mm; CRM) margin). The acceptable and unacceptable rates of good quality TME were defined based on the incidence of high-quality TME in laparoscopic (unacceptable rate = 81.7%) and open (acceptable rate = 86.9%) arms of the ACOSOG Z6051 trial. RESULTS A total of 87 consecutive cases were included with mean tumor height 4.8 cm (SD 2.7) and 80% (70/87) received neoadjuvant chemoradiation. Post-operative morbidity occurred in 44% (38/87) of cases, including 21% (18/87) readmissions. Median length of stay was 4 days [IQR 3-8]. A good quality TME was performed in 95% (83/87) of cases including 98% (85/87) negative CRM, 99% (86/87) negative DRM, and 99% (86/87) complete or near-complete mesorectal envelope. CUSUM analysis reported that the good quality TME rate reaches an acceptable rate after 51 cases overall, and 45 cases if abdominoperineal resections are excluded. CONCLUSION TA-TME is a complex technique that requires a minimum of 45-51 cases to reach an acceptable incidence of high-quality TME and lower operative duration.
Collapse
Affiliation(s)
- Lawrence Lee
- Center for Colon and Rectal Surgery, Florida Hospital, 2415 N Orange Ave, suite 102, Orlando, FL, 32804, USA.
| | - Justin Kelly
- Center for Colon and Rectal Surgery, Florida Hospital, 2415 N Orange Ave, suite 102, Orlando, FL, 32804, USA
| | - George J Nassif
- Center for Colon and Rectal Surgery, Florida Hospital, 2415 N Orange Ave, suite 102, Orlando, FL, 32804, USA
| | - Teresa C deBeche-Adams
- Center for Colon and Rectal Surgery, Florida Hospital, 2415 N Orange Ave, suite 102, Orlando, FL, 32804, USA
| | - Matthew R Albert
- Center for Colon and Rectal Surgery, Florida Hospital, 2415 N Orange Ave, suite 102, Orlando, FL, 32804, USA
| | - John R T Monson
- Center for Colon and Rectal Surgery, Florida Hospital, 2415 N Orange Ave, suite 102, Orlando, FL, 32804, USA
| |
Collapse
|
3
|
Lee L, Wong-Chong N, Kelly JJ, Nassif GJ, Albert MR, Monson JRT. Minimally invasive surgery for stage III colon adenocarcinoma is associated with less delay to initiation of adjuvant systemic therapy and improved survival. Surg Endosc 2018; 33:460-470. [PMID: 29967992 DOI: 10.1007/s00464-018-6319-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 06/29/2018] [Indexed: 01/29/2023]
Abstract
BACKGROUND Minimally invasive surgery (MIS) may improve surgical recovery and reduce time to adjuvant systemic therapy after colon cancer resection. The objective of this study was to determine the effect of MIS on the initiation of adjuvant systemic therapy and survival in patients with stage III colon cancer. METHODS The 2010-2014 National Cancer Database was queried for patients with resected stage III colon adenocarcinoma, and divided into MIS, which included laparoscopic and robotic approaches, and open surgery. Propensity-score matching was used to balanced open and MIS groups. The main outcome measures were delayed initiation of adjuvant systemic therapy (defined as > 8 weeks after surgery) and 5-year overall survival (OS). Multiple Cox regression was performed to identify independent predictors for 5-year OS, including an interaction between delayed systemic therapy and MIS, and adjusted for clustering at the hospital level. RESULTS There were 86,680 patients that were included in this study. Overall, 45% (38,713) underwent MIS colectomy, of which 93% underwent laparoscopic and 7% robotic surgery. After matching, 33,183 open patients were balanced to 33,183 MIS patients. Patient, tumor, and facility characteristics were similar in the matched cohort. More patients in the MIS group received adjuvant therapy within 8 weeks of surgery (49% vs. 42%, p < 0.001), and fewer MIS patients did not receive any systemic therapy (30% vs. 35%, p < 0.001). Delayed initiation of systemic therapy > 8 weeks was associated with worse 5-year OS (HR 1.27, 95%CI 1.19-1.36). MIS was independently associated with improved survival (HR 0.92, 95%CI 0.86-0.97). This relationship remained even if 90-day mortality was excluded. CONCLUSIONS MIS approaches are associated with less delay to the initiation of adjuvant systemic therapy and improved survival in patients with stage III colon adenocarcinoma. Surgeons should favor MIS approaches for the treatment of stage III colon adenocarcinoma whenever possible.
Collapse
Affiliation(s)
- Lawrence Lee
- Center for Colon and Rectal Surgery, Florida Hospital, Orlando, FL, USA. .,Department of Surgery, McGill University Health Centre, Montreal, QC, Canada. .,Colon and Rectal Surgery, McGill University Health Centre, 1001 Decarie Blvd, DS1-3310, Montreal, QC, H4A 3J1, Canada.
| | - Nathalie Wong-Chong
- Department of Surgery, McGill University Health Centre, Montreal, QC, Canada.,Colon and Rectal Surgery, McGill University Health Centre, 1001 Decarie Blvd, DS1-3310, Montreal, QC, H4A 3J1, Canada
| | - Justin J Kelly
- Center for Colon and Rectal Surgery, Florida Hospital, Orlando, FL, USA
| | - George J Nassif
- Center for Colon and Rectal Surgery, Florida Hospital, Orlando, FL, USA
| | - Matthew R Albert
- Center for Colon and Rectal Surgery, Florida Hospital, Orlando, FL, USA
| | - John R T Monson
- Center for Colon and Rectal Surgery, Florida Hospital, Orlando, FL, USA
| |
Collapse
|
4
|
Lee L, Kelly J, Nassif GJ, Atallah SB, Albert MR, Shridhar R, Monson JRT. Chemoradiation and Local Excision for T2N0 Rectal Cancer Offers Equivalent Overall Survival Compared to Standard Resection: a National Cancer Database Analysis. J Gastrointest Surg 2017; 21:1666-1674. [PMID: 28819913 DOI: 10.1007/s11605-017-3536-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 08/04/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Local excision (LE) alone is associated with worse survival compared to radical surgery (RS) for T2 rectal cancer, but LE with additional chemoradiation (CRT) may improve outcomes. The objective of this study was to compare combined CRT and LE versus RS for T2 rectal cancer. METHODS The 2004-2014 National Cancer Database was queried for patients with T2N0M0 rectal cancer undergoing LE with neoadjuvant(NA-CRT + LE) or adjuvant(LE + Adj-CRT) CRT, or RS. The main outcome was 5-year overall survival (OS). Cox proportional hazards was used to determine the independent effect of treatment on OS. RESULTS A total of 4822 patients were included (4367 RS, 242 CRT + LE, 213 LE + Adj-CRT). Mean follow-up was 48.6 (SD28.5) months. There were no differences in patient characteristics, but more high-risk features in the LE + Adj-CRT group. There were no differences in 90-day mortality. Five-year OS was similar (RS 77.4% vs. CRT + LE 76.1% vs. LE + Adj-CRT 79.7%, p = 0.786). Older age, male gender, and higher Charlson score were independently associated with worse OS, whereas treatment type was not. If 90-day mortality was excluded, LE + Adj-CRT was independently associated with worse OS compared to RS. CONCLUSIONS CRT with LE for T2N0M0 rectal cancer was not associated with worse OS compared to RS, and may be a viable treatment modality.
Collapse
Affiliation(s)
- Lawrence Lee
- Center for Colon and Rectal Surgery, Florida Hospital, 2401 North Orange Ave, Suite 240, Orlando, FL, 32804, USA.
| | - Justin Kelly
- Center for Colon and Rectal Surgery, Florida Hospital, 2401 North Orange Ave, Suite 240, Orlando, FL, 32804, USA
| | - George J Nassif
- Center for Colon and Rectal Surgery, Florida Hospital, 2401 North Orange Ave, Suite 240, Orlando, FL, 32804, USA
| | - Sam B Atallah
- Center for Colon and Rectal Surgery, Florida Hospital, 2401 North Orange Ave, Suite 240, Orlando, FL, 32804, USA
| | - Matthew R Albert
- Center for Colon and Rectal Surgery, Florida Hospital, 2401 North Orange Ave, Suite 240, Orlando, FL, 32804, USA
| | - Ravi Shridhar
- Department of Radiation Oncology, Florida Hospital, Orlando, FL, USA
| | - John R T Monson
- Center for Colon and Rectal Surgery, Florida Hospital, 2401 North Orange Ave, Suite 240, Orlando, FL, 32804, USA
| |
Collapse
|
5
|
Lee L, Kelly J, Nassif GJ, Keller D, Debeche-Adams TC, Mancuso PA, Monson JR, Albert MR, Atallah SB. Establishing the learning curve of transanal minimally invasive surgery for local excision of rectal neoplasms. Surg Endosc 2017; 32:1368-1376. [PMID: 28812153 DOI: 10.1007/s00464-017-5817-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 08/03/2017] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Transanal minimally invasive surgery (TAMIS) is an endoscopic operating platform for local excision of rectal neoplasms. However, it may be technically demanding, and its learning curve has yet to be adequately defined. The objective of this study was to determine the number of TAMIS procedures for the local excision of rectal neoplasm required to reach proficiency. METHODS AND PROCEDURES All TAMIS cases performed from 07/2009 to 12/2016 at a single high-volume tertiary care institution for local excision of benign and malignant rectal neoplasia were identified from a prospective database. A cumulative summation (CUSUM) analysis was performed to determine the number of cases required to reach proficiency. The main proficiency outcome was rate of margin positivity (R1 resection). The acceptable and unacceptable R1 rates were defined as the R1 rate of transanal endoscopic microsurgery (TEM-10%) and traditional transanal excision (TAE-26%), which was obtained from previously published meta-analyses. Comparisons of patient, tumor, and operative characteristics before and after TAMIS proficiency were performed. RESULTS A total of 254 TAMIS procedures were included in this study. The overall R1 resection rate was 7%. The indication for TAMIS was malignancy in 57%. CUSUM analysis reported that TAMIS reached an acceptable R1 rate between 14 and 24 cases. Moving average plots also showed that the mean operative times stabilized by proficiency gain. The mean lesion size was larger after proficiency gain (3.0 cm (SD 1.5) vs. 2.3 cm (SD 1.3), p = 0.008). All other patient, tumor, and operative characteristics were similar before and after proficiency gain. CONCLUSIONS TAMIS for local excision of rectal neoplasms is a complex procedure that requires a minimum of 14-24 cases to reach an acceptable R1 resection rate and lower operative duration.
Collapse
Affiliation(s)
- Lawrence Lee
- Center for Colon and Rectal Surgery, Department of Surgery, Florida Hospital, 2501 North Orange Ave, suite 240, Orlando, FL, 32804, USA.
| | - Justin Kelly
- Center for Colon and Rectal Surgery, Department of Surgery, Florida Hospital, 2501 North Orange Ave, suite 240, Orlando, FL, 32804, USA
| | - George J Nassif
- Center for Colon and Rectal Surgery, Department of Surgery, Florida Hospital, 2501 North Orange Ave, suite 240, Orlando, FL, 32804, USA
| | - Deborah Keller
- Department of Surgery, Baylor University Medical Center, Dallas, TX, USA
| | - Teresa C Debeche-Adams
- Center for Colon and Rectal Surgery, Department of Surgery, Florida Hospital, 2501 North Orange Ave, suite 240, Orlando, FL, 32804, USA
| | - Paul A Mancuso
- Center for Colon and Rectal Surgery, Department of Surgery, Florida Hospital, 2501 North Orange Ave, suite 240, Orlando, FL, 32804, USA
| | - John R Monson
- Center for Colon and Rectal Surgery, Department of Surgery, Florida Hospital, 2501 North Orange Ave, suite 240, Orlando, FL, 32804, USA
| | - Matthew R Albert
- Center for Colon and Rectal Surgery, Department of Surgery, Florida Hospital, 2501 North Orange Ave, suite 240, Orlando, FL, 32804, USA
| | - Sam B Atallah
- Center for Colon and Rectal Surgery, Department of Surgery, Florida Hospital, 2501 North Orange Ave, suite 240, Orlando, FL, 32804, USA
| |
Collapse
|