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Cavallaro PM, Bordeianou L. Development and Validation of a Symptom-Based Scoring System for Bowel Dysfunction After Ileoanal Pouch Reconstruction: The Ileoanal Pouch Syndrome Severity Score. Dis Colon Rectum 2023; 66:87-96. [PMID: 36441832 DOI: 10.1097/dcr.0000000000002663] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The Patient-Reported Outcomes After Pouch Surgery Delphi Consensus Study identified 7 symptoms and 7 consequences as key domains for evaluating and analyzing ileoanal pouch function. OBJECTIVE This study aimed to use items identified as priorities by the Patient-Reported Outcomes After Pouch Surgery Delphi Consensus Study to create a validated tool for quantifying pouch function. DESIGN Patients were administered a questionnaire-based survey eliciting responses regarding frequency of a variety of bowel symptoms. SETTING Patients with pouches were recruited at IBD centers and via patient advocacy websites. MAIN OUTCOME MEASURES Associations between items and quality of life were computed in a score generation cohort of 298 patients by logistic regression modeling. Individual score values were designated to items to create an additive score titled the Ileoanal Pouch Syndrome Severity Score. Validity was tested in a subsequent cohort of 386 patients using receiver operating characteristic area under the curve. In addition, test-retest validity, convergent validity, and clinical validity were evaluated. RESULTS After the determination of item weights, the range of possible scores was found to be 0 to 145. Score ranges were then determined as cutoff values for "ileoanal pouch syndrome." The score was then validated on the second patient cohort, with a receiver operating characteristic area under the curve of 0.83. Importantly, worsening severity of Ileoanal Pouch Syndrome Score significantly correlated with higher rates of poor quality of life. Finally, the questionnaire was rigorously validated to show test-retest validity, convergent validity compared to other bowel function scores, and clinical validity. CONCLUSIONS This study developed a patient-centered, clinically useful scoring system that can quantify the range and severity of symptoms experienced by patients with ileoanal pouches and their correlation with quality of life. DESARROLLO Y VALIDACIN DE UN SISTEMA DE PUNTUACIN BASADO EN SNTOMAS PARA LA DISFUNCIN INTESTINAL DESPUS DE LA RECONSTRUCCIN CON RESERVORIO ILEOANAL LA PUNTUACIN DE GRAVEDAD DEL SNDROME DE RESERVORIO ILEOANAL ANTECEDENTES:En el estudio Delphi Consensus los resultados informados por el paciente después de la cirugía de reservorio identificaron 7 síntomas y 7 consecuencias como dominios clave para evaluar y analizar la función del reservorio ileoanal.OBJETIVO:Utilizar elementos identificados como prioritarios por el estudio de consenso Delphi de resultados informados por el paciente después de la cirugía de reservorio para crear una herramienta validada para cuantificar la función del reservorio.DISEÑO:A los pacientes se les administró una encuesta basada en un cuestionario que obtuvo respuestas con respecto a la frecuencia de una variedad de síntomas intestinales.ESCENARIO:Los pacientes con reservorio fueron reclutados en centros de enfermedad inflamatoria intestinal y a través de sitios web dirigidos al paciente.PRINCIPALES MEDIDAS DE RESULTADO:Las asociaciones entre los elementos y la calidad de vida se calcularon en una cohorte de generación de puntuación de 298 pacientes mediante un modelo de regresión logística. Se asignaron valores de puntuación individuales a los elementos para crear una puntuación aditiva denominada Puntuación de gravedad del síndrome de reservorio ileoanal. La validez se probó en una cohorte posterior de 386 pacientes utilizando el área característica operativa del receptor bajo la curva. Además, se evaluaron la validez del test-retest, la validez convergente y la validez clínica.RESULTADOS:Después de determinar el peso de los elementos, el rango de puntajes posibles fue de 0 a 145. Los rangos de puntaje se determinaron luego como valores de corte para el "síndrome de la reservorio ileoanal". A continuación, la puntuación se validó en la segunda cohorte de pacientes, con un área característica operativa del receptor bajo la curva de 0.3. Es importante destacar que el empeoramiento de la gravedad de la puntuación del síndrome de reservorio ileoanal se correlacionó significativamente con tasas más altas de mala calidad de vida. Por último, el cuestionario fue rigurosamente validado para mostrar validez test-retest, validez convergente en comparación con otras puntuaciones de función intestinal y validez clínica.CONCLUSIONES:Este estudio desarrolló un sistema de puntuación clínicamente útil y centrado en el paciente que puede cuantificar el rango y la gravedad de los síntomas experimentados por los pacientes con reservorio ileoanal y su correlación con la calidad de vida. (Traducción-Dr. Jorge Silva Velazco ).
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Affiliation(s)
- Paul M Cavallaro
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Liliana Bordeianou
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
- Division of Gastrointestinal and Oncologic Surgery, Section of Colon and Rectal Surgery, Massachusetts General Hospital, Boston, Massachusetts
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Cavallaro PM, Fearnhead NS, Bissett IP, Brar MS, Cataldo TE, Clarke R, Denoya P, Elder AL, Gecse KB, Hendren S, Holubar S, Jeganathan N, Myrelid P, Norton BA, Wexner SD, Wilson L, Zaghiyan K, Bordeianou L. Patients Undergoing Ileoanal Pouch Surgery Experience a Constellation of Symptoms and Consequences Representing a Unique Syndrome: A Report From the Patient-Reported Outcomes After Pouch Surgery (PROPS) Delphi Consensus Study. Ann Surg 2021; 274:138-145. [PMID: 33914449 PMCID: PMC8968673 DOI: 10.1097/sla.0000000000004829] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The primary aim was to create a patient-centered definition of core symptoms that should be included in future studies of pouch function. BACKGROUND Functional outcomes after ileoanal pouch creation have been studied; however, there is great variability in how relevant outcomes are defined and reported. More importantly, the perspective of patients has not been represented in deciding which outcomes should be the focus of research. METHODS Expert stakeholders were chosen to correlate with the clinical scenario of the multidisciplinary team that cares for pouch patients: patients, colorectal surgeons, gastroenterologists/other clinicians. Three rounds of surveys were employed to select high-priority items. Survey voting was followed by a series of online patient consultation meetings used to clarify voting trends. A final online consensus meeting with representation from all 3 expert panels was held to finalize a consensus statement. RESULTS One hundred ninety-five patients, 62 colorectal surgeons, and 48 gastroenterologists/nurse specialists completed all 3 Delphi rounds. Fifty-three patients participated in online focus groups. One hundred sixty-one stakeholders participated in the final consensus meeting. On conclusion of the consensus meeting, 7 bowel symptoms and 7 consequences of undergoing ileoanal pouch surgery were included in the final consensus statement. CONCLUSIONS This study is the first to identify key functional outcomes after pouch surgery with direct input from a large panel of ileoanal pouch patients. The inclusion of patients in all stages of the consensus process allowed for a true patient-centered approach in defining the core domains that should be focused on in future studies of pouch function.
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Affiliation(s)
- Paul M. Cavallaro
- Department of General Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Nicola S. Fearnhead
- Department of Colorectal Surgery, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom
| | - Ian P. Bissett
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Mantaj S. Brar
- Division of General Surgery, Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Thomas E. Cataldo
- Division of Colon and Rectum Surgery, Beth Israel-Deaconess Health Medical Center, Harvard Medical School, Boston, Massachusetts
| | | | - Paula Denoya
- Division of Colon and Rectal Surgery, Department of Surgery, Stony Brook University Hospital. Stony Brook, New York
| | | | - Krisztina B. Gecse
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Samantha Hendren
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Stefan Holubar
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Nimalan Jeganathan
- Department of Surgery, Division of Colon and Rectal Surgery, Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Pär Myrelid
- Department of Surgery, County Council of Östergötland, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Beth-Anne Norton
- Crohn’s and Colitis Center, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Steven D. Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida
| | - Lauren Wilson
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Karen Zaghiyan
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Liliana Bordeianou
- Massachusetts General Hospital Colorectal Surgery and Crohn’s Colitis Centers, Department of Gastrointestinal Surgery and Surgical Oncology, Boston, Massachusetts
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Ji YD, Cavallaro PM, Orgill BD. Perioperative considerations in the management of cold agglutinin disease in laparoscopic surgery. BMJ Case Rep 2021; 14:14/5/e241294. [PMID: 33980554 PMCID: PMC8118000 DOI: 10.1136/bcr-2020-241294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
An 80-year-old man with idiopathic cold agglutinin disease presented with acute cholecystitis. We describe operating room and anaesthetic considerations for patients with cold agglutinin disease and measures that can be taken to prevent disease exacerbation in this case report. Multidisciplinary collaboration and planning between the operative room staff, anaesthesia team and surgical team are needed to ensure safe surgery and optimal patient outcomes.
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Affiliation(s)
- Yisi D Ji
- Harvard Medical School, Boston, Massachusetts, USA
| | - Paul M Cavallaro
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Britlyn D Orgill
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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Perez NP, Chang DC, Goldstone RN, Bordeianou L, Ricciardi R, Cavallaro PM. Relationship Between Diverticular Disease and Incisional Hernia After Elective Colectomy: a Population-Based Study. J Gastrointest Surg 2021; 25:1297-1306. [PMID: 32748338 PMCID: PMC7854815 DOI: 10.1007/s11605-020-04762-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 05/21/2020] [Accepted: 07/19/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Recent genetic studies identified common mutations between diverticular disease and connective tissue disorders, some of which are associated with abdominal wall hernias. Scarce data exists, however, shedding light on the potential clinical implications of this shared etiology, particularly in the era of laparoscopic surgery. METHODS The New York Statewide Planning and Research Cooperative System database was used to identify adult patients undergoing elective sigmoid and left hemicolectomy (open or laparoscopic) from January 1, 2010, to December 31, 2016, for diverticulitis or descending/sigmoid colon cancer. The incidences of incisional hernia diagnosis and repair were compared using competing risks regression models, clustered by surgeon and adjusted for a host of demographic/clinical variables. Subsequent abdominal surgery and death were considered competing risks. RESULTS Among 8279 patients included in the study cohort, 6811 (82.2%) underwent colectomy for diverticulitis and 1468 (17.8%) for colon cancer. The overall 5-year risk of incisional hernia was 3.5% among patients with colon cancer, regardless of colectomy route, which was significantly lower than that among diverticulitis patients after both open (10.7%; p < 0.001) and laparoscopic (7.2%; p = 0.007) colectomies. Multivariable analyses demonstrated that patients with diverticulitis experienced a two-fold increase in the risk for hernia diagnosis (aHR 1.8; p < 0.001) and repair (aHR 2.1; p < 0.001), and these findings persisted after stratification by colectomy route. CONCLUSIONS Patients undergoing elective colectomy for diverticulitis, including via laparoscopic approach, experience higher rates of incisional hernia compared with patients undergoing similar resections for colon cancer. When performing resections for diverticulitis, surgeons should strongly consider adherence to evidence-based guidelines for fascial closure to prevent this important complication.
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Affiliation(s)
- Numa P. Perez
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA,Healthcare Transformation Lab, Massachusetts General Hospital, Boston, MA, USA
| | - David C. Chang
- Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Rocco Ricciardi
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Paul M. Cavallaro
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
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Liu Y, Cavallaro PM, Kim BM, Liu T, Wang H, Kühn F, Adiliaghdam F, Liu E, Vasan R, Samarbafzadeh E, Farber MZ, Li J, Xu M, Mohad V, Choi M, Hodin RA. A role for intestinal alkaline phosphatase in preventing liver fibrosis. Am J Cancer Res 2021; 11:14-26. [PMID: 33391458 PMCID: PMC7681079 DOI: 10.7150/thno.48468] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/27/2020] [Indexed: 12/12/2022] Open
Abstract
Rationale: Liver fibrosis is frequently associated with gut barrier dysfunction, and the lipopolysaccharides (LPS) -TLR4 pathway is common to the development of both. Intestinal alkaline phosphatase (IAP) has the ability to detoxify LPS, as well as maintain intestinal tight junction proteins and gut barrier integrity. Therefore, we hypothesized that IAP may function as a novel therapy to prevent liver fibrosis. Methods: Stool IAP activity from cirrhotic patients were determined. Common bile duct ligation (CBDL) and Carbon Tetrachloride-4 (CCl4)-induced liver fibrosis models were used in WT, IAP knockout (KO), and TLR4 KO mice supplemented with or without exogenous IAP in their drinking water. The gut barrier function and liver fibrosis markers were tested. Results: Human stool IAP activity was decreased in the setting of liver cirrhosis. In mice, IAP activity and genes expression decreased after CBDL and CCl4 exposure. Intestinal tight junction related genes and gut barrier function were impaired in both models of liver fibrosis. Oral IAP supplementation attenuated the decrease in small intestine tight junction protein gene expression and gut barrier function. Liver fibrosis markers were significantly higher in IAP KO compared to WT mice in both models, while oral IAP rescued liver fibrosis in both WT and IAP KO mice. In contrast, IAP supplementation did not attenuate fibrosis in TLR4 KO mice in either model. Conclusions: Endogenous IAP is decreased during liver fibrosis, perhaps contributing to the gut barrier dysfunction and worsening fibrosis. Oral IAP protects the gut barrier and further prevents the development of liver fibrosis via a TLR4-mediated mechanism.
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Abstract
While fecal incontinence and constipation can be measured through physiological testing, the subjective experience of severity and impact on health-related quality of life lead to both being most effectively captured through patient-reported measures. Patient-reported measures of severity and impact help to determine baseline symptoms, guide clinical decision making, and compare various treatments. Here, we take pause to review the psychometric qualities that make effective instruments, and discuss some of the most commonly used instruments along with the reasons behind their use. In addition, we highlight the benefits of a standardized instrument designed to evaluate the major symptoms of patients presenting with pelvic floor disorders (including fecal incontinence and constipation). Ultimately, we aim to provide guidance in choosing appropriate instruments for clinical and research use.
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Affiliation(s)
- Cameron W. Hunt
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Paul M. Cavallaro
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Liliana G. Bordeianou
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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Cavallaro PM, Fields AC, Bleday R, Kaafarani H, Yao Y, Sequist TD, Ahmed KF, Rubin M, Ricciardi R, Bordeianou LG. A multi-center analysis of cumulative inpatient opioid use in colorectal surgery patients. Am J Surg 2020; 220:1160-1166. [PMID: 32684292 DOI: 10.1016/j.amjsurg.2020.06.038] [Citation(s) in RCA: 5] [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: 02/11/2020] [Revised: 03/27/2020] [Accepted: 06/25/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND There are little data on risk factors for increased inpatient opioid use and its relationship with persistent opioid use after colorectal surgery. METHODS We identified colorectal surgery patients across five collaborating institutions. Patient comorbidities, surgery data, and outcomes were captured in the American College of Surgeons National Surgical Quality Improvement Program. We recorded preoperative opioid exposure, inpatient opioid use, and persistent use 90-180 days after surgery. RESULTS 1646 patients were analyzed. Patients receiving ≥250 MMEs (top quartile) were included in the high use group. On multivariable analysis, age <65, emergent surgery, inflammatory bowel disease, and postoperative complications, but not prior opioid exposure, were predictive of high opioid use. Patients in the top quartile of use had an increased risk of persistent opioid use (19.8% vs. 9.7%, p < 0.001), which persisted on multivariable analysis (OR 1.48; p = 0.037). CONCLUSIONS We identified risk factors for high inpatient use that can be used to identify patients that may benefit from opioid sparing strategies. Furthermore, high postoperative inpatient use was associated with an increased risk of persistent opioid use.
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Affiliation(s)
- Paul M Cavallaro
- Colorectal Surgery Center, Department of General and Gastrointestinal Surgery, Massachusetts General Hospital, USA
| | - Adam C Fields
- Division of Colorectal Surgery, Brigham and Women's Hospital, USA
| | - Ronald Bleday
- Division of Colorectal Surgery, Brigham and Women's Hospital, USA
| | - Haytham Kaafarani
- Department of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, USA
| | | | | | | | - Marc Rubin
- Colorectal Surgery, North Shore Medical Center, USA
| | - Rocco Ricciardi
- Colorectal Surgery Center, Department of General and Gastrointestinal Surgery, Massachusetts General Hospital, USA
| | - Liliana G Bordeianou
- Colorectal Surgery Center, Department of General and Gastrointestinal Surgery, Massachusetts General Hospital, USA.
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Kühn F, Adiliaghdam F, Cavallaro PM, Hamarneh SR, Tsurumi A, Hoda RS, Munoz AR, Dhole Y, Ramirez JM, Liu E, Vasan R, Liu Y, Samarbafzadeh E, Nunez RA, Farber MZ, Chopra V, Malo MS, Rahme LG, Hodin RA. Intestinal alkaline phosphatase targets the gut barrier to prevent aging. JCI Insight 2020; 5:134049. [PMID: 32213701 PMCID: PMC7213802 DOI: 10.1172/jci.insight.134049] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 02/20/2020] [Indexed: 12/16/2022] Open
Abstract
Gut barrier dysfunction and gut-derived chronic inflammation play crucial roles in human aging. The gut brush border enzyme intestinal alkaline phosphatase (IAP) functions to inhibit inflammatory mediators and also appears to be an important positive regulator of gut barrier function and microbial homeostasis. We hypothesized that this enzyme could play a critical role in regulating the aging process. We tested the role of several IAP functions for prevention of age-dependent alterations in intestinal homeostasis by employing different loss-of-function and supplementation approaches. In mice, there is an age-related increase in gut permeability that is accompanied by increases in gut-derived portal venous and systemic inflammation. All these phenotypes were significantly more pronounced in IAP-deficient animals. Oral IAP supplementation significantly decreased age-related gut permeability and gut-derived systemic inflammation, resulted in less frailty, and extended lifespan. Furthermore, IAP supplementation was associated with preserving the homeostasis of gut microbiota during aging. These effects of IAP were also evident in a second model system, Drosophilae melanogaster. IAP appears to preserve intestinal homeostasis in aging by targeting crucial intestinal alterations, including gut barrier dysfunction, dysbiosis, and endotoxemia. Oral IAP supplementation may represent a novel therapy to counteract the chronic inflammatory state leading to frailty and age-related diseases in humans.
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Affiliation(s)
- Florian Kühn
- Department of Surgery, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, Massachusetts, USA
- Department of General, Visceral and Transplant Surgery, Hospital of the University of Munich, Munich, Germany
| | - Fatemeh Adiliaghdam
- Department of Surgery, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, Massachusetts, USA
| | - Paul M. Cavallaro
- Department of Surgery, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, Massachusetts, USA
| | - Sulaiman R. Hamarneh
- Department of Surgery, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, Massachusetts, USA
| | - Amy Tsurumi
- Department of Surgery, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, Massachusetts, USA
| | | | - Alexander R. Munoz
- Department of Surgery, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, Massachusetts, USA
| | - Yashoda Dhole
- Department of Surgery, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, Massachusetts, USA
| | - Juan M. Ramirez
- Department of Surgery, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, Massachusetts, USA
| | - Enyu Liu
- Department of Surgery, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, Massachusetts, USA
| | - Robin Vasan
- Department of Surgery, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, Massachusetts, USA
| | - Yang Liu
- Department of Surgery, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, Massachusetts, USA
| | - Ehsan Samarbafzadeh
- Department of Surgery, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, Massachusetts, USA
| | - Rocio A. Nunez
- Department of Surgery, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew Z. Farber
- Department of Surgery, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, Massachusetts, USA
| | - Vanita Chopra
- Department of Neurology,, MGH, Harvard Medical School, Boston, Massachusetts, USA
| | - Madhu S. Malo
- Department of Surgery, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, Massachusetts, USA
| | - Laurence G. Rahme
- Department of Surgery, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, Massachusetts, USA
- Shriners Hospital for Children, Boston, Massachusetts, USA
- Department of Microbiology and Immunobiology, Harvard Medical School, Boston, Massachusetts, USA
| | - Richard A. Hodin
- Department of Surgery, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, Massachusetts, USA
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Fields AC, Weiner SG, Maldonado LJ, Cavallaro PM, Melnitchouk N, Goldberg J, Stopfkuchen-Evans MF, Baker O, Bordeianou LG, Bleday R. Implementation of liposomal bupivacaine transversus abdominis plane blocks into the colorectal enhanced recovery after surgery protocol: a natural experiment. Int J Colorectal Dis 2020; 35:133-138. [PMID: 31797098 DOI: 10.1007/s00384-019-03457-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/11/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) programs are now standard of care for colorectal surgery. Efforts have been aimed at decreasing postoperative opioid consumption. The goal of this study is to evaluate the effect of liposomal bupivacaine transversus abdominis plane (TAP) blocks on opioid use and its downstream effect on rates of ileus and hospital length of stay (LOS). METHODS We performed a retrospective pre- and postintervention time-trend analysis (2016-2018) of ERAS patients undergoing laparoscopic colorectal surgery at two academic medical centers within the same hospital system. The intervention was liposomal bupivacaine TAP blocks versus standard local infiltration with bupivacaine with a primary outcome of total morphine milligram equivalents (MME) administered within 72 h of surgery. Secondary outcomes included hospital LOS and rate of postoperative ileus. RESULTS There were 556 patients included at the control hospital, and 384 patients were included at the treatment hospital. Patients at both hospitals were similar with regard to age, body mass index, comorbidities, and surgical indication. In an adjusted time-trend analysis, the treatment hospital was associated with a significant decrease in MME administered (- 15.9 mg, p = 0.04) and hospital LOS (- 0.8 days, p < 0.001). There was no significant decrease in the rate of ileus at the treatment hospital (- 6.9%, p = 0.08). CONCLUSIONS In a time-trend analysis, the addition of liposomal bupivacaine TAP blocks into the ERAS protocol resulted in significantly reduced opioid use and shorter hospital LOS for patients undergoing surgery at the treatment hospital. Liposomal bupivacaine TAP blocks should be considered for inclusion in the standard ERAS protocol.
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Affiliation(s)
- Adam C Fields
- Division of Colorectal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- Department of Quality and Safety, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Scott G Weiner
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Luisa J Maldonado
- Division of Colorectal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Paul M Cavallaro
- Division of Colorectal Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Nelya Melnitchouk
- Division of Colorectal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Joel Goldberg
- Division of Colorectal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Olesya Baker
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Liliana G Bordeianou
- Division of Colorectal Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ronald Bleday
- Division of Colorectal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Cavallaro PM, Milch H, Savitt L, Hodin RA, Rattner DW, Berger DL, Kunitake H, Bordeianou LG. Addition of a scripted pre-operative patient education module to an existing ERAS pathway further reduces length of stay. Am J Surg 2018; 216:652-657. [DOI: 10.1016/j.amjsurg.2018.07.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 04/03/2018] [Accepted: 07/17/2018] [Indexed: 01/20/2023]
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