Enhanced recovery in liver surgery decreases postoperative outpatient use of opioids

Abstract

Background: Pathways of Enhanced Recovery in Liver Surgery (ERILS) decrease inpatient opioid use, however, there is little existing data regarding their effect on discharge prescriptions and post-discharge opioid intake. Methods: For consecutive patients undergoing liver resection from 2011-2018, clinicopathologic factors were compared between patients exposed to ERILS and traditional pathways. Multivariable analysis was used to determine factors predictive for traditional opioid use at the first postoperative follow-up. The ERILS protocol included opioid-sparing analgesia, goal-directed fluid therapy, early postoperative feeding, and early ambulation. Results: Of 244 cases, 147 ERILS patients were compared to 97 traditional pathway patients. ERILS patients were older (median 57 vs. 52 years, p=0.031) and more frequently had minimally invasive operations (37% vs. 16%, p<0.001), with fewer major complications (2% vs. 9%, p=0.011). ERILS patients were less likely to be discharged with a prescription for traditional opioids (26% vs. 79%, p<0.001) and less likely to require opioids at their first postoperative visit (19% vs. 61%, p<0.001) despite similarly low, patient-reported pain scores (median 2/10 both groups, p=0.500). On multivariable analysis, traditional recovery pathway were associated with traditional opioid use at first follow-up (OR 6.4, 95% CI 3.5-12.1; p<0.001). Conclusions: The implementation of an ERILS pathway with opioid-sparing techniques was associated with decreased postoperative discharge prescriptions for opioids and outpatient opioid use after oncologic liver surgery, while achieving the same level of pain control. For this and other

Reducing New Persistent Opioid Use After Surgery: A Review of Interventions

“…Implementation of the ERATS protocol resulted in a drastic reduction of new persistent opioid use without adversely affecting outcomes [ 13 ]. Similar longitudinal results have been reported in liver surgery [ 14 ], indicating potentially unrealized benefits of ERAS protocols that extend beyond discharge.…”

Risk-stratified posthepatectomy pathways based upon the Kawaguchi–Gayet complexity classification and impact on length of stay

“…Currently, enhanced recovery pathways are an advantageous contemporary perioperative care model for hepatectomy patients with benefits that include reduced LOS, decreased morbidity, decreased opioid use, and earlier recovery to baseline [ [3] , [4] , [5] , 23 , 24 ]. However, enhanced recovery pathways are often singular for all patients regardless of operative complexity.…”

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

“…Discharge prescriptions <200 mg OME were not associated with increased refill rates, as would be expected by nterventions reported by others at ours and other institutions have shown that implementation of opioid education and prescribing guidelines can effectively reduce the quantity of opioid prescribed for patients undergoing surgery for various indications. [17][18][19][20][21] Such interventions have centered on implementation of education for prescribers, evidence-based prescribing guidelines, and standardized patient instructions. 17,18,20,21 Implementation of enhanced recovery pathways that encompass opioid-sparing techniques has been widely…”