Postoperative Pain After Enhanced Recovery Pathway Robotic Colon and Rectal Surgery: Does Specimen Extraction Site Matter?

Brown, Rebecca; Brockhaus, Kara; Rajkumar, Dixy; Battaglia, Michael A; Cleary, Robert K.

doi:10.1097/dcr.0000000000001868

Cited by 12 publications

(12 citation statements)

References 25 publications

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“…Differences in enhanced recovery protocols and variation in surgeon expertise may be confounding factors. It is also possible that the intracorporeal anastomosis is utilized in a higher percentage of robotic-assisted than laparoscopic colectomies, resulting in less mesenteric traction and shorter incisions with less pain and opioid use [ 21 – 23 ]. The intracorporeal anastomosis is commonly used for robotic-assisted right colectomy and may also explain why right colectomy is associated with less long-term opioid use in this study [ 21 , 23 ].…”

Section: Discussionmentioning

confidence: 99%

A national database propensity score-matched comparison of minimally invasive and open colectomy for long-term opioid use

et al. 2021

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Background Opioid dependence is a public health crisis and surgery is a risk factor for long-term opioid use. Though minimally invasive surgery (MIS) is associated with less perioperative pain, demonstrating an association with less long-term opioid use would be another reason to justify adoption of minimally invasive techniques. We compared the rates for long-term opioid prescriptions among patients in a large national database who underwent minimally invasive and open colectomy. Methods Using the MarketScan Database, we retrospectively analyzed patients undergoing colon resection for benign and malignant diseases between 2013 and 2017. Among opioid-naïve patients who had ≥ 1 opioid prescriptions filled perioperatively (30 days before surgery to 14 days after discharge), propensity score matching was applied for group comparisons [open (OS) versus MIS, and laparoscopic (LS) versus robotic-assisted surgery (RS)]. The primary outcome was long-term opioid use defined as the proportion of patients with ≥ 1 long-term opioid prescriptions filled 90–180 days after discharge. Risks factors for long-term opioid use were assessed using logistic regression. Results Among the 5413 matched pairs in the MIS versus OS cohorts, MIS significantly reduced long-term opioid use of ‘any opioids’ (13.3% vs. 20.9%), schedule II/III opioids (11.7% vs. 19.2%), and high-dose opioids (4.3% vs. 7.7%; all p < 0.001). Among the 1195 matched pairs in the RS versus LS cohorts, RS was associated with less high-dose opioids (2.1% vs. 3.8%, p = 0.015) 90–180 days after discharge. Other risk factors for long-term opioid use included younger age, benign indications, tobacco use, mental health conditions, and > 6 Charlson comorbidities. Conclusion Minimally invasive colectomy is associated with a significant reduction in long-term opioid use when compared to OS. Robotic-assisted colectomy was associated with less high-dose opioids compared to LS. Increasing adoption of minimally invasive surgery for colectomy and including RS, where appropriate, may decrease long-term opioid use.

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Section: Discussionmentioning

confidence: 99%

A national database propensity score-matched comparison of minimally invasive and open colectomy for long-term opioid use

et al. 2021

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“…Each member of the perioperative interdisciplinary team provides valuable knowledge that contributes to opioid stewardship efforts. Where resources are available, perioperative pain management and opioid stewardship is ideally pharmacist-led, from preoperative evaluation through the inpatient stay and postdischarge follow-up [531]. Described below is an example of the teamwork required in a colorectal enhanced recovery pathway to minimize opioid use while effectively treating postoperative pain.…”

Section: From the Surgeon Perspectivementioning

confidence: 99%

“…The average number of 5 mg oxycodone tablets prescribed in those who received prescriptions was 6 to 8 while the average number used was 2.5 to 3 tablets. Only 0.5% to 0.75% of patients required opioid prescription refills [531].…”

Section: From the Surgeon Perspectivementioning

confidence: 99%

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

et al. 2021

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Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a “roadmap” for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.

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“…Pain and psychiatric diagnoses can complicate each other, and effects of psychotropic medications on postoperative pain are poorly understood, and neither are the interactions of multiple medications. This study did not show an association with increased MME requirement in patients with psychiatric diagnoses or using psychiatric medications on multivariate analysis.In 2021, Brown et al published a retrospective cohort study comparing Pfannenstiel extraction site incisions with other locations (on or off midline) in patients having robotic colorectal resections and found Pfannenstiel to be associated with similar postoperative pain and postoperative opioid use; however the prescription of nonopioid analgesics was signi cantly less in the Pfannenstiel group [27]. This study did not reveal an association between surgical approach and postoperative opioid use with open procedure being performed in 63.9% of cases.…”

mentioning

confidence: 59%

Male gender, smoking, younger age, and preoperative pain found to increase postoperative opioid requirements in 592 elective colorectal resections

Karlsdottir

Wahba

et al. 2022

Int J Colorectal Dis

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With increased awareness of the opioid epidemic, understanding contributing factors to postoperative opioid use is important. The purpose of this study was to evaluate patient and perioperative factors that contribute to postoperative opioid use after colorectal resections and their relation to pre-existing pain conditions and psychiatric diagnoses. MethodsA retrospective review was conducted identifying adult patients who underwent elective colorectal resection at a single tertiary center between 2015 and 2018. Patient demographics, preoperative factors, surgical approach, and perioperative pain management were evaluated to determine standard conversion morphine milligram equivalents required for postoperative days 0 to 3 and total hospital stay. ResultsFive hundred and ninety-two patients: 46% male, median age 58 years undergoing colorectal resections for indications including cancer, in ammatory bowel disease, and diverticulitis were identi ed. Less opioid use was found to be associated with female gender (β = -42), patients who received perioperative lidocaine infusion (β = -30), and older adults (equivalents/year) (β = -4, all p < 0.01). Preoperative opioid use, preoperative abdominal pain, epidural use and smoking were all independently associated with increased postoperative opioid requirements. ConclusionsIn this study of patients undergoing elective colorectal resection, factors that were associated with higher perioperative opioid use included male gender, smoking, younger age, preoperative opioid use, preoperative abdominal pain, and epidural use. Perioperative administration of lidocaine was associated with decreased opioid requirements. Understanding risk factors and stratifying postoperative pain regimens may aid in improved pain control and decrease long-term dependency.

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Postoperative Pain After Enhanced Recovery Pathway Robotic Colon and Rectal Surgery: Does Specimen Extraction Site Matter?

Cited by 12 publications

References 25 publications

A national database propensity score-matched comparison of minimally invasive and open colectomy for long-term opioid use

A national database propensity score-matched comparison of minimally invasive and open colectomy for long-term opioid use

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

Male gender, smoking, younger age, and preoperative pain found to increase postoperative opioid requirements in 592 elective colorectal resections

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