General Surgery

DATA ANALYSIS

• Patient Reported Outcomes data collected via Michigan Surgical Quality Collaborative
• January 1, 2018 – October 31, 2021
• 609 Opioid Naïve Patients from 55 Michigan Hospitals

SUPPORTING LITERATURE

Haskins et al 2021 (Level 3 evidence)

• DOI: https://doi.org/10.1007/s00464-022-09123-y
• Analyzed data from 17,530 patients who underwent laparoscopic fundoplication, hiatal hernia repair, or Heller myotomy from 2010 to 2018.
• 9652 patients had at least one opioid prescription filled in the perioperative period.
• 0.4% were found to have persistent postoperative opioid use at 365 days postoperatively.
• The risk of progression to persistent postoperative opioid use was less than 1%.
• Persistent postoperative opioid use was most common during the first 30 days.

DATA ANALYSIS

Enterolysis – Laparoscopic

• Patient Reported Outcomes data collected via Michigan Surgical Quality Collaborative
• January 1, 2018 – October 31, 2021
• 64 Opioid Naive Patients from 31 Michigan Hospitals

SUPPORTING LITERATURE

Chiem et al. 2022 (Level 2 evidence)

• DOI: https://doi.org/10.1097/pq9.0000000000000548
• 641 patients (3yo-18yo) were assigned to study groups based on time period, and were given either standard anesthesia, multimodal anesthesia, or opioid-free anesthesia for inguinal hernia repair. Pain scores were measured.
• Opioids can be safely minimized without sacrificing satisfaction with pain management. Only 12% of patients required a rescue dose of morphine in PACU.

Hageman et al. 2022 (Level 3 evidence)

• DOI: https://doi.org/10.1016/j.jpedsurg.2022.02.039
• Retrospective review of 15 studies were compared with a retrospective review of patients at the authors’ institution. Opioid use was analyzed.
• Opioids were mostly administered while admitted during the first 24h after surgery. One institution used opioids sparingly in PACU and successfully eliminated opioid prescriptions at discharge.

Svetanoff et al. 2022 (Level 2 evidence)

• DOI: https://doi.org/10.1016/j.jpedsurg.2021.10.012
• Patients were contacted 1-4 weeks after different day surgeries and were surveyed about opioid use. Results between procedure types were compared.
• 89% of inguinal hernia patients filled opioid scripts at discharge, and 91% of those opioids went unused. 94% of patients using non-opioid pain relief methods were satisfied with pain management.

DATA ANALYSIS

Transanal Excision of Rectal Tumor

• Patient Reported Outcomes data collected via Michigan Surgical Quality Collaborative
• January 1, 2018 – October 31, 2021
• 71 Opioid Naive Patients from 19 Michigan Hospitals

SUPPORTING LITERATURE

Swaraup et al. 2018 (Level 3 evidence)

• DOI: https://doi.org/10.1016/j.jss.2018.04.005
• Analyzed opioid prescribing trends and patient use of opioids for 42 outpatient anorectal operations at a single institution from May 2016-April 2017. Procedures included 6 transanal excision of rectal tumors.
• 90% were prescribed opioids postoperatively with a median of 20 pills (range 0-120 pills)
• For those prescribed an opioid, the median number of pills taken was 4.
• 80% of pills prescribed were not used.
• Most patients had adequate pain control after surgery with little to no use of opioids.

DATA ANALYSIS

Thyroidectomy

• Patient Reported Outcomes data collected via Michigan Surgical Quality Collaborative
• January 1, 2018 – October 31, 2021
• 814 Opioid Naive Patients from 57 Michigan Hospitals

SUPPORTING LITERATURE

Lou, I. 2017

• DOI: https://doi.org/10.1245/s10434-017-5781-y
• Annals of surgical oncology
• Analyzed data from patients undergoing thyroid and parathyroid surgery at two large academic institutions from 1 January-30 May 2014.
• 83% of patients took ten or fewer OMEs, and 93% took 20 or fewer OMEs.
  

Shindo et al. 2018

• DOI: 10.1001/jamaoto.2018.2427
• Analyzed data from 1702 individuals who underwent thyroid and parathyroid surgery as a single institution from 1 January 2012-31 December 2017.
• 57.5% were discharged without any opioid prescription for parathyroidectomy, 37.5% for hemithyroidectomy, and 33.3% for total thyroidectomy.
• Recommended prescription = “little, if any, postoperative opioids”

Sada, A. The Journal of surgical research. 2020. (Level 3 Evidence)

• https://doi.org/10.1016/j.jss.2019.07.039
• Analyzed data from patients undergoing parathyroidectomy at three institutions between 13 March 2017 – 19 January 2018
• A total of 91 patients were included; 90% were opioid-naive.
• Median prescribed was 10 pills but median consumed was 0 pills
• Over 50% of patients undergoing parathyroidectomy did not consume any opioid, and very few needed more than 2 doses of opioid.
• Top users reported higher pain scores than standard users
• Of those receiving a prescription, 94.6% had left-over opioids at the time of survey meaning that 82% of prescribed opioids were unused.

DATA ANALYSIS

Laparscopic Appendectomy

• Patient Reported Outcomes data collected via Michigan Surgical Quality Collaborative
• January 1, 2018 – October 31, 2021
• 3887 Opioid Naive Patients from 70 Michigan Hospitals

SUPPORTING LITERATURE

Dr. Robert Bree Collaborative & Agency Medical Directors’ Group (Level 4 evidence)

• Prescribing Opioids for Postoperative Pain — Supplemental Guidance 2018
• Reviewed data collected from academics, pain experts, and practicing surgeons.
• Recommended prescription = 0-12 tablets

DATA ANALYSIS

Laparoscopic Cholecystectomy

• Patient Reported Outcomes data collected via Michigan Surgical Quality Collaborative
• January 1, 2018 – October 31, 2021
• 9877 Opioid Naive Patients from 70 Michigan Hospitals

Open Cholecystectomy

• Patient Reported Outcomes data collected via Michigan Surgical Quality Collaborative
• January 1, 2018 – October 31, 2021
• 242 Opioid Naive Patients from 50 Michigan Hospitals

SUPPORTING LITERATURE

Hlavin et al. 2022 (Level 2 evidence)

• DOI: https://doi.org/10.3390/jcm11185453
• Analyzed data from veterans at the Veteran’s Affairs Pittsburgh Healthcare System (VAPHS) who underwent a cholecystectomy, inguinal hernia repair, or an umbilical hernia repair between November 2019-October 2020
• Recommended opioid prescription for cholecystectomy: 8 pills
• Number of days prescribed = 2.8

DATA ANALYSIS

Laparoscopic Colectomy

• Patient Reported Outcomes data collected via Michigan Surgical Quality Collaborative
• January 1, 2018 – October 31, 2021
• 1735 Opioid Naive Patients from 65 Michigan Hospitals

Open Colectomy

• • Patient Reported Outcomes data collected via Michigan Surgical Quality Collaborative
  • January 1, 2018 – October 31, 2021
  • 1262 Opioid Naive Patients from 69 Michigan Hospitals

SUPPORTING LITERATURE

Vu et al. 2022 (Level 3 evidence)

• DOI: http://doi.org/10.1097/SLA.0000000000004240
• Retrospective observational study of patients undergoing minimally invasive or open colectomy from January 2017- May 2018. Analyzed data from 562 patients at 43 institutions.
• No difference in opioid consumption or likelihood of using no opioids between open vs minimally invasive colectomy. discharge. The size of the postoperative prescription, patient age, and diagnosis are more important in determining opioid use.
• Age > 65yo and diagnosis of cancer/adenoma were associated with less opioid use
• Patients only used 28% of the opioid tablets prescribed

Nguyen et al. 2019 (Level 2 evidence)

• DOI: https://doi.org/10.1016/j.jsurg.2019.11.010
• Prospective cohort study of opioid naive patients who underwent general surgery at a single institution between November 2017- February 2018.
• Patients who underwent laparoscopic surgery were prescribed 18.3% fewer MME.
• Smaller prescription amounts were not associated with an increased rate of opioid refills.
• 19.1% of patients who were given a prescription did not fill it and patients were not less likely to fill their prescriptions after opioid counseling.

Bleicher et al. 2021 (Level 3 evidence)

• DOI: http://doi.org/10.1016/j.jss.2021.01.048
• Retrospective study of 596 patients who underwent major abdominal surgery at a single institution. Assessed inpatient opioid use and discharge prescriptions.
• Median length of stay = 3.5 days
• Discharge prescription = 5.1 days
• Lack of patient-centered opioid prescribing led to an over- and under prescribing of opioids for patients.

Eurosurg Collaborative 2019 (Level 3 evidence)

• DOI: 10.1002/bjs.11326
• Cohort study including 4164 patients undergoing elective colorectal resection between January- April 2018
• Mean time to gastrointestinal recovery did not differ significantly between patients who received NSAIDs and those who did not
• Mean recovery time for patients receiving NSAIDS = 4-6 days
• Mean recovery time for patients not receiving NSAIDS = 4-8 days
• Conclusion: NSAIDs did not reduce recovery time after colorectal surgery, but they did reduce postoperative opioid requirement.

SUPPORTING LITERATURE

Marti et al. 2021 (Level 2 evidence)

• DOI: https://doi.org/10.3390/jcm11185453
• Retrospective chart review comparing pain management in a historical cohort (control) compared to pain management in a test cohort that used multimodal analgesia
• Multimodal cohort patients had lower pain scores on POD 0, POD 1, and POD 2 compared to historical cohort patients using opioid PCA

Brown et al. 2019 (Level 2 evidence)

• DOI: 10.1308/rcsann.2019.0172
• Analyzed data from 81 patients undergoing laparoscopic living-donor nephrectomy over a 25-month period at a single institution between 17 April 2013 and 20 May 2015.
• All patients up to 8 October 2013 received standard perioperative care while the rest followed an enhanced recovery protocol.
• Standard care = Analgesia provided with six-hourly intravenous paracetamol and patient-controlled morphine administration as required.
• Enhanced recovery = No intravenous fluid was administered. Patients were given a carbohydrate drink and received counseling prior to surgery. Analgesia was six-hourly intravenous paracetamol with oral oxycodone administration for breakthrough pain as required.
• Administered intraoperative fluid volume and time spent in the post-anesthetic care unit was relatively similar between the standard and the enhanced recovery group
• Conclusion: “Enhanced recovery for living-donor nephrectomy is a safe approach for donors and recipients.”

Dong et al 2022 (Level 2 evidence)

• DOI: https://doi.org/10.1016/j.jclinane.2022.110751
• Retrospective analysis of 929 laparoscopic donor nephrectomy patients at a single institution from 3 April 2019- 9 June 2020
• Adoption of ERAS protocol led to a significant reduction in intraoperative fentanyl use and a significant increase in intraoperative
  hydromorphone use.
• ERAS protocol = +/− fentanyl 50μg for induction and intubation, hydromorphone 0.4 mg 10 min prior to incision, acetaminophen 1000 mg, ketorolac 30 mg per surgeon if estimated blood loss (EBL) was less than 300 ml and titrate hydromorphone 0.2 to 0.4 mg as needed at conclusion of surgery.
• Saw a significant reduction in opioid use with ERAS protocol, but no change in pain scores

Talwar et al. 2020 (Level 2 evidence)

• DOI: https://doi.org/10.1089/end.2019.0362
• Analyzed data from 170 patients undergoing laparoscopic donor nephrectomy at a single institution between September 2018- January 2019
• Implemented a standardized nonopioid analgesia pathway
• 87 patients underwent robot-assisted radical prostatectomy (RARP), 25 patients underwent robot-assisted radical nephrectomy (RARN), and 58 patients underwent robot-assisted partial nephrectomy (RAPN)
• Before September 2018, 100% of patients were discharged on varying amounts of oxycodone (range: 75–337.5 MME)
• After implementation:
  • 67.7% were discharged without opioids
  • 24.4% were discharged with 10 pills of tramadol (50 MME)
  • 8.2% were discharged with 10 pills of oxycodone (75 MME)
• Needed for opioids at discharge decreased with older age
• No difference in pain scores between those discharged with and without opioids
• Conclusion: “The majority of robotic surgery patients do not require opioids upon discharge”

DATA ANALYSIS

Enterostomy Closure – Laparoscopic

• Patient Reported Outcomes data collected via Michigan Surgical Quality Collaborative
• January 1, 2018 – October 31, 2021
• 55 Opioid Naive Patients from 26 Michigan Hospitals

DATA ANALYSIS

Gastrorrhaphy

• Patient Reported Outcomes data collected via Michigan Surgical Quality Collaborative
• January 1, 2018 – October 31, 2021
• 66 Opioid Naive Patients from 30 Michigan Hospitals

DATA ANALYSIS

Minor Hernia Repair

• Patient Reported Outcomes data collected via Michigan Surgical Quality Collaborative
• January 1, 2018 – October 31, 2021
• 11473 Opioid Naive Patients from 70 Michigan Hospitals

Major Hernia Repair

• Patient Reported Outcomes data collected via Michigan Surgical Quality Collaborative
• January 1, 2018 – October 31, 2021
• 1604 Opioid Naive Patients from 68 Michigan Hospitals

SUPPORTING LITERATURE

Lindros et al. 2022 (Level 2 evidence)

• DOI: https://doi.org/10.1016/j.jss.2022.09.021
• Implementation of a patient-tailored opioid prescribing guideline for patients undergoing ventral hernia surgery at a single institution between March 2018-December 2019.
• Assessed opioid utilization and patient reported outcomes of 163 patients
• MME prescribed at discharge was lower for patients receiving guideline-based care (median = 65) than standard care (median = 100)
• The odds of receiving an opioid prescription after discharge did not differ between the groups. Pain scores did not differ
• Conclusion: patients who received tailored guideline prescriptions were discharged with lower dosages and did not require more opioid refills than patients receiving standard opioid prescriptions.
  

Gentle et al. 2022 (Level 3 evidence)

• DOI: https://doi.org/10.1007/s10029-022-02708-5
• Analyzed data from 490 patients who underwent a laparoscopic inguinal hernia repair (LIHR) at a single institution between March 2019- March 2021
• Collected information on opioid prescriptions at discharge and opioid refills
• Median number of tablets prescribed = 12 – 12% of patients were prescribed ≤ 5 tablets, 31% were prescribed 6-10 tablets, 40% 11-15 tablets, and 17% > 15 tablets – 46% of patients reported using 0 tablets after discharge, 70% reported using ≤ 4 tablets, and 84% reported using no more than 10 tablets
• Only 4% requested a refill and there was a 12% increase in odds of opioid refill for every 1 tablet of oxycodone prescribed at discharge
• Recommended prescription: 0-10 tablets
• Conclusion: “Most patients use fewer opioid tablets than prescribed” and “requests for opioid refills are rare following LIHR (4%)”

Ciampa et al. 2022 (Level 2 evidence)

• DOI: 10.1007/s00464-022-09464-8.
• Collected data on pre-intervention and post-intervention prescribing habits for patients undergoing hernia repair surgery between 31 December 2018- 11 December 2020. Postoperative surveys were administered to all patients during or after 2-week postoperative visit.
• Included data from 131 patients
• Average prescription size decreased from 12.29 tablets to 6.8 tablets per surgery after intervention.
• Percentage of unused pills decreased from 70.5% pre-intervention to 48.5% post-intervention
• No increase in number of refills between pre- and post-intervention
• Patients reported higher satisfaction with current surgeries compared to prior surgeries.
• Recommended prescription for inguinal hernia surgery = 5-7 tablets
• Recommended prescription for ventral hernia surgery = 4.5-8.5 tablets

Knight et al. 2019 (Level 3 evidence)

• DOI: https://doi-org.proxy.lib.umich.edu/10.1053/j.jfas.2022.01.022
• Analyzed data from 195 opioid-naive patients undergoing open or minimally invasive surgery (MIS) inguinal hernia repair at three institutions between 13 March 2017- 19 January 2018
• Included unilateral and bilateral hernia repairs
• Overall patient cohort stopped utilizing opioids 3.2 ± 4.0 days after inguinal hernia repair
• Median opioids consumed after 26 days post-discharge = 2 tablets
• 91.6% of patients had opioids left over after 26 days post-discharge
• Opioid prescription and consumption were similar for open and MIS inguinal hernia repair
• Both groups had similar amounts of unused opioids (open 16 vs minimally invasive 15)
• More than 1/3 of patients required no opioids after discharge (38% of open patients and 44% of MIS patients did not consume opioids)
• Recommended prescription for open and MIS hernia repair = 0-8 tablets

DATA ANALYSIS

Ileostomy/colostomy Creation, re-siting, or closure

• Patient Reported Outcomes data collected via Michigan Surgical Quality Collaborative
• January 1, 2018 – October 31, 2021
• 379 Opioid Naive Patients from 56 Michigan Hospitals

SUPPORTING LITERATURE

Aryaie et al. 2018 (Level 1 evidence)

• DOI: https://doi.org/10.1007/s00464-018-6062-y
• Randomized study in which 97 patients undergoing colorectal surgery received either IV acetaminophen or placebo in addition to opioid PCA.
• Mean opioid consumption in study group = 2.86 ± 0.24 pills at 24hrs and 4.6 ± 0.44 pills at 48hrs
• Mean opioid consumption in control group = 4.9 ± 0.55 pills at 24 hrs and 7.96 ± 0.9 pills at 48 hrs
• Conclusion: IV acetaminophen helps to reduce opioid consumption for patients undergoing colorectal surgery.

Meyer et al. 2020 (Level 3 evidence)

• DOI: http://doi.org/10.1097/SLA.0000000000005025
• Cohort study of elective colorectal operations at a single institution from September 2019-Febuary 2020. Included 201 patients (100 patients before and 101 after guideline adoption).
• Saw a 41% reduction in mean prescription quantity and 53% reduction in excess pills per prescription.
• Saw no change in opioid consumption or refill rates
• Mean quantity of opioids prescribed after guideline adoption = 10.3 pills
• Mean opioid consumption after guideline adoption = 5.2 pills

DATA ANALYSIS

Pancreatectomy

• Patient Reported Outcomes data collected via Michigan Surgical Quality Collaborative
• January 1, 2018 – October 31, 2021
• 105 Opioid Naive Patients from 20 Michigan Hospitals

SUPPORTING LITERATURE

Kluger et al. 2021 (Level 3 evidence)

• DOI: https://doi.org/10.1016/j.hpb.2021.10.021
• Analyzed data from 8325 patients undergoing pancreatomy between 2009-2017
• 35.6% used opioids within the year prior to surgery.
• Median used by opioid naive patients = 53.5 pills
• Median used by chronic opioid patients = 240 pills
• 15.1% of opioid naive patients used opioids, 77.3% of chronic opioid users used opioids, and 27.2% of intermittent users used opioids.
• Those who were prescribed ≥ 200 pills and a ≥ 14-day supply were most at risk of persistent opioid use.
• There was a 2-3 fold increase in anxiety, depression, and substance use disorder between the opioid naive and chronic patients.

Witt et al. 2022 (Level 3 evidence)

• DOI: http://doi.org/10.1002/jhbp.1216
• Analyzed data from 114 patients undergoing open or robotic pancreatectomy at a single institution between March 2019-May 2021
• Robotic PD patients required fewer opioids while maintaining similar pain scores
• Total inpatient opioid use: Robotic PD patients consumed 10.53 while open patients consumed 16.8 pills.
• Discharge prescription for robotic = 0 pills
• Discharge prescription for open = 3.3 pills

Maurer et al. 2021 (Level 2 evidence)

• DOI: http://doi.org/10.1097/SLA.0000000000005042
• Comparison of discharge opioid prescription before and after Enhanced Recovery After Surgery (ERAS) programs.
• Analyzed data from 3,983 patients undergoing hysterectomy between October 2016-November 2020 and pancreatectomy or hepatectomy between April 2017-November 2020 at a single institution.
• Matched post-ERAS patients were prescribed fewer opioid pills (17.4 pills vs.22.0 pills) and lower OME (129.4mg vs. 167.6mg) than pre-ERAS patients.

Kim et al. 2018 (Level 4 evidence)

• DOI: http://doi.org/10.1016/j.yasu.2018.03.002
• Review of pancreatomy analgesics including TAP Infiltration, Intrathecal Analgesia, Epidural Analgesia, Intravenous Patient Controlled Analgesia, and Continuous Infusion through a Wound Catheter.
• Epidural Analgesia (EA) is supported to be the most effective analgesic modality.

SUPPORTING LITERATURE

Hoehn et al. 2019 (Level 2 evidence)

• DOI: https://doi.org/10.1007/s11605-018-04091-y
• Retrospective chart review of opioid use, LOS, complications, and readmissions before and after implementation of ERAS protocol for LSG.
• After ERAS, 52% of LSG patients did not use opioids and 33% did not receive opioids of any kind.

Pardue et al. 2020 (Level 2 evidence)

• DOI: http://doi.org/10.1007/s11695-020-04980-9
• Retrospective cohort study of recovery time, pain scores, and opioid use among LSG patients before and after implementation of opioid-sparing protocol.
• Opioid-sparing protocol reduced recovery time and postoperative opioid use without changed pain scores.

Sapin et al. 2021 (Level 2 evidence)

• DOI: http://doi.org/10.1016/j.soard.2021.04.017
• Retrospective review of LOS, costs, and readmission rates before and after implementation of ERAS protocol for LSG.
• 61% fewer MMEs prescribed after ERAS, and shorter LOS with better patient outcomes.

DATA ANALYSIS

Small bowel resection or Enterolysis-open

• Patient Reported Outcomes data collected via Michigan Surgical Quality Collaborative
• January 1, 2018 – October 31, 2021
• 438 Opioid Naive Patients from 58 Michigan Hospitals

SUPPORTING LITERATURE

Spinelli et al. 2021 (Level 2 evidence)

• DOI: http://doi.org/10.1007/s11605-012-2012-5
• Analyzed data from 90 patients who underwent laparoscopic ileocecal resection at two institutions. Study then compared patients who received an enhanced recover pathway (ERP) to patients who received conventional care
• Mean postoperative and total length of stay were shorter in the ERP group as well as a significantly earlier return of bowel function
• Suggests that “optimized perioperative care combined with minimally invasive techniques may lead to further improvements in surgical outcomes for CD patients.”