Multimodal Postoperative Pain Control Is Effective and Reduces Opioid Use After Laparoscopic Roux-en-Y Gastric Bypass

Perioperative Dexmedetomidine Infusion Improves Perioperative Care of Bariatric-Metabolic Surgery: A Single Center Experience with Meta-Analysis

PURPOSE

This study aims to determine the effects of perioperative dexmedetomidine infusion (PDI) on Asian patients undergoing bariatric-metabolic surgery (BMS), focusing on the need for pain medications and management of postoperative nausea and vomiting (PONV), and to investigate the association with these variables, including patients' characteristics and BMS data.

MATERIALS AND METHODS

A retrospective review of prospectively collected data was conducted in an Asian weight management center from August 2016 to October 2021. A total of 147 native patients with severe obesity were enrolled. All patients were informed of the full support of perioperative pain medications for BMS. The pain numeric rating scale scores, events of PONV, needs for pain medications, and the associated patients' characteristics were analyzed. A p-value of < 0.05 was considered statistically significant. Furthermore, to verify the effects of perioperative usage of dexmedetomidine for BMS, a systematic review with meta-analysis of currently available randomized control trials was performed.

RESULTS

Among the 147 enrolled patients, 107 underwent laparoscopic sleeve gastrectomy and 40 underwent laparoscopic Roux-en-Y gastric bypass. PDI has been used as an adjunct multimodal analgesia for BMS in our institution since June 2017 (group D; n = 114). In comparison with those not administered with perioperative dexmedetomidine (group C; n = 33), lower pain numeric rating scale scores (2.52 ± 2.46 vs. 4.27 ± 2.95, p = 0.007) in the postanesthesia care unit, fewer PONV (32.46% vs. 51.52%; p = 0.046), and infrequent needs of additional pain medications (19.47% vs. 45.45%; p = 0.003) were observed in group D. Multivariable analysis demonstrated that type II diabetes mellitus was correlated with the decreased need of pain medications other than PDI (p = 0.035). Moreover, dexmedetomidine seemed to have a better analgesic effect for patients with longer surgical time based on our meta-analysis.

CONCLUSION

Based on our limited experience, PDI could be a practical solution to alleviate pain and PONV in Asian patients undergoing BMS. Moreover, it might reduce the need for rescue painkillers with better postoperative pain management for patients with type II diabetes mellitus or longer surgical time.

Adherence to Opioid Prescribing Guidelines in a Statewide Surgical Quality Improvement Collaborative

INTRODUCTION

The opioid crisis is an ongoing crisis in the United States. Postoperative patients who receive opioid prescriptions have a 3%-7% risk of developing a chronic opioid abuse problem. This study aims to describe on-target opioid prescribing and use of multimodal pain management strategies 2 y after the implementation of a multicomponent quality improvement initiative across our statewide collaborative.

METHODS

From July 2020 to September 2021, we prospectively collected data on opioid-prescribing and multimodal strategies for 10 targeted procedures in general, gynecologic, and orthopedic surgery at three hospitals. Prescribing was on-target if a patient was prescribed ≤50 daily morphine milligram equivalents. Multimodal strategies were defined as two or more nonopioid adjuncts used within 48 h of surgery.

RESULTS

One thousand and eleven targeted procedures were performed with prescription data available for 993 cases. The on-target prescribing rate was 79.6% (n = 790), with general surgery 92.5% (n = 285), gynecology 84.9% (n = 331), and orthopedic surgery 59.0% (n = 174). Patients who received multimodal pain approaches were associated with interventions such as patient education, transversus abdominus plane block, and prescriptions for nonopioid analgesics at discharge. There was no evidence to support a difference in the use of multimodal pain control approaches between patients whose opioid prescribing was on-target or not (73.8% versus 77.3%, P = 0.30). At the first postoperative visit, data on continued opioid use were missing in 57.3% of patients, number of pills used was missing in 93.8%, and adequate pain control was missing in 52.8%.

CONCLUSIONS

On-target prescribing and multimodal strategies are common but vary by specialty. Additionally, postoperative pain control and opioid use are often not documented. To better match prescribing to patient needs, understanding patient-level and specialty-level opioid use is important.

Selective COX-2 inhibitors after bariatric surgery: Celecoxib, etoricoxib and etodolac post-bariatric solubility/dissolution and pharmacokinetics

Anatomical/physiological gastrointestinal changes after bariatric surgery may influence the fate of orally administered drugs.Since non-selective NSAIDs are not well-tolerated post-surgery, selective cyclooxygenase-2 (COX-2) inhibitors may be important for these patients. In this work we investigated celecoxib, etoricoxib and etodolac, for impaired post-bariatric solubility/dissolution and absorption. Solubility was studied in-vitro, and ex-vivoin aspirated gastric contents from patients pre- vs. post-surgery. Dissolution was studied in conditions simulating pre- vs. post-surgery stomach. Finally, the experimental solubility data were used in physiologically-based biopharmaceutics model (PBBM) (GastroPlus®) to simulate pre- vs. post-surgery celecoxib/etoricoxib/etodolac pharmacokinetic (PK) profiles.For etoricoxib and etodolac (but not celecoxib), pH-dependent solubility was demonstrated: etoricoxib solubility decreased ∼1000-fold, and etodolac solubility increased 120-fold, as pH increased from 1 to 7, which was also confirmed ex-vivo. Hampered etoricoxib dissolution and improved etodolac dissolution post-surgery was revealed. Tablet crushing, clinically recommended after surgery, failed to improve post-bariatric dissolution. PBBM simulations revealed significantly impaired etoricoxib absorption post-surgery across all conditions; for instance, 79% lower Cmax and 53% decreased AUC was simulated post-gastric bypass procedure, after single 120 mg dose. Celecoxib and etodolac maintained unaffected absorption after bariatric surgery.This mechanistically-based analysis suggests to prefer the acidic drug etodolac or the neutral celecoxib as selective COX-2 inhibitors, over the basic drug etoricoxib, after bariatric surgery.

Evaluation of Postoperative Care Protocol for Roux-en-Y Gastric Bypass Patients with Same-Day Discharge

INTRODUCTION

Same-day discharge (SDD) after bariatric surgery is increasingly being performed and is safe with careful patient selection. However, detecting early complications during the first postoperative days can be challenging. We developed a postoperative care protocol for these patients and aimed to evaluate its effectiveness in detecting complications and monitoring patient recovery.

METHODS

A single-center retrospective observational study was conducted with patients with who underwent Roux-en-Y Gastric Bypass (RYGB) with successful SDD. The study evaluated the effectiveness of the safety net that included simple remote monitoring with a pulsoximeter and thermometer, a phone consultation on postoperative day (POD) 1, and a physical consultation on POD 2-4. Furthermore, an analysis was performed on various factors including pain scores, painkiller usage, and incidences of nausea and vomiting on POD 1.

RESULTS

In this study, 373 consecutive patients were included, of whom 19 (5.1%) were readmitted until POD 4. Among these, 12 patients (3.2%) reached out to the hospital themselves, while 7 (1.9%) were readmitted after phone or physical consultations. Ten of the readmitted patients had tachycardia. On POD 1, the mean numeric rating scale was 4 ± 2, and 96.6% of the patients used acetaminophen, 35.5% used naproxen, and 9.7% used oxynorm. Of the patients, 13.9% experienced nausea and 6.7% reported vomiting.

CONCLUSION

A postoperative care protocol for SDD after RYGB, comprising simple remote monitoring along with a phone consultation on POD 1 and a physical checkup on POD 2-4, was effective in monitoring patient recovery and detecting all early complications.

Reduction of Pain After Laparoscopic Bariatric Surgery by Personalized Checkpoint Acupuncture-Data of a STRICTA Conform Pilot Study

BACKGROUND

It remains challenging in clinical practice to perform optimal pain management following bariatric surgeries. Acupuncture (AC) is an effective method of postoperative pain management, but its clinical efficacy depends on the rationale used to select AC points.

METHODS

We developed a method to identify individual patterns of pain and a corresponding set of acupoints (corrAC) based on the relative pressure sensitivity of six abdominal visceral pressure points, i.e., the gastrointestinal (GI) checkpoints (G1-G6). Patients with moderate to severe pain were included and received a single AC treatment following surgery. The visual analog scale (VAS) score, pain threshold, and skin temperature were assessed before AC and at 5 min, 1 h, and 24 h following AC. AC was performed with 1-mm-deep permanent needles.

RESULTS

From April 2021 to March 2022, 72 patients were included in the analysis. Fifty-nine patients received corrAC, whereas 13 received a noncorresponding AC (nonAC) as an internal control. Patients receiving corrAC showed a significant reduction (74%) in pain at 5 min after treatment (p < 0.0001) and a significant increase (37%) in the pain threshold (p < 0.0001). In this group, a significant increase in skin temperature above G1, G3, G4, and G5 was observed. Patients receiving nonAC showed neither significant pain reduction nor significant changes in pain threshold. The skin above G3 and G4 did not reveal temperature changes.

CONCLUSION

Checkpoint AC may be an effective tool in postoperative pain therapy after bariatric surgery. Vegetative functional involvement might be associated with pain relief.

Efficacy and Safety of Gabapentin on Postoperative Pain Management After Bariatric Surgery: A Systematic Review and Meta-Analysis

PURPOSE

Examine the efficacy and safety of perioperative gabapentin in bariatric surgical patients.

DESIGN

Systematic Review and Meta-analysis.

METHODS

An exhaustive search was conducted using PubMed, Cochrane Library, MEDLINE, CINAHL, Google Scholar, and other gray literature. Only randomized controlled trials evaluating the use of gabapentin in bariatric surgery were included. Risk ratio (RR) and mean difference (MD) were used to estimate outcomes with suitable effect models. Quality of evidence was assessed using the Risk of Bias and GRADE system.

FINDINGS

Four trials consisting of 283 patients were analyzed. The use of gabapentin significantly lowered the cumulative pain score in the first 24 hours after surgery by an average of 1.04 (MD, -1.04; 95% CI, -1.45 to -0.63; P < .00001). Gabapentin also reduced the overall morphine equivalent consumption by 7.89 mg (MD, -7.89; 95% CI, -13.56 to -2.2; P = .006). However, gabapentin did not affect the incidence of PONV (RR, 0.61; 95% CI, 0.38-1.00; P = .05), somnolence (RR, 1.25; 95% CI, 0.57-2.73; P = .57), dizziness (RR, 1.01; 95% CI, 0.40-2.54; P = .99), and headache (RR, 0.76; 95% CI, 0.25-2.30; P = .62). Substantial heterogeneity, imprecision of the effect size, and potential publication bias were limitations of this review.

CONCLUSIONS

The use of gabapentin is effective in the management of postoperative pain in bariatric surgery. However, there is limited data regarding the opioid-sparing effect and adverse effect profiles of gabapentin in the bariatric surgical population.

Efficacy and Safety of Parenteral Injection of an Extended Release κ-receptor Opioid Sebacoyl Dinalbuphine Ester for Acute and Chronic Pain After Laparoscopic Bariatric Surgery: a Randomized, Placebo-Controlled, Double-Blind Trial

PURPOSE

μ-receptor opioids are associated with unwanted gastrointestinal side effects and respiratory depression. A long-acting non-μ-receptor parenteral opioid is not currently available for management of acute and chronic postsurgical pain (CPSP). This double-blind clinical trial tested an extended-release κ-receptor agonist, sebacoyl dinalbuphine ester (SDE, Naldebain®) for management of surgical pain after laparoscopic bariatric surgery.

MATERIALS AND METHODS

Patients were randomly assigned to receive a single intramuscular injection of SDE (150 mg, n = 30) or vehicle solution (n = 30) at > 12 h before surgery. All patients received standard perioperative multimodal analgesia (MMA). The primary endpoint was the pain intensity in the beginning 7 days after operation. The secondary endpoints were adverse reactions up to 7 days and incidence of CPSP at 3 months after surgery.

RESULTS

Compared with placebos, the area under curves of visual analog scale (VAS) for 0-48 h after operation were significantly reduced in SDE group (143.3 ± 65.4 and 105.9 ± 36.3, P = 0.025). There were significantly fewer patients in the SDE group who had moderate-to-severe pain (VAS ≥ 4) (16.7% vs 50%; P = 0.012) at postoperative 48 h. Pain intensities were similar between the two groups at 72 h and 7 days postoperatively. The incidence of CPSP at 3 months was not different. SDE did not increase drug-related systemic adverse events.

CONCLUSION

In addition to the standard perioperative MMA, a single-dose injection of long-acting κ-receptor agonist SDE provides significantly better pain management for 48 h following laparoscopic bariatric surgery. A long-acting κ-receptor agonist opioid could improve in-hospital pain management and potentiate early discharge after operation without increasing drug-related systemic complications.

Implementation of a standardized multimodal pain regimen significantly reduces postoperative inpatient opioid utilization in patients undergoing bariatric surgery

BACKGROUND

Routine opioid use in surgical patients has received attention given the opioid epidemic and a renewed focus on the dangers and drawbacks of opioids in the postoperative setting. Little is known about opioid use in bariatric surgery, especially in the inpatient setting. We hypothesize that a standardized opioid-sparing protocol reduces postoperative inpatient opioid use in bariatric surgery patients.

METHODS

A retrospective cohort study was conducted of bariatric surgery patients at a single institution. From March to September 2019, a standardized intraoperative and postoperative opioid-sparing protocol was designed and implemented along with an educational program for patients regarding safe pain management. Inpatient opioid utilization in patients undergoing surgery in the preintervention phase between April and March 2019 was compared to patients from a postintervention phase of October 2019 to December 2020. Opioid utilization was measured in morphine milliequivalents (MME).

RESULTS

A total of 359 patients were included; 192 preintervention and 167 postintervention. Patients were similar demographically. For all patients, mean age was 44.1 years, mean BMI 49.2 kg/m2, and 80% were female. Laparoscopic sleeve gastrectomy was performed in 48%, laparoscopic gastric bypass in 34%, robotic sleeve gastrectomy in 17%, and robotic gastric bypass in 1%. In the postintervention phase inpatient opioid utilization was significantly lower [median 134.8 [79.0-240.8] MME preintervention vs. 61.5 [35.5-150.0] MME postintervention (p < 0.001)]. MME prescribed at discharge decreased from a median of 300 MME preintervention to 75 MME postintervention (p < 0.001). In the postintervention phase, 16% of patients did not receive an opioid prescription at discharge compared to 0% preintervention (p < 0.001). When examining by procedure, statistically significant reductions in opioid utilization were seen for each operation.

CONCLUSION

Implementation of a standardized intraoperative and postoperative multimodal pain regimen and educational program significantly reduces inpatient opioid utilization in patients undergoing bariatric surgery.

Efficacy and safety of intravenous acetaminophen (2 g/day) for reducing opioid consumption in Chinese adults after elective orthopedic surgery: A multicenter randomized controlled trial

Background: Acetaminophen is an important component of a multimodal analgesia strategy to reduce opioid consumption and pain intensity after an orthopedic surgery. The opioid-sparing efficacy of intravenous acetaminophen has been established at a daily dose of 4 g. However, it is still unclear for the daily dose of 2 g of acetaminophen, which is recommended by the China Food and Drug Administration Center for Drug Evaluation, in terms of its efficacy and safety.

Objectives: This study aimed to evaluate the efficacy and safety of intravenous acetaminophen at a daily dose of 2 g for reducing opioid consumption and pain intensity after orthopedic surgery.

Methods: In this multicenter, randomized, double-blind, placebo-controlled phase III trial, 235 patients who underwent orthopedic surgery were randomly assigned to receive intravenous acetaminophen 500 mg every 6 h or placebo. Postoperative morphine consumption, pain intensity at rest and during movement, and adverse events were analysed.

Results: For the mean (standard deviation) morphine consumption within 24 h after surgery, intravenous acetaminophen was superior to placebo both in the modified intention-to-treat analysis [8.7 (7.7) mg vs. 11.2 (9.2) mg] in the acetaminophen group and the placebo group, respectively. Difference in means: 2.5 mg; 95% confidence interval, 0.25 to 4.61; p = 0.030), and in the per-protocol analysis (8.3 (7.0) mg and 11.7 (9.9) mg in the acetaminophen group and the placebo group, respectively. Difference in means: 3.4 mg; 95% confidence interval: 1.05 to 5.77; p = 0.005). The two groups did not differ significantly in terms of pain intensity and adverse events.

Conclusion: Our results suggest that intravenous acetaminophen at a daily dose of 2 g can reduce morphine consumption by Chinese adults within the first 24 h after orthopedic surgery, but the extent of reduction is not clinically relevant.

Clinical Trial Registration: [ClinicalTrials.gov], identifier [NCT02811991].

Laparoscopic-Assisted Transversus Abdominis Plane Block is Superior to Port Site Infiltration in Reducing Post-Operative Opioid Use in Laparoscopic Surgery

BACKGROUND

The ultrasound-guided transversus abdominis plane (TAP) block can be time-consuming, costly, and technically challenging in the bariatric patient population. Laparoscopic-assisted TAP (L-TAP) block was developed and has been shown to be non-inferior to ultrasound-guided blocks. Postoperative pain can be significant, and pain control in the morbidly obese patients can be challenging. This study's aim was to compare L-TAP block to traditional port site infiltration in terms of postoperative opioid requirement for morbidly obese patients after laparoscopic Roux-en-Y gastric bypass (RYGB) surgery.

METHODS

A retrospective chart review was performed from February 2019 through February 2020. Two study groups: L-TAP block and port site infiltration. Outcomes examined the amount of opioid used at different time segments relative to the operation. All intravenous (IV) and oral opioids used were converted into IV morphine milligram equivalents (MME) for standardization.

RESULTS

150 patients were included. The patient characteristics were not statistically significant between the two groups. Post-operative opioid use trended lower in the L-TAP block group in all time segments. A significant difference was detected in IV opioid use during post-operative day 0 with the mean MME for the L-TAP block group being 1.1±3.8 and port site infiltration group being 2.8±4.5 (P = .02).

CONCLUSIONS

The L-TAP block more effectively reduces postoperative opioid use in comparison to port site infiltration in laparoscopic Roux-en-Y gastric bypass (RYGB) surgery. Based on these findings, as well as the efficiency and cost-effectiveness of L-TAP blocks, its routine use in laparoscopy should be considered.

A comparative evaluation of robotic and laparoscopic Roux-en-Y gastric bypass: a critical evaluation on the impact of postoperative pain and opioid requirements

INTRODUCTION

The benefits of minimally invasive surgery using laparoscopy on postoperative pain and opioid use are well established. Our goal was to determine whether patients who underwent Roux-en-Y gastric bypass using a robotic approach (RA-RYGB) had lower postoperative pain and required less opioids than those undergoing laparoscopic Roux-en-Y gastric bypass (L-RYGB). Secondary outcomes evaluated included length of stay, operative time, and readmissions.

METHODS AND PROCEDURES

This was a retrospective cohort study from a tertiary academic medical center. Patients who underwent L-RYGB or RA-RYGB between 5/1/2018 and 10/31/2019 were included. Cases with concomitant hernia repair, chronic opioid use, and those who did not receive a TAP block or multimodal pain control were excluded. Baseline demographics were compared. Inpatient and outpatient opioid use in Morphine Milligram Equivalents (MME) and pain scores (10-point Likert scale) were compared.

RESULTS

There were 573 RY patients included (462 L-RYGB; 111 RA-RYGB). Median and maximum inpatient pain scores were similar for L-RYGB and RA-RYGB (3.0 vs 3.1, p = 0.878; 7.0 vs 7.0, p = 0.688). Median inpatient opioid use and maximum single day use were similar for L-RYGB and RA-RYGB (40.0 MME vs. 42.0 MME, p = 0.671; 30.0 MME vs 30.0 MME, p = 0.648). Both the outpatient prescribing of opioids (50.2% vs. 42.3%, p = 0.136) and outpatient opioid MME at 2 weeks (L-RYGB 30.0 MME vs. 33.8 MME, p = 0.854) were comparable between cohorts. Patient reported pain at 2-week follow-up was significantly higher for RA-RYGB (68.1%) than L-RYGB (55.6%) (p = 0.030). RA-RYGB had a higher rate of 30-day readmission and longer operative times compared to the L-RYGB (6.3% vs 13.5%, p = 0.010; 144.5 vs 200.0 min, p < 0.001).

CONCLUSION

This study identified no benefit for postoperative pain or opioid requirements in patients undergoing RA-RYGB compared to L-RYGB. The RA-RYGB group was significantly more likely to report pain at the two-week follow-up.

Outcomes of Bariatric Surgery in Patients on Chronic Opioids: Can Bariatric Surgery Assist with Decreasing Long-term Opioid Utilization?

PURPOSE

The aim of our study was to assess long-term opioid use following bariatric surgery in patients on preoperative narcotics.

METHODS

We evaluated patients utilizing preoperative opioids (OP) who underwent primary laparoscopic Roux-en-Y gastric bypass (LRYGB) from 2013 to 2020. Patients were propensity-matched to those without preoperative opioid use (NOP) by demographics and comorbidities. Our objectives were to compare opioid use at 1 and 3 years after surgery and evaluate perioperative outcomes.

RESULTS

A total of 806 patients, matched 1:1 were evaluated, with 82.7% being females. Mean age was 46.5 years in the OP and 45.6 years in the NOP (p = 0.0018), preoperative BMI was 45.8 in the OP and 46.1 in the NOP (p = 0.695). All patients were followed up for 1 year. In the OP, 156 (38.7%) patients were taking opioids 1 year after surgery as opposed to 27 (6.7%) in the NOP (p < 0.0001). Three years after surgery, 74 (37.5%) patients in the OP and 27 (14.4%) in the NOP were taking outpatient opioids (p < 0.0001). There was no statistically significant difference between OP and NOP groups in terms of readmissions (9.4% vs. 5.7% p = 0.06), reinterventions (3.7 vs. 1.7% p = 0.13), reoperations (3.5% vs. 1.5% p = 0.11), or emergency room visits (8.9% vs. 7.2% p = 0.44). There were no mortalities.

CONCLUSION

Most patients requiring preoperative opioids can be weaned off after bariatric surgery. Enhanced recovery pathways are key to obtaining these results. Preoperative opioid use is not associated with increased complications compared to opioid-naïve patients.

Prescriptions for pain medication before and after bariatric surgery

BACKGROUND

Significant and sustained weight loss resulting from bariatric surgery have demonstrated clinical reduction in severe obesity-related pain. Subsequentially, post-surgical pain reduction may reduce pain medication use. However, clear evidence regarding use of prescribed pain medications before and after bariatric surgery is absent.

METHODS

Linking two state-wide databases, patients who underwent bariatric surgery between July 1, 2013 and December 31, 2015 were identified. Proportion tests were used to compare percent of patients with pain medication prescriptions 1 year before and 1 year after bariatric surgery. Logistic regression was used to identify baseline factors that were associated with pain medication use 1-year following surgery.

RESULTS

A total of 3535 bariatric surgical patients aged 18-64 years at surgery were identified. Of these patients, 1339 patients met the following study criteria: covered by private insurance; known pre-surgical BMI; and continuous enrollment with health plan(s) from 12-month pre-surgery to 13-month post-surgery. While comparison of average number of overall pain medication prescriptions before and after surgery did not change, from 3.46 to 3.32 prescriptions (p value = 0.26), opioid prescription use increased from 1.62 vs. 2.05 (p value < 0.01). Patients prescribed more types of pain medications before surgery were more likely to have prescribed pain medications after surgery. Patients prescribed benzodiazepines at baseline had higher odds being prescribed post-surgery corticosteroids (OR = 1.89, p value < 0.01), muscle relaxants (OR = 2.18, p value < 0.01), and opioids (OR = 3.06, p value =  < 0.01) compared to patients without pre-surgery--prescribed benzodiazepine.

CONCLUSION

While comparison of average number of overall pain medication prescriptions before and after bariatric surgery did not decrease, opioid prescription increased post-surgery. Further studies are needed to examine whether post-surgery opioids are prescribed in lieu of or in tandem with other pain medication prescriptions.

Auricular nerve stimulation using the NSS-2 BRIDGE device to reduce opioid requirement following laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Evidence supports the use of complementary techniques to reduce pain and opioid use after surgery. The NSS-2 BRIDGE device (NBD; Innovative Health Solutions, Inc., Versailles, Indiana) modulates pain via stimulation of the nucleus of the auricular branch of the cranial nerves at the level of the brainstem and the limbic system.

OBJECTIVE

To investigate the role of auricular nerve field stimulation for pain control following gastric bypass surgery.

SETTINGS

U.S. academic medical center.

METHODS

A total of 18 subjects were included. Subjects were divided in 2 groups: NBD group (n = 8) and a control group (n = 10). The NBD was placed following laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery in the recovery room. The effectiveness of NBD was assessed comparing the relative use of opioid consumption (oral morphine equivalents) and pain (0 = no pain to 10= worst possible pain) at 24 and 48 hours after surgery. In addition, the device tolerability (1-10) was assessed, with 8-10 considered excellent. Data were analyzed using unpaired t tests and presented as mean ± standard deviation. Alpha was set up at .1.

RESULTS

Compared with the control group, the use of NBD was associated with a 60.2% reduction in oral morphine equivalents (38.15 vs 15.2 mg; P < .1) and a 28% reduction in pain (5.0 vs 3.6; P = .1) at 24 hours after surgery. The tolerability of NBD was reported to be excellent.

CONCLUSIONS

This report suggests that NBD may represent an interesting alternative to control perioperative pain and limit opioid use following bariatric surgery. This needs to be confirmed by a placebo-controlled, randomized study.

Efficacy of an opioid-sparing analgesic protocol in pain control after less invasive cranial neurosurgery

An opioid-sparing protocol for postoperative pain management in less invasive cranial neurosurgery significantly lowered opioid usage while reducing pain scores.

Introduction:

Opioid overuse in postoperative patients is a worrisome trend, and potential alternatives exist which warrant investigation. Nonsteroidal anti-inflammatory drug use in treating postoperative cranial surgery pain has been hampered by concern for inadequate pain control and increased risk of hemorrhagic complications. A safe and effective alternative to opioid-based pain management is critical to improving postoperative care.

Objective:

The objective of this retrospective study was to determine whether an NSAID-based opioid-sparing pain management protocol (OSP) is effective in analgesic control of less invasive cranial surgery patients at 6-, 12-, and 24-hour postoperatively. Secondary aims included investigating differences in hemorrhagic complications.

Methods:

Five hundred sixty-six consecutive patients who underwent cranial surgery before and after implementation of the celecoxib-based OSP were eligible. Propensity score matching was used to match patients in each cohort.

Results:

The opioid-sparing cohort had lower pain scores at 6 hours (3.45 vs 4.19, P = 0.036), 12 hours (3.21 vs 4.00, P = 0.006), and 24 hours (2.90 vs 3.59, P = 0.010). Rates of postoperative hemorrhage were not significantly different (5% intervention vs 8% control, P = 0.527). The opioid-sparing pain management protocol provided comparable or better pain control in the first 24 hours after less invasive cranial surgery. Hemorrhage rates did not change with the use of an NSAID-based OSP.

Conclusion:

An effective alternative to the current standard opioid-based pain management is feasible for less invasive cranial surgery. Determinations of hemorrhage risk and more complex cranial surgery will require larger prospective randomized trials.

Low-Dose Ketamine Infusion for Perioperative Pain Management in Patients Undergoing Laparoscopic Gastric Bypass: A Prospective Randomized Controlled Trial

Introduction

Obesity is a common comorbidity seen in the perioperative setting and is associated with many diseases including cardiovascular disease and obstructive sleep apnea. Laparoscopic Roux-en-Y gastric bypass is the gold standard surgical treatment for patients whose weight is refractory to diet and exercise. Caring for these patients perioperatively presents unique challenges to anesthesiologists and is associated with an increased risk of adverse respiratory events. In our study, we hypothesize that a low-dose perioperative ketamine infusion will reduce opioid consumption and improve analgesia when compared to standard therapy.

Methods

This is a single-center, prospective randomized controlled study enrolling 35 patients in total. Patients were randomized equally into the ketamine and control group. Preop, intraop, and postop management regimens were standardized. The ketamine group received a 0.3 mg/kg ideal body weight ketamine bolus after induction followed by a 0.2 mg/kg/hr ketamine infusion continued into the postop setting for up to 24 hours. Data collected included total perioperative opioids used converted to oral morphine equivalents (ME), pain scores, side effects, hospital length of stay, and patient satisfaction captured via postoperative questionnaires.

Results

The use of perioperative opioid consumption was significantly lower in the ketamine group when compared with the control group (179.9 ME versus 248.7 ME, P=0.03). There was no statistically significant difference in pain scores or hospital length of stay postoperatively between the two groups. There were also no reported adverse respiratory events, prolonged sedation, agitation, or other side effects reported in either group. The patient satisfaction questionnaires showed a significant difference with the ketamine group reporting lower maximum pain scores, a decrease in how pain limited activities of daily living once discharged, and increased hospital pain management satisfaction scores.

Conclusions

Perioperative low-dose ketamine infusions significantly reduced opioid consumption in morbidly obese patients undergoing laparoscopic gastric bypass surgery.

Comparison of three intraoperative analgesic strategies in laparoscopic bariatric surgery: a retrospective study of immediate postoperative outcomes

Introduction and objectives

Multimodal Analgesia (MMA) has shown promising results in postoperative outcomes across a broad spectrum of surgeries, including bariatric surgery. We compared the analgesic effect immediately after Laparoscopic Bariatric Surgery (LBS) of the combined effect of MMA and methadone against two techniques that were based mainly on the use of high-potency medium-acting opioids.

Methods

Two hundred seventy-one patients were retrospectively reviewed. The primary outcome was postoperative pain score > 3/10 measured by the Verbal Numeric Scale (VNS) during the Postanesthetic Care Unit (PACU) stay. The three protocols of intraoperative analgesia were: (P1) sufentanil at anesthetic induction followed by remifentanil infusion; (P2) sufentanil at induction followed by dexmedetomidine infusion; and (P3) remifentanil at induction followed by MMA including dexmedetomidine, magnesium, lidocaine, and methadone. Only P1 and P2 patients received morphine toward the end of surgery. Poisson regression was used to adjust confounding factors and calculate Prevalence Ratio (PR).

Results

Postoperative VNS > 3 was recorded in 135 (49.81%) patients, of which 93 (68.89%) were subjected to P1, 25 (18.56%) to P2, and 17 (12.59%) to P3. In the final adjusted model, both anesthetic techniques (P3) (PR = 0.10; 95% CI [0.03–0.28]), and (P2) (PR = 0.42%; 95% CI [0.20–0.90]) were associated with lower occurrence of VNS > 3, whereas age range 20–29 was associated to higher occurrence of VNS > 3 (PR = 3.21; 95% CI [1.22–8.44]) in PACU. Postoperative Nausea and Vomiting (PONV) was distributed as follows: (P1) 20.3%, (P2) 31.25% and (P3) 6.77%; (P3 < P1, P2; p < 0.05). Intraoperative hypotension occurred more often in P3 (39%) compared to P2 (20.31%) and P1 (17.46%) (p < 0.05).

Conclusion

MMA + methadone was associated with higher incidence of intraoperative hypotension and lower incidence of moderate/severe pain in PACU after LBS.

Reduction in Opiate Use, Pain, Nausea, and Length of Stay After Implementation of a Bariatric Enhanced Recovery After Surgery Protocol

PURPOSE

Evaluate adherence to bariatric surgery enhanced recovery after surgery (ERAS) protocols in pre-operative, operative, and post-operative phases, and to compare opiate use, nausea control, and length of stay (LOS) versus historical controls.

MATERIALS AND METHODS

A retrospective, observational cohort study was conducted to evaluate adherence to ERAS protocols and compare opiate and antiemetic use, pain intensity, and LOS versus those of traditional care (TC) patients preceding protocol implementation at Erie County Medical Center, a community-based hospital in Buffalo, NY, USA.

RESULTS

One hundred ERAS and TC patients were compared. Patients were similar in age (42.5 years), gender (female, ~ 80%), race (~ 80 white), and BMI (47 kg/m²). The primary procedure performed was sleeve gastrectomy (89% ERAS, 86% TC). Protocol adherence was high for ERAS phases: prior to admission (85-98%), pre-operative (96-100%), operative (93-99%), post-anesthesia care unit (PACU) (55-61%), and floor (86-98%). Opiate morphine milligram equivalent (MME) was reduced in ERAS vs. TC in hospital by 73% (43.5 ± 42.4 vs. 160 ± 116; p < 0.001), discharge prescribing by 53% (34.8 ± 38.2 vs. 74 ± 125 MME; p = 0.003), and in total by 69% (78.3 ± 67.5 vs. 252 ± 160; p < 0.001). Despite lower opiate use, ERAS had lower pain intensity entering PACU (1.1 ± 1.8 vs. 1.9 ± 2.6; p < 0.011), leaving PACU (1.7 ± 1.5 vs. 2.9 ± 1.5; p < 0.001), and floor day 0 (5.0 ± 2.1 vs. 5.9 ± 1.8; p < 0.001). Fewer ERAS required antiemetic day 0 (63% vs. 94%; p < 0.001). ERAS were discharged in fewer hours than TC (41.1 ± 15.5 vs. 52.1 ± 18.9 h; p < 0.001).

CONCLUSIONS

Bariatric surgery ERAS protocols were implemented with a high rate of adherence and yielded profound reduction in operative and post-operative opiate use while improving pain control and nausea management in hospital and decreasing LOS.

Postoperative Opioid Utilization and Patient Satisfaction in General Surgery Procedures: A Prospective Observational Study

BACKGROUND

Wide variation of opioid prescribing persists despite attempts to quantify number of opioids utilized postoperatively. We aim to prospectively determine number of opioids used after common surgery procedures to guide future prescribing.

METHODS

A prospective observational trial was performed of opioids prescribed and used postoperatively. Patients filled out pre- and postoperative surveys, and number of opioids utilized was captured at postoperative visit.

RESULTS

One-hundred-and-thirteen patients met inclusion. Median opioids prescribed exceeded number of opioids taken for all procedures. Median number of opioids taken postoperatively was fewer than 10 for all categories of procedures: simple skin/soft tissue 2 (IQR 1-4), complex skin/soft tissue 1.5 (IQR 0-14), simple laparoscopy 1 (IQR 0-20) and complex laparoscopy 4 (IQR 0-20), laparotomy 0 (IQR 0-26), and open inguinal hernia 2 (IQR 0-2). Nearly 80% of patients had leftover opioids, and 31% planned to keep them. There was little difference between preoperative and postoperative level of satisfaction with a pain control regimen.

DISCUSSION

Postoperatively, patients utilize opioids less frequently than prescribed and often keep leftover pills. Patient pain control satisfaction is unrelated to number of opioids prescribed and taken postoperatively.

An Opioid-Sparing Protocol Improves Recovery Time and Reduces Opioid Use After Laparoscopic Sleeve Gastrectomy

PURPOSE

The current literature is sparse on post discharge pain management for bariatric surgical patients. This study aimed to determine if an opioid-sparing protocol could decrease opioid use during the postoperative period (hospital to home).

MATERIALS AND METHODS

In this retrospective cohort study, we implemented an opioid-sparing protocol in January 2018, for patients undergoing laparoscopic sleeve gastrectomy (LSG) at our institution. We compared recovery time, pain scores (in hospital and at home), and perioperative opioid use between the historic control group (February 2017 to December 2017) and the opioid-sparing group (January 2018 to December 2018). A p value of < .05 was considered statistically significant.

RESULTS

The study included 400 patients (200 in each group), and 165 participated in the phone survey. Baseline characteristics were similar, except the control group had a higher body mass index and body weight. The average recovery time was significantly shorter in the opioid-sparing group (18.9 versus 35.3 days, P = .043). There was no significant difference in mean postoperative pain scores in the hospital or at home. The opioid-sparing group required significantly fewer opioids postoperatively (10.4 versus 16.1 morphine milligram equivalents, P < .001). Only 1 out of the 200 patients in the opioid-sparing arm requested an opioid prescription after discharge.

CONCLUSION

Implementation of an opioid-sparing protocol improved recovery time and reduced postoperative opioid use in the hospital and after discharge without changing perceived pain in patients undergoing LSG.

Community hospital decreases narcotic usage in postoperative bariatric patients

BACKGROUND

Opioids have long been used as an effective form of analgesia for pain in the postoperative setting; however, their addictive potential and associated complications have become a detriment. There has been an increasing movement to decrease opioid prescribing.

OBJECTIVE

The aim of this study was to look at common bariatric surgery procedures at a single institution and compare opioid usage before and after the implementation of a multimodal pain regimen.

SETTING

Community program, hospital-employed, and private practice, United States.

METHODS

Six hundred twelve laparoscopic gastric bypass and laparoscopic sleeve gastrectomy patients were included in this single-institution retrospective cohort study. Data were obtained from chart review. Comparison was made between patients from 2016 and patients from a 3-month period in 2017 when the new pain management protocol had been instituted.

RESULTS

The postoperative opioid usage of 516 patients from 2016 was compared with that of 96 patients from a 3-month period in 2017 after initiating the new pain management protocol. The mean intravenous hydromorphone usage of the control group, 16.0 ± 14.6 morphine milligram equivalent (or 4.0 mg ± .2), over the postoperative inpatient stay decreased to 7.3 ± 6.7 morphine milligram equivalent (or 1.8 mg ± .2) in the study group. This represents a 55% decrease. The study group did show less 30-day postoperative complications compared with the control, 1.04% and 2.13%, respectively, although this was not statistically significant.

CONCLUSION

A multimodal pain regimen is an effective way to cut opioid usage with no statistical difference in overall 30-day complications.

Clinical practice guidelines of the European Association for Endoscopic Surgery (EAES) on bariatric surgery: update 2020 endorsed by IFSO-EC, EASO and ESPCOP

BACKGROUND

Surgery for obesity and metabolic diseases has been evolved in the light of new scientific evidence, long-term outcomes and accumulated experience. EAES has sponsored an update of previous guidelines on bariatric surgery.

METHODS

A multidisciplinary group of bariatric surgeons, obesity physicians, nutritional experts, psychologists, anesthetists and a patient representative comprised the guideline development panel. Development and reporting conformed to GRADE guidelines and AGREE II standards.

RESULTS

Systematic review of databases, record selection, data extraction and synthesis, evidence appraisal and evidence-to-decision frameworks were developed for 42 key questions in the domains Indication; Preoperative work-up; Perioperative management; Non-bypass, bypass and one-anastomosis procedures; Revisional surgery; Postoperative care; and Investigational procedures. A total of 36 recommendations and position statements were formed through a modified Delphi procedure.

CONCLUSION

This document summarizes the latest evidence on bariatric surgery through state-of-the art guideline development, aiming to facilitate evidence-based clinical decisions.

Sleeve gastrectomy relieves exocrine pancreatic insufficiency in morbidly obese patients: a prospective case-control study

Introduction

Bariatric surgery is the most effective treatment modality in morbidly obese patients. Compared to Roux-en Y gastric bypass (RYGB), sleeve gastrectomy (SG) has better metabolic and nutritional outcomes after surgery. Exocrine pancreatic insufficiency (EPI) can be seen after RYGB but there is not any knowledge about EPI-SG association.

Aim

To assess exocrine pancreatic functions before and after the SG procedure.

Material and methods

This is a single-center, prospective and case-control study. Forty morbidly obese patients were included in the study. Their pre-operative and post-operative, third month fecal samples were collected. Exocrine pancreatic insufficiency was determined by using fecal elastase-1 and diagnosed when fecal elastase-1 levels were < 200 μg/g.

Results

The mean fecal elastase-1 level was 256.25 ±137.16 μg/g and the mean post-surgical fecal elastase-1 level was 437.7 ±212.43 μg/g (p = 0.001). In the pre-operative period, half of patients had FE levels under 200 μg/g. In the third month after surgery, only 4 patients had fecal elastase-1 levels under 200 μg/g. Comparison of fecal elastase-1 between pre-surgery and post-surgery revealed a significant difference (p = 0.001).

Conclusions

This is the first study to investigate EPI-SG association. Surgery-associated morbidity and mortality are the leading limitations of bariatric surgery procedures. Exocrine pancreatic insufficiency is one of them; prior studies demonstrate its increased frequency after RYGB. Our study revealed that SG relieves exocrine pancreatic insufficiency.

Chronic abdominal pain and persistent opioid use after bariatric surgery

Background and aims

Bariatric surgery remains a mainstay for treatment of morbid obesity. However, long-term adverse outcomes include chronic abdominal pain and persistent opioid use. The aim of this review was to assess the existing data on prevalence, possible mechanisms, risk factors, and outcomes regarding chronic abdominal pain and persistent opioid use after bariatric surgery.

Methods

PubMed was screened for relevant literature focusing on chronic abdominal pain, persistent opioid use and pharmacokinetic alterations of opioids after bariatric surgery. Relevant papers were cross-referenced to identify publications possibly not located during the ordinary screening.

Results

Evidence regarding general chronic pain status after bariatric surgery is sparse. However, our literature review revealed that abdominal pain was the most prevalent complication to bariatric surgery, presented in 3–61% of subjects with health care contacts or readmissions 1–5 years after surgery. This could be explained by behavioral, anatomical, and/or functional disorders. Persistent opioid use and doses increased after bariatric surgery, and 4–14% initiated a persistent opioid use 1–7 years after the surgery. Persistent opioid use was associated with severe pain symptoms and was most prevalent among subjects with a lower socioeconomic status. Alteration of absorption and distribution after bariatric surgery may impact opioid effects and increase the risk of adverse events and development of addiction. Changes in absorption have been briefly investigated, but the identified alterations could not be separated from alterations caused solely by excessive weight loss, and medication formulation could influence the findings. Subjects with persistent opioid use after bariatric surgery achieved lower weight loss and less metabolic benefits from the surgery. Thus, remission from comorbidities and cost effectiveness following bariatric surgery may be limited in these subjects.

Conclusions

Pain, especially chronic abdominal, and persistent opioid use were found to be prevalent after bariatric surgery. Physiological, anatomical, and pharmacokinetic changes are likely to play a role. However, the risk factors for occurrence of chronic abdominal pain and persistent opioid use have only been scarcely examined as have the possible impact of pain and persistent opioid use on clinical outcomes, and health-care costs. This makes it difficult to design targeted preventive interventions, which can identify subjects at risk and prevent persistent opioid use after bariatric surgery. Future studies could imply pharmacokinetic-, pharmacodynamics-, and physiological-based modelling of pain treatment. More attention to social, physiologic, and psychological factors may be warranted in order to identify specific risk profiles of subjects considered for bariatric surgery in order to tailor and optimize current treatment recommendations for this population.