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Chen SY, Laifman E, Mack SJ, Zhou S, Stein JE, Kim ES. Epidural Analgesia Is Associated With Reduced Inpatient Opioid Consumption and Length of Stay After Wilms Tumor Resection. J Surg Res 2023; 290:141-146. [PMID: 37267703 PMCID: PMC10756221 DOI: 10.1016/j.jss.2023.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 04/25/2023] [Accepted: 04/30/2023] [Indexed: 06/04/2023]
Abstract
INTRODUCTION Wilms' tumor (WT) is the most common renal malignancy in children and requires an extensive laparotomy for resection. Epidural analgesia (EA) is commonly used in postoperative pain management, but previous literature suggests it may prolong length of stay (LOS). We hypothesized that EA is associated with prolonged LOS but decreased postoperative opioid use in children undergoing WT resection. MATERIALS AND METHODS A retrospective chart review was performed for all WT patients who underwent nephrectomy between January 1, 1998, and December 31, 2018, at a tertiary children's hospital. Patients with incomplete records, bilateral WT, caval or cardiac tumor extension, or intubation postoperatively were excluded. Outcomes included postoperative opioid consumption measured in oral morphine equivalents per kilogram, receipt of opioid prescription at discharge, and postoperative LOS. Mann-Whitney and multivariable regression analyses were performed. RESULTS Overall, 46/77 children undergoing WT resection received EA. Children with EA used significantly less inpatient opioids than children without EA (median 1.0 vs. 3.3 oral morphine equivalents per kilogram; P < 0.001). Comparing patients with EA to patients without, there was no significant difference in opioid discharge prescriptions (57% vs. 39%; P = 0.13) or postoperative LOS (median 5 d vs. 6 d; P = 0.10). Controlling for age and disease stage, EA was associated with shorter LOS by multivariable regression (coefficient -0.73, 95% confidence interval: -1.4, -0.05; P = 0.04). CONCLUSIONS EA is associated with decreased opioid use in children without an associated increase in postoperative LOS following WT resection. EA should be considered as part of multimodal pain management for children undergoing WT resection.
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Affiliation(s)
- Stephanie Y Chen
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California; Division of Pediatric Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric Laifman
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Shale J Mack
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Shengmei Zhou
- Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, California; Department of Clinical Pathology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - James E Stein
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California; Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Eugene S Kim
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California; Division of Pediatric Surgery, Cedars-Sinai Medical Center, Los Angeles, California; Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California.
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Lascano D, Zamora AK, Mahdi E, Ourshalimian S, Russell CJ, Kim E, Kelley-Quon LI. Gabapentin is Associated With Decreased Postoperative Opioid Use and Length of Stay After Appendectomy in Children With Perforated Appendicitis: A Propensity Score-Matched Analysis. J Pediatr Surg 2023; 58:1935-1941. [PMID: 37029026 PMCID: PMC10771856 DOI: 10.1016/j.jpedsurg.2023.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 02/17/2023] [Accepted: 03/13/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND Gabapentin is increasingly used as an off-label, opioid-sparing pain medication in children. We investigated perioperative gabapentin administration and postoperative opioid use in children who underwent appendectomy for perforated appendicitis. METHODS A retrospective cohort study of healthy children ages 2-18 years undergoing appendectomy for perforated appendicitis from 2014 to 2019 was performed using the Pediatric Health Information System®. Propensity score matched (PSM) analysis was conducted with 1:1 matching based on patient and hospital characteristics. Multivariable linear regression analysis was used to evaluate an association between gabapentin, postoperative opioid use, and postoperative length of stay. RESULTS Of 29,467 children with perforated appendicitis who underwent appendectomy, 236 (0.8%) received gabapentin. In 2014, <10 children received gabapentin, but by 2019, 110 children received gabapentin. On univariate analysis of the PSM cohort, children receiving gabapentin had decreased total postoperative opiate use (2.3 SD ± 2.3 versus 3.0 SD ± 2.5 days, p < 0.001). On adjusted analysis, children receiving gabapentin had 0.65 fewer days of postoperative total opioid use (95% CI: -1.09, -0.21) and spent 0.69 fewer days in the hospital after surgery (95% CI: -1.30, -0.08). CONCLUSION While overall use is infrequent, gabapentin is increasingly administered to children with perforated appendicitis who undergo an appendectomy and is associated with decreased postoperative opioid use and reduced postoperative length of stay. Multimodal pain management strategies incorporating gabapentin may reduce postoperative opioid consumption, but further studies of drug safety are needed for this off-label use in children undergoing surgery. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Danny Lascano
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Abigail K Zamora
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Elaa Mahdi
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Shadassa Ourshalimian
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Christopher J Russell
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA; Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Eugene Kim
- Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA; Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA, USA.
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Invited commentary on Moon, et al: An enhanced recovery after surgery protocol in children who undergo nephrectomy for Wilms tumor safely shortens hospital stay. J Pediatr Surg 2022; 57:266-267. [PMID: 35811166 DOI: 10.1016/j.jpedsurg.2022.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 05/27/2022] [Indexed: 11/23/2022]
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Moon JK, Hwang R, Balis FM, Mattei P. An enhanced recovery after surgery protocol in children who undergo nephrectomy for Wilms tumor safely shortens hospital stay. J Pediatr Surg 2022; 57:259-265. [PMID: 35768311 DOI: 10.1016/j.jpedsurg.2022.05.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 05/19/2022] [Accepted: 05/24/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Pediatric unilateral renal tumors in the US are treated with upfront nephrectomy and surgical staging. We applied enhanced recovery after surgery (ERAS) principles in care of children after Wilms nephrectomy. METHODS We reviewed records of pediatric unilateral nephrectomies for Wilms tumors, and analyzed tumor stage, surgical approach, length of operation, use of anesthesia adjuncts and catheters, diet advancement, hospital length of stay (LOS), and complications. Our ERAS protocol includes: parental education regarding discharge criteria and anticipated LOS, avoiding thoraco abdominal incisions, avoiding routine nasogastric tubes, clear liquids starting day of surgery, minimizing opiates, routine IV ketorolac use, and avoiding routine ICU stay. We examined the effects of our protocol on postoperative hospital LOS and complication rates. RESULTS Sixty six children (31 boys, mean age 3.8y, range 0-11.9) underwent unilateral total nephrectomy for Wilms tumor. Mean nephrectomy duration was 2.7 h. Post operatively, seven (11%) had temporary gastric tubes and 24 (36%) had epidural catheters. Ten (15%) recovered in the ICU. Patients were given regular diets mean of 1.9 days post op. Mean LOS was 3.7 days, with 56% of patients being discharged within 2-3 days. Presence of tumor thrombus, longer epidural catheter duration, delayed diet advancement, and total IV narcotic usage were associated with longer LOS. Routine use of IV ketorolac was associated with shorter LOS. CONCLUSIONS Use of an ERAS protocol in children undergoing nephrectomy for Wilms tumor is safe, resulting in rapid return to regular diet and compared to the published literature, shorter postoperative LOS without an increase in complications or return to ED/OR. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- James K Moon
- Division of General, Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA; Department of General Surgery, Mount Sinai Hospital, New York, NY, USA.
| | - Rosa Hwang
- Division of General, Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Frank M Balis
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Peter Mattei
- Division of General, Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
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Ali S, Latif T, Sheikh MA, Shafiq MB, Zahra DEZ, Abu Bakar M. Review of Perioperative Care Pathway for Children With Renal Tumors. Cureus 2022; 14:e24928. [PMID: 35706749 PMCID: PMC9187842 DOI: 10.7759/cureus.24928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2022] [Indexed: 11/05/2022] Open
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Saltzman AF, Carrasco A, Hecht S, Walker J, Caldwell BT, Bruny JL, Cost NG. A decision tree to guide long term venous access placement in children and adolescents undergoing surgery for renal tumors. J Pediatr Surg 2020; 55:1334-1338. [PMID: 31128844 DOI: 10.1016/j.jpedsurg.2019.04.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 04/25/2019] [Accepted: 04/28/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND/PURPOSE While many children with renal tumors require long term venous access (VA) for adjuvant chemotherapy, certainly not all do. This study develops and tests a VA decision tree (DT) to direct the placement of VA in patients with renal tumors. METHODS Utilizing data readily available at surgery a VADT was developed. The VADT was tested retrospectively by 2 independent reviewers on a historic cohort. The ability of the VADT to appropriately select which patients would benefit from VA placement was tested. RESULTS 160 patients underwent renal tumor surgery between 2005 and 2018. 70 (43.8%) patients met study criteria with median age of 45.1 months (range 1.1-224); 73% required VA. Using the VADT, VA placement was "needed" in 67.1% of patients and "deferred" in 32.9%. Interrater reliability was very high (kappa = 0.97, 95% CI 0.91-1, p < 0.001). The sensitivity and specificity of the VADT to correctly decide on VA placement were 0.92 (0.8-0.98) and 1 (0.79-1). Using the VADT, no patient would have undergone unnecessary VA placement. In reality, 4.3% of patients had an unnecessary VA placed which required a subsequent removal. CONCLUSIONS These preliminary data support the continued study of this VADT to guide intraoperative decisions regarding VA placement in patients with renal tumors. LEVEL OF EVIDENCE III - Study of diagnostic test.
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Affiliation(s)
- Amanda F Saltzman
- Department of Urology, University of Kentucky, Lexington, KY; Department of Surgery, Division of Urology, University of Colorado and Children's Hospital Colorado, Aurora, CO
| | - Alonso Carrasco
- Department of Surgery, Division of Urology, University of Colorado and Children's Hospital Colorado, Aurora, CO; Department of Pediatric Urology, Kansas Mercy Children's Hospital, Kansas City, MO
| | - Sarah Hecht
- Department of Surgery, Division of Urology, University of Colorado and Children's Hospital Colorado, Aurora, CO
| | - Jonathan Walker
- Department of Surgery, Division of Urology, University of Colorado and Children's Hospital Colorado, Aurora, CO
| | - Brian T Caldwell
- Department of Surgery, Division of Urology, University of Colorado and Children's Hospital Colorado, Aurora, CO
| | - Jennifer L Bruny
- Department of Surgery, Division of Pediatric Surgery, University of Colorado and Children's Hospital Colorado, Aurora, CO
| | - Nicholas G Cost
- Department of Surgery, Division of Urology, University of Colorado and Children's Hospital Colorado, Aurora, CO.
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Waters AM, Mathis MS, Beierle EA, Russell RT. A Synopsis of Pediatric Patients With Hepatoblastoma and Wilms Tumor: NSQIP-P 2012-2016. J Surg Res 2019; 244:338-342. [PMID: 31310947 DOI: 10.1016/j.jss.2019.06.064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 04/18/2019] [Accepted: 06/14/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND Hepatoblastoma and Wilms tumor are the most common primary liver and kidney tumor in children, respectively, and little is documented about patient outcomes in the immediate perioperative period. The aim of this study was to analyze the short-term outcomes of pediatric patients after surgical resection for hepatoblastoma and Wilms tumor. METHODS We queried the 2012-2016 ACS National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database for patients with hepatoblastoma who underwent liver resection and patients with Wilms tumor who underwent a partial or total nephrectomy. Patient demographics, preoperative, intraoperative, and postoperative characteristics were analyzed. Multivariate logistic regression was used to determine independent risk factors for unplanned reoperations. RESULTS There were a total of 189 patients with hepatoblastoma and 586 patients with Wilms in National Surgical Quality Improvement Program-Pediatric. The mean age of patients with hepatoblastoma was 3.1 y and 4.2 y in the Wilms group. Nine percent (n = 17) of patients underwent an unplanned reoperation after hepatectomy, and 4.1% (n = 24) of patients with Wilms experienced an unplanned reoperation. Over half of patients with hepatoblastoma (59.8%, n = 113) and 29.7% (n = 174) patients with Wilms tumor received a blood transfusion in the perioperative period. Patients in both groups demonstrated low rates of surgical site infections, but 6.3% (n = 12) of hepatoblastoma patients showed evidence of sepsis. CONCLUSIONS This study will allow providers to more effectively counsel families of the common morbidities in the associated perioperative period following surgical resection of either solid tumor type including the substantial risk of blood transfusion.
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Affiliation(s)
- Alicia M Waters
- Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL
| | - Michelle S Mathis
- Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL
| | - Elizabeth A Beierle
- Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL
| | - Robert T Russell
- Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL.
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