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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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Reppucci ML, Wehrli LA, Schletker J, Nolan MM, Rieck J, Fares S, Ketzer J, Rove K, Pena A, de la Torre L, Bischoff A. The effect of an enhanced recovery protocol in pediatric patients who undergo colostomy closure and Malone procedures. Pediatr Surg Int 2022; 38:1701-1707. [PMID: 36098796 DOI: 10.1007/s00383-022-05213-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/02/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Pediatric colorectal studies have shown enhanced recovery after surgery (ERAS) protocols can safely improve outcomes. This study sought to determine the impact of an ERAS pathway on the outcomes of children with colorectal conditions who underwent colostomy closure or Malone procedure. METHODS A single-institution, retrospective cohort study of children who underwent colostomy closure or Malone procedure between 2016 and 2020 was performed. Differences in outcomes between pre-ERAS and ERAS cohorts were tested. A sub-analysis based on procedure type was performed. RESULTS There were 96 patients included: 22 prior to ERAS implementation and 74 after. Patients who underwent ERAS had shorter mean time (hours) to oral intake, mean days until regular diet, post-operative opioid volume, and median length of stay (p < 0.05). There was no difference in complication rates in the ERAS and pre-ERAS cohort (12.2 vs 9.1%, p = 0.99). Patients who underwent colostomy closure after ERAS had lower post-operative opioid use, but no differences were seen in those who underwent Malone. CONCLUSION Implementation of an ERAS protocol resulted in quicker time to oral intake, normal diet, and decreased opioid use without increasing complication rates. Differences seen based on procedure type may reflect that the effect of an ERAS protocol is procedure specific.
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Affiliation(s)
- Marina L Reppucci
- International Center for Colorectal and Urogenital Care, Division of Pediatric Surgery, Anschutz Medical Campus, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Aurora, CO, 80045, USA
| | - Lea A Wehrli
- International Center for Colorectal and Urogenital Care, Division of Pediatric Surgery, Anschutz Medical Campus, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Aurora, CO, 80045, USA
| | - Julie Schletker
- International Center for Colorectal and Urogenital Care, Division of Pediatric Surgery, Anschutz Medical Campus, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Aurora, CO, 80045, USA
| | - Margo M Nolan
- International Center for Colorectal and Urogenital Care, Division of Pediatric Surgery, Anschutz Medical Campus, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Aurora, CO, 80045, USA
| | - Jared Rieck
- Research in Outcomes in Children's Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | - Souha Fares
- Research in Outcomes in Children's Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | - Jill Ketzer
- International Center for Colorectal and Urogenital Care, Division of Pediatric Surgery, Anschutz Medical Campus, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Aurora, CO, 80045, USA
| | - Kyle Rove
- Department of Pediatric Urology, Children's Hospital Colorado, Aurora, CO, USA
| | - Alberto Pena
- International Center for Colorectal and Urogenital Care, Division of Pediatric Surgery, Anschutz Medical Campus, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Aurora, CO, 80045, USA
| | - Luis de la Torre
- International Center for Colorectal and Urogenital Care, Division of Pediatric Surgery, Anschutz Medical Campus, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Aurora, CO, 80045, USA
| | - Andrea Bischoff
- International Center for Colorectal and Urogenital Care, Division of Pediatric Surgery, Anschutz Medical Campus, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Aurora, CO, 80045, USA.
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Orthopaedic, trauma surgery, and Covid-2019 pandemic: clinical panorama and future prospective in Europe. Eur J Trauma Emerg Surg 2022; 48:4385-4402. [PMID: 35523966 PMCID: PMC9075714 DOI: 10.1007/s00068-022-01978-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 04/16/2022] [Indexed: 12/13/2022]
Abstract
Purpose This study investigated the impact of the Covid-19 pandemic in Europe on consultations, surgeries, and traumas in the field of orthopaedic and trauma surgery. Strategies to resume the clinical activities were also discussed. Methods This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the 2020 PRISMA statement. All the comparative studies reporting data on the impact of Covid-19 in the field of orthopaedic and trauma surgery in Europe were accessed. Only comparative clinical studies which investigated the year 2020 versus 2019 were eligible. Results 57 clinical investigations were included in the present study. Eight studies reported a reduction of the orthopaedic consultations, which decreased between 20.9 and 90.1%. Seven studies reported the number of emergency and trauma consultations, which were decreased between 37.7 and 74.2%. Fifteen studies reported information with regard to the reasons for orthopaedic and trauma admissions. The number of polytraumas decreased between 5.6 and 77.1%, fractures between 3.9 and 63.1%. Traffic accidents admissions dropped by up to 88.9%, and sports-related injuries dropped in a range of 59.3% to 100%. The overall reduction of the surgical interventions ranged from 5.4 to 88.8%. Conclusion The overall trend of consultations, surgeries, and rate of traumas and fragility fractures appear to decrease during the 2020 European COVID pandemic compared to the pre-pandemic era. Given the heterogeneities in the clinical evidence, results from the present study should be considered carefully. Level of evidence Level IV, systematic review.
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