Pain management, fluid therapy and thromboprophylaxis after pancreatoduodenectomy: a worldwide survey among surgeons

Groen, Jesse V.; Henrar, Rutger B; Sawires, Randa G Hanna; Aleassa, Essa M.; Martini, C.H.; Bonsing, Bert A.; Vahrmeijer, Alexander L.; Besselink, Marc G.; Pecorelli, Nicolò; Hackert, Thilo; Ishizawa, Takeaki; Miller, Timothy E.; Mungroop, Timothy H.; Samra, Jaswinder S.; Sauvanet, Alain; Adham, Mustapha; Demartines, Nicolas; Christophi, Christopher; Morris‐Stiff, Gareth; Mieog, J. Sven D.

doi:10.1016/j.hpb.2021.09.006

Cited by 5 publications

(14 citation statements)

References 27 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…However, rather than focusing on the exact opioid volumes, we emphasize that the learning health system model of iterative opioid reduction is freely adaptable by other hospitals. Although the global experience of post–pancreatic resection care may be different than our US hospital, the components of our enhanced recovery program, including the purposeful opioid reduction protocols, can benefit patients regardless of international differences in LOS . While numerical pain scores and refill rates following discharge are an acceptable measure of pain control, we did not solicit patient feedback (through surveys) regarding their pain control expectations or postoperative quality of life.…”

Section: Discussionmentioning

confidence: 99%

Opioid-Free Discharge After Pancreatic Resection Through a Learning Health System Paradigm

Boyev,

Jain,

Newhook

et al. 2023

JAMA Surg

View full text Add to dashboard Cite

ImportancePostoperative opioid overprescribing leads to persistent opioid use and excess pills at risk for misuse and diversion. A learning health system paradigm using risk-stratified pancreatectomy clinical pathways (RSPCPs) may lead to reduction in inpatient and discharge opioid volume.ObjectiveTo analyze the outcomes of 2 iterative RSPCP updates on inpatient and discharge opioid volumes.Design, Setting, and ParticipantsThis cohort study included 832 consecutive adult patients at an urban comprehensive cancer center who underwent pancreatic resection between October 2016 and April 2022, comprising 3 sequential pathway cohorts (version [V] 1, October 1, 2016, to January 31, 2019 [n = 363]; V2, February 1, 2019, to October 31, 2020 [n = 229]; V3, November 1, 2020, to April 30, 2022 [n = 240]).ExposuresAfter V1 of the pathway established a baseline and reduced length of stay (n = 363), V2 (n = 229) updated patient and surgeon education handouts, limited intravenous opioids, suggested a 3-drug (acetaminophen, celecoxib, methocarbamol) nonopioid bundle, and implemented the 5×-multiplier (last 24-hour oral morphine equivalents [OME] multiplied by 5) to calculate discharge volume. Pathway version 3 (n = 240) required the nonopioid bundle as default in the recovery room and scheduled conversion to oral medications on postoperative day 1.Main Outcomes and MeasuresInpatient and discharge opioid volume in OME across the 3 RSPCPs were compared using nonparametric testing and trend analyses.ResultsA total of 832 consecutive patients (median [IQR] age, 65 [56-72] years; 410 female [49.3%] and 422 male [50.7%]) underwent 541 pancreatoduodenectomies, 285 distal pancreatectomies, and 6 other pancreatectomies. Early nonopioid bundle administration increased from V1 (acetaminophen, 320 patients [88.2%]; celecoxib or anti-inflammatory, 98 patients [27.0%]; methocarbamol, 267 patients [73.6%]) to V3 (236 patients [98.3%], 163 patients [67.9%], and 238 patients [99.2%], respectively; P &lt; .001). Total inpatient OME decreased from a median 290 mg (IQR, 157-468 mg) in V1 to 184 mg (IQR, 103-311 mg) in V2 to 129 mg (IQR, 75-206 mg) in V3 (P &lt; .001). Discharge OME decreased from a median 150 mg (IQR, 100-225 mg) in V1 to 25 mg (IQR, 0-100 mg) in V2 to 0 mg (IQR, 0-50 mg) in V3 (P &lt; .001). The percentage of patients discharged opioid free increased from 7.2% (26 of 363) in V1 to 52.5% (126 of 240) in V3 (P &lt; .001), with 187 of 240 (77.9%) in V3 discharged with 50 mg OME or less. Median pain scores remained 3 or lower in all cohorts, with no differences in postdischarge refill requests. A subgroup analysis separating open and minimally invasive surgical cases showed similar results in both groups.Conclusions and RelevanceIn this cohort study, the median total inpatient OME was halved and median discharge OME reduced to zero in association with a learning health system model of iterative opioid reduction that is freely adaptable by other hospitals. These findings suggest that opioid-free discharge after pancreatectomy and other major cancer operations is realistic and feasible with this no-cost blueprint.

show abstract

Section: Discussionmentioning

confidence: 99%

Opioid-Free Discharge After Pancreatic Resection Through a Learning Health System Paradigm

Boyev,

Jain,

Newhook

et al. 2023

JAMA Surg

View full text Add to dashboard Cite

show abstract

“…The reported use of EA varies from 11% to 85%, 1 and a recent international survey showed that only 61% of surgeons regularly follow ERAS protocols. 7 Other acute pain management options include continuous wound infiltration, spinal or intrathecal (IT) blocks, and regional blocks such as transversus abdominis plane (TAP) blocks. In North America, TAP block was ranked as the most commonly used technique for analgesia, but there is a lack of research on the effectiveness of this strategy for PD.…”

Section: Introductionmentioning

confidence: 99%

“…In North America, TAP block was ranked as the most commonly used technique for analgesia, but there is a lack of research on the effectiveness of this strategy for PD. 7 With substantial variability in current clinical practice and the paucity of data, further research is needed to determine the optimal method for pain control after open PD that uses an opioid-sparing approach. The current study aims to evaluate our institutional experience and compare the effectiveness of EA, IT morphine blocks, and regional TAP blocks for open PD.…”

Section: Introductionmentioning

confidence: 99%

Comparison of epidural infusion versus intrathecal morphine block as part of enhanced recovery after open pancreatoduodenectomy

El‐Mallah,

Greene,

Clegg

et al. 2024

Journal of Surgical Oncology

View full text Add to dashboard Cite

Background and ObjectivesThe accepted approach to pain management following open pancreatoduodenectomy (PD) remains controversial, with the most recent enhanced recovery after surgery (ERAS) protocols recommending epidural anesthesia (EA). Few studies have investigated intrathecal (IT) morphine, combined with transversus abdominis plane (TAP) blocks. We aim to compare the different approaches to pain management for open PD.MethodsPatients who underwent open PD at our institution from 2020 to 2022 were included in the study. Patient characteristics, pain management, and postoperative outcomes between EA, IT morphine with TAP blocks, and TAP blocks only were compared using univariate analysis.ResultsFifty patients were included in the study (58% male, median age 66 years [interquartile range, IQR: 58–73]). Most patients received IT morphine (N = 24, 48%) or EA (N = 18, 36%). The TAP block‐only group required higher doses of postoperative narcotics while hospitalized (p = 0.004) and at discharge (p = 0.017). The IT morphine patients had a shorter median time to Foley removal (p = 0.007). Postoperative pain scores, non‐opioid administration, postoperative bolus requirements, postoperative outcomes, and length of stay were similar between pain modalities.ConclusionsIT morphine and EA showed comparable efficacy with superior results compared to TAP blocks alone. Integration of IT morphine into PD ERAS protocols should be considered.

show abstract

“… 2–6 The most used alternative to EA is intravenous (iv) morphine. 1–3 , 7 _ENREF_3 The advantages of iv morphine are that most patients are eligible (eg patients with coagulation disorders or spine anatomy alterations) and that it is a less invasive method compared to EA. The disadvantages of iv morphine are the suboptimal pain control and a higher consumption of opioids compared to EA with associated side effects.…”

Section: Introductionmentioning

confidence: 99%

Sublingual Sufentanil versus Standard-of-Care (Patient-Controlled Analgesia with Epidural Ropivacaine/Sufentanil or Intravenous Morphine) for Postoperative Pain Following Pancreatoduodenectomy: A Randomized Trial

Groen¹,

Boon²,

Minderhoud³

et al. 2022

JPR

View full text Add to dashboard Cite

Background The optimal treatment strategy for postoperative pain following pancreatoduodenectomy remains unknown. The aim of this study was to investigate whether sublingual sufentanil tablet (SST) is a non-inferior analgesic compared to our standard-of-care (patient-controlled epidural analgesia [PCEA] or PCA morphine) in the treatment of pain following pancreatoduodenectomy. Methods This was a pragmatic, strategy, open-label, non-inferiority, parallel group, randomized (1:1) trial. The primary outcome was an overall mean pain score (Numerical Rating Scale: 0–10) on postoperative days 1 to 3 combined. The non-inferiority margin was −1.5 since this difference was considered clinically relevant. Results Between October 2018 and July 2021, 190 patients were assessed for eligibility and 36 patients were included in the final analysis: 17 patients were randomized to SST and 19 patients to standard-of-care. Early treatment failure in the SST group occurred in 2 patients (12%) due to inability to operate the SST system and in 2 patients (12%) due to severe nausea despite antiemetics. Early treatment failure in the standard-of-care group occurred in 2 patients (11%) due to preoperative PCEA placement failure and in 1 patient (5%) due to hemodynamic instability caused by PCEA. The mean difference in pain score on postoperative day 1 to 3 was −0.10 (95% CI −0.72–0.52), and therefore the non-inferiority of SST compared to standard-of-care was demonstrated. The mean pain score, number of patients reporting unacceptable pain (pain score >4), Overall Benefit of Analgesia Score, and patient satisfaction per postoperative day, perioperative hemodynamics and postoperative outcomes did not differ significantly between groups. Conclusion This first randomized study investigating the use of SST in 36 patients following pancreatoduodenectomy showed that SST is non-inferior compared to our standard-of-care in the treatment of pain on postoperative days 1 to 3. Future research is needed to confirm that these findings are applicable to other settings.

show abstract

Pain management, fluid therapy and thromboprophylaxis after pancreatoduodenectomy: a worldwide survey among surgeons

Cited by 5 publications

References 27 publications

Opioid-Free Discharge After Pancreatic Resection Through a Learning Health System Paradigm

Opioid-Free Discharge After Pancreatic Resection Through a Learning Health System Paradigm

Comparison of epidural infusion versus intrathecal morphine block as part of enhanced recovery after open pancreatoduodenectomy

Sublingual Sufentanil versus Standard-of-Care (Patient-Controlled Analgesia with Epidural Ropivacaine/Sufentanil or Intravenous Morphine) for Postoperative Pain Following Pancreatoduodenectomy: A Randomized Trial

Contact Info

Product

Resources

About