2019 General Surgery Presentations

Brooke A Pati, MD, Dylan M Russell, MD, Robert B Lim, MD, FACS; TAMC

INTRODUCTION: Enhanced recovery after surgery (ERAS) protocols integrate evidence-based interventions and utilize multimodal perioperative interventions which are designed to reduce physiological stress and accelerate recovery in patients undergoing major surgery. Enhanced recovery after bariatric surgery (ERAS-B) protocols are becoming more prevalent and often favor limited opioid regimens as a critical component. The current opioid crisis underscores the need to thoroughly investigate surgical protocols that limit opioid prescription. Published evidence is equivocal about how decreased opioid use affects length of stay. The purpose of this study is to determine if a bariatric limited opioid ERAS protocol reduces postoperative opioid medication use without increasing length of stay.

METHODS: A historically controlled prospective study comparing a non-limited opioid protocol (standard care) and a limited opioid bariatric protocol (ERAS-B) in patients undergoing bariatric surgery. The non-limited opioid protocol was employed between 10 January 2015 and 31 December 2017. The limited opioid (ERAS-B) protocol was employed between 01 January 2018 and 31 August 2018. All procedures were performed at Tripler Army Medical Center, a tertiary military treatment facility. Unpaired t-tests were used to compare continuous means; two-sample Z-tests were used to compare proportions. An alpha value of 0.05 was set for significance.

RESULTS: A total of 111 patients were included in this study - 57 patients were included in the non-limited opioid arm and 54 patients in the limited opioid arm. There was a significant difference in mean dose (mg) per day of morphine in the non-limited opioid group compared to the limited opioid group (7.76 ± 0.83 vs. 2.69 ± 0.31 days, p<0.05). The frequency of morphine use was significantly higher in the non-limited opioid group (mean difference [%], 52.5 ± 15.3, p <0.05).  The frequency of hydromorphone use was significantly higher in the non-limited opioid group (mean difference [%], 28.9 ± 16.3, p<0.05). Length of stay (days) was significantly longer in the non-limited opioid group (2.54 ± 0.37 vs.1.52 ± 0.17, p<0.05).

CONCLUSIONS: Opioid limited ERAS bariatric (ERAS-B) protocols significantly reduce opioid use without increasing length of stay.  Due to the severity of the current opioid epidemic, physicians should implement limited opioid protocols.