Martin Alvarez, MD, Katherine Foley, MD, Steven A Fassler, MD, D M Zebley, MD, Soo Y Kim, MD. Department of Surgery, Abington Memorial Hospital.
A comprehensive enhanced recovery pathway (ERP) was implemented in patients undergoing laparoscopic colectomy in an attempt to reduce postoperative intravenous (I.V.) narcotic consumption. We hypothesized that improved local analgesia and increased use of non-narcotic pain medication combined with earlier feeding and ambulation would allow for earlier return of bowel function and shorter postoperative length of stay (LOS).
METHODS AND PROCEDURES
We retrospectively reviewed the charts of 89 patients who underwent elective partial laparoscopic colectomy in the first 6 months since our new ERP became fully integrated. Results were compared to a control group of 162 patients who underwent similar operations in the 9 months before its implementation. Differences between the ERP and control groups average return of bowel function, postoperative LOS, narcotic medication usage, and complications were compared statistically using the student’s t-test.
The ERP was a fully integrated program that included a laparoscopically guided transversus abdominis plane (TAP) local analgesic block performed by the surgeon at the time of surgery. Postoperative pain was controlled through scheduled doses of acetaminophen, greatly expanded use of non-steroidal anti-inflammatory drugs (ketorolac and ibuprofen), with the use of narcotics reserved for patients reporting severe pain. Patients were given an instruction sheet preoperatively that included expectations of early ambulation, diet with rapid progression as tolerated, and anticipated discharge criteria. Early ambulation was mandated and systematically enforced on postoperative day 1.
Patients in the ERP group had a significant decrease in the use of postoperative I.V. narcotics, earlier return of bowel function, and shorter postoperative hospital LOS. Narcotic use was reduced by 74% from 75 mg to 19 mg I.V. morphine (p = 0.0001). Patients had an average return of bowel function of 0.66 days earlier from post operative day (POD) 2.99 to POD 2.33 (p = 0.0001) and were discharged from the hospital 1.02 days sooner on POD 2.68 compared to POD 3.7 (p = 0.0013). There was no statistically significant difference in postoperative complications between the control and ERP groups with the most common complications being early postoperative small bowel obstruction/ileus (6.7% vs. 5.6%, p = 0.7937) and bleeding (4.3% vs. 6.7%, p = 0.5526).
The new ERP, including TAP block and postoperative pain medication protocol limiting I.V. narcotics, is effective in controlling pain in elective laparoscopic colectomy. Pain control management together with regimented early feeding and ambulation allow for significantly earlier return of bowel function and shorter postoperative LOS.