Deborah S Keller, MS, MD1, David R Flum, MD, FACS2. 1Baylor University Medical Center, 2University of Washington Medical Center
Background: The concept and benefits of enhanced recovery after surgery (ERAS) has been well established in colorectal surgery. While multimodal pain management is a tenet of ERAS, the ideal protocol is yet to be established, and no prior survey of current use of available agents has been performed. Our goal was to assess the current utilization of common, multimodal pain management interventions and their impact on outcomes in laparoscopic colorectal surgery. Our hypothesis was use of multiple agents in synergy improves patient and financial outcomes.
Methods: Review of the Premier Perspective national inpatient database was performed for patients undergoing elective laparoscopic colorectal surgery between 7/1/13 and 11/30/14. Patients were stratified into 3 groups by pain control regimen: 1) Ofirmev and Ketoralac only; 2) Ofirmev, Ketoralac, and Exparel, and 3) No Ofirmev, Ketoralac or Exparel (control). Propensity score matching was used to compare differences between two sets of treatment regimens: 1) Ofirmev and Ketoralac only vs. Ofirmev, Ketoralac and Exparel and 2) Ofirmev, Ketoralac and Exparel vs. control. The main outcome measures were length of stay (LOS), ICU utilization, total costs, postoperative complications, opioid related adverse effects (ORAE), readmissions, and mortality in each cohort.
Results: During the study period, 18,161 laparoscopic colorectal procedures were evaluated- 14% (2,578) used Ofirmev and Ketoralac, 2% (402) used Ofirmev, Ketoralac and Exparel, and 31% (5,600) used none of the opioid-sparing agents. Groups were well matched in patient, procedure, and hospital demographics. In the adjusted analysis, compared to controls, use of a multimodal regimen with Ofirmev, Ketoralac and Exparel significantly reduced mean LOS (7.0 vs. 5.5 days, p<0.001), ICU days (9.7% vs. 5.6%, p=0.04), and total costs ($14,718 vs. $12,091, p=0.001). Using the combination of Ofirmev, Ketoralac and Exparel compared to Ofirmev and Ketoralac alone revealed a greater benefit in total costs ($12,101 vs. $15,501, p<0.001) and ORAE (15.6% vs. 16.5%, p<0.001), in addition to reducing LOS (5.6 vs. 5.9 days, p<0.001).
Conclusions: Our study demonstrates multimodal opioid-sparing pain management is underutilized in elective laparoscopic colorectal surgery in the US. The benefit of using multiple agents was supported with the improvements in cost and quality outcomes for Ofirmev, Ketoralac and Exparel versus Ofirmev and Ketoralac alone and no agents. These results suggest an overall cost-benefit with opioid-sparing agents, and support increased adoption of multimodal regimens in enhanced recovery after surgery protocols.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 78895
Program Number: S041
Presentation Session: Colorectal 1
Presentation Type: Podium