Deborah S Keller, MS, MD, Madhu Ragupathi, MD, Reena Tahilramani, MD, Jean Paul LeFave, MD, Juan R Flores-Gonzales, MD, Sergio Ibarra, MD, Eric M Haas, MD, FACS, FASCRS. Colorectal Surgical Associates
Introduction: Our objective was to evaluate postoperative pain, narcotic use, and length of stay using a novel multimodal pain management protocol.
Methods and Procedures: Consecutive patients undergoing elective minimally invasive colorectal resection were managed with a SMART protocol. The protocol uses a post-induction, pre-incision bilateral TAP block (20 ml long-acting liposomal Bupivacaine, 30 ml 0.25% Bupivacaine, 30 ml Saline), limited intraoperative opioids (<150 mcg Fentanyl), and local peritoneal port-site infiltration with long-acting liposomal Bupivacaine. SMART patients were matched on age, body mass index (BMI), gender, comorbidities, and procedure to a control group. All followed a standardized postoperative Enhanced Recovery Pathway. Demographic and perioperative outcomes were collected. The main outcome measures were postoperative pain, opioid use and length of stay. Drug utilization was described using the World Health Organization’s Defined Daily Dose (DDD).
Results: 35 patients were analyzed: 17 SMART and 18 controls. Age, gender, BMI, ASA, and procedure were comparable across groups. The main diagnosis and primary procedure in both groups were colorectal cancer (38.9% control, 52.9% SMART) and segmental resection (77.8% control, 76.5% SMART), respectively. Operative times were similar between groups. By postoperative day 3, only 5 SMART patients continued opioid use. By postoperative day 4, only one SMART patient remained. One control had postoperative ileus; however, complication, readmission and reoperative rates were similar. The SMART group had significantly lower mean pain scores in the post anesthesia care unit (PACU) (p=0.05), lower opioid use throughout their hospitalization, and significantly shorter LOS (2.6 vs. 4.1 days, p=0.01) compared to controls.
Conclusions: Our multimodal pain management strategy has the potential to significantly impact patient and financial outcomes. Future trials are needed to fully evaluate its benefits.
| Postoperative Outcomes | Control (n=18) | SMART (n=17) | p-value |
|---|---|---|---|
| Median Operative Time (minutes, range) | 186.4 (52-310) | 163.1(64-360) | 0.46 |
| Median PACU Pain Score (range) | 4 (3-10) | 2 (0-4) | 0.05* |
| Mean Opioid Defined Daily Dose | |||
| POD #0 | 2.0 | 0.7 | <0.01* |
| POD #1 | 1.5 | 1.2 | |
| POD #2 | 1.6 | 1.2 | |
| POD #3 | 1.9 | 0.8 | |
| POD #4 | 4.3 | 2.2 | |
| POD #5 | 7.3 | 2.0 | |
| POD #6 | 3.8 | 2.0 | |
| POD #7 | 4.3 | ||
| POD# 8 | 5.0 | ||
| Mean LOS (days, SD) | 4.1 (2.5) | 2.6 (1.4) | 0.01* |
| Readmission (n, %) | 1 (5.5%) | 1.0 | |
| Reoperation (n, %) | 1 (5.5%) | 1.0 | |
| Postoperative Complications (n, %) | 2 (11.1%) | 2 (11.1%) | 1.0 |