Predictors of Opioid Related Adverse Events in Open and Laparoscopic Colorectal Surgery

Deborah S Keller, MS, MD1, David R Flum, MD, MPH, FACS2, Eric M Haas, MD, FACS, FASCRS3. 1Colorectal Surgical Associates, 2University of Washington, 3Colorectal Surgical Associates; Houston Methodist Hospital; University of Texas Medical Center at Houston

Background: Opioids remain a mainstay of postsurgical pain control despite the potential impact of opioid related adverse events (ORAEs) on patient outcomes and resource utilization. Our goal was to evaluate the incidence, predictors, and impact of ORAE in patients who underwent colorectal surgery.

Methods: The Premier Perspective national inpatient database was reviewed for patients undergoing a colorectal resection from 7/2013-11/2014. Patients were stratified into laparoscopic or open cohorts. The outcome measures were the incidence of ORAE (identified by ICD-9 diagnosis codes), opioid consumption (identified from charges), total hospital costs (estimated from cost to charge ratios), and resource utilization in patients with/without an ORAE. Multivariate logistic regression was used to evaluate factors associated with ORAEs in open and laparoscopic colorectal surgery.

Results: 35,008 patients were evaluated- 18,779 open and 16,229 laparoscopic. Median opioid consumption was 446 mg (inter-quartile range, 217.5-900) in the open group and 272 mg (inter-quartile range, 126-611) in the laparoscopic group. 26.2% of open and 24.7% of laparoscopic patients had a patient controlled analgesia for pain control. Rates of ORAE were 19.8% and 17.6% in the open and laparoscopic cohorts, respectively. The most common ORAE was ileus (10.9% open, 10.1% laparoscopic). The regression model found patients consuming >300mg of opiates, age >65, males, comorbidities of primary malignancy and chronic obstructive pulmonary disease, and undergoing abdominoperineal resection were associated with higher likelihood of ORAE in both open and laparoscopic cohorts. In the open procedure group, additional predictors included presence of congestive heart failure, obesity, chronic pain, and urgent/emergent cases. In the laparoscopic group, additional predictors included chronic renal failure and a total abdominal colectomy. On an unadjusted basis, patients who experienced an ORAE had significantly longer length of stay (9.8 vs. 10.8 days, p<0.01 open; 5.4 vs. 8.2 days, p<0.01 laparoscopic), higher mortality (2.9% vs. 3.9%, p<0.01 open; 0.31% vs. 1.2%, p<0.01 laparoscopic), and higher hospitalization costs ($21,459 vs. $24,712, p<0.01 open; $14,928 vs. $20,318, p<0.01 laparoscopic).  

Conclusions: Currently, nearly 20% of patients undergoing open and laparoscopic colorectal surgery experience an ORAE. ORAEs carry a significant clinical and financial burden, potentially increasing length of stay, costs, and mortality rate. This study found level of opiate consumption, age, gender, and comorbidities to be predictive of an ORAE. With ORAE incidence and predictors identified, preemptive measures can be taken to improve postoperative recovery and resource utilization.

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