Cohort
Five hundred and ninety-two patients underwent elective colon and/or rectal resection between 2015 to 2018 at a single tertiary institution (Table 1). The mean age was 57.3 years (range 19.2 – 95.2 years), 54.2% female. Comorbidities included hypertension (40.7%), diabetes (15.0%), COPD (6.4%), and current smoking (22.1%). Preoperative steroid use was present in 104 patients (17.6%) and weight loss > 10% within the last 6 months in 44 patients (7.4%). Pre-surgery status was evaluated with American Society of Anesthesiologists (ASA) scoring system and patients ranged: ASA 1 (3.4%), ASA 2 (56.6%), ASA 3 (38.5%), and ASA 4 (1.5%). Approximately 40% of patients had one or more psychiatric diagnoses (Table 2), with 64.4% of these patients taking one or more prescription psychiatric medications. The most common conditions included major depression (22.1%), anxiety (18.6%), and substance abuse (14.0%). Several patients (8.6%) were taking a psychotropic medication without an associated psychiatric diagnosis.
Table 1: Patient Demographics. Original table.
|
Demographic
|
Mean (range)
|
Age
|
57.3 (19.2-95.2)
|
BMI
|
29.2 (14.1-60.3)
|
Demographic and Category
|
n (%)
|
Female
|
321 (54.2)
|
Insulin-dependent diabetes mellitus
|
26 (4.4)
|
Non-insulin dependent diabetes mellitus
|
63 (10.6)
|
Current smoker within one year
|
131 (22.1)
|
COPD
|
38 (6.4)
|
Hypertension requiring medication
|
241 (40.7)
|
Steroid use for chronic condition
|
104 (17.6)
|
> 10% weight loss in 6 months
|
44 (7.4)
|
Indication
|
|
Malignancy
|
299 (50.5)
|
Crohn's disease and ulcerative colitis
|
112 (19.0)
|
Diverticulitis
|
95 (16.0)
|
Non-malignant polyp and other
|
86 (14.5)
|
ASA
|
|
1
|
20 (3.4)
|
2
|
335 (56.6)
|
3
|
228 (38.5)
|
4
|
9 (1.5)
|
Preoperative Abdominal Pain
|
333 (60.9)
|
Minimally Invasive Incisions
|
214 (36.1)
|
Open Incisions a
|
378 (63.9)
|
a Minimally invasive incisions include extraction sites, laparoscopic and robotic ports.
Open incisions are midline and Pfannenstiel incisions, through which a significant portion of dissection was performed, even if minimally invasive technique was used for another part of dissection.
Table 2: DSM-V diagnoses, medical treatments, and preoperative pain medications Original table
|
Psychiatric Diagnosisa
|
|
Depressive Disorders
|
131 (22.1)
|
Anxiety Disorders
|
110 (18.6)
|
Substance Abuse
|
83 (14.0)
|
Psychoactive Medicationsb
|
|
Benzodiazepine
|
90 (15.2)
|
Selective Serotonin Reuptake Inhibitors
|
83 (14.0)
|
Anxiolytics, Sedatives & Hypnotics
|
40 (6.8)
|
Serotonin Norepinephrine Reuptake Inhibitors
|
29 (4.9)
|
Preoperative Pain Medications
|
|
Acetaminophen
|
156 (26.4)
|
Opioids
|
173 (29.2)
|
NSAIDs
|
79 (13.3)
|
GABA Analogue
|
41 (6.9)
|
Muscle Relaxant
|
28 (4.7)
|
a Neurocognitive disorder, sleep-wake disorders, trauma and stress disorders, schizophrenia, personality disorders, neurodevelopmental disorders, somatic symptom disorders, obsessive-compulsive disorders, and bipolar disorders each represented <1.5% of patients
b Anti-convulsants, tricyclic and tetracyclic antidepressants, antimigraine agents, atypical antipsychotics, anti-psychotics, central nervous system stimulants were used by <5% of patients
Preoperatively, many patients reported abdominal pain (60.9%). Most patients were opioid naive (70.8%) with pre-existing use of non-opioid pain medication use including NSAIDs (13.3%), gabapentin (6.9%), and muscle relaxants (4.7%) (Table 2). Patients using opioids preoperatively reported use due to tumor related factors, inflammatory bowel disease (IBD) associated abdominal pain, and previous surgeries. Some opioid prescriptions were for chronic pain syndromes.
The most common indication for surgery was malignancy (50.5%), followed by IBD (18.9%), and diverticulitis (16.0%). Open approach was more frequent than laparoscopic (63.9% versus 36.1%). Perioperative adjuvant pain control included lidocaine (65.9%), acetaminophen (26.4%), NSAIDS (13.3%), and epidural (6.1%). Contraindications to perioperative lidocaine use were hypotension, significant hepatic or renal insufficiency, and seizure disorders, as well as epidural use. A minority of patients required consultation to acute pain service (8.3%).
The mean postoperative length of stay was 6.2 days (std dev: 4.3) with mean total hospital MME being 371.4 units (std dev: 367.3). MME requirements were greatest on POD 0 (MME = 152.1, std dev = 82.6) and subsequently decreased from POD1-3. Opioid naive patients required fewer opioids overall but followed a similar tapering trend from POD0-3. Almost half of patients (44.6%) had a postoperative opioid-related complication, including but not limited to urinary retention, falls, nausea/vomiting, pruritus, and ileus. Both opioid and non-opioid medications were prescribed at discharge and these amounts were not standardized. Almost all patients were discharged with an opioid prescription (94.3%). Adjunct pain medications upon discharge included acetaminophen (64.4%), NSAIDs (7.3%), gabapentin (7.6%), and muscle relaxants (5.1%).
Follow-up data was available for almost all patients (590/592) (Table 2). First postoperative visits were done on average of 15.8 days (range: 1-120 days) after discharge. Some patients requested an early refill on opioids before their first postoperative visit (11.2%) and a portion required a refill at their first postoperative visit (13.2%).
Univariate analysis
In univariate analysis (Table 3) of MME requirements POD0-POD3, increased usage was associated with patients who were younger, male, and comorbidities including current smoking, steroid use, and psychiatric diagnoses and medications. Increased opioid use was also associated with patients who experienced preoperative abdominal pain, as well as received preoperative opioids, intraoperative epidurals, and postoperative NSAIDs. Decreased MME requirements were associated with non-diabetic and non-insulin dependent diabetic patients, patients with dyspnea, or hypertension requiring medication. Patients who received perioperative lidocaine were associated with decreased MME requirement. Other demographic factors and incision type were not significantly associated with increased MME requirements in the immediate postoperative period.
Table 3: Univariate Analysis Results of Post-Operative Opiate Use (POD 0-3) Original table
|
Factor
|
Beta
|
95% Confidence Interval
|
p value
|
Current Smoker within one year
|
94.7
|
63.3 126.2
|
<0.01
|
Pre-op Opioids
|
88.0
|
59.3 116.6
|
<0.01
|
Number of psychiatric medications (2+ compared to 0)
|
81.9
|
42.6 121.2
|
<0.01
|
Number of psychiatric medications (1 compared to 0)
|
43.3
|
9.9 76.6
|
Pre-op Abdominal Pain
|
75.9
|
47.8 104.1
|
<0.01
|
Steroid use for chronic condition
|
68.6
|
33.7 103.5
|
<0.01
|
Number of psychiatric diagnoses (2+ compared to 0)
|
58.5
|
21.4 95.6
|
<0.01
|
Post-op NSAID
|
45.2
|
14.0 76.3
|
<0.01
|
Epidural
|
36.0
|
86.1 196.3
|
<0.01
|
Number of psychiatric diagnoses (1 compared to 0)
|
35.8
|
3.4 68.2
|
<0.01
|
Age (unit = 1)
|
-4.8
|
-5.7 -4.0
|
<0.01
|
Insulin dependent diabetes mellitus
|
-17.9
|
-83.2 47.4
|
0.02
|
Non-insulin dependent diabetes mellitus
|
-63.4
|
-106.8 -20.0
|
Female
|
-37.0
|
-63.8 -10.2
|
<0.01
|
Hypertension requiring medication
|
-70.8
|
-97.6 -44.1
|
<0.01
|
Dyspnea with moderate exertion
|
-102.5
|
-165.3 -39.8
|
<0.01
|
Multivariable analysis
Multivariable analysis (Table 4) performed on variables of significance identified on univariate analysis found the following persisted in association with increased total MME requirements POD0-POD3: younger age, male gender, and current smoker status. For each year decrease in age, MME usage was associated with an increase by 3.7 units on average (β = 3.7; 95% CI 2.8 - 4.6; p<0.01). Male gender was associated with mean increased MME requirements of 41.6 units total (β = 41.6; 95% CI 17.4 - 65.7; p<0.01). Current smokers were associated with an increased MME requirement of 44.4 units on average (β = 44.4; 95% CI 14.9 - 73.9; p<0.01). However, steroid use for chronic conditions, psychiatric diagnoses and active use of psychiatric medications, diabetes mellitus, dyspnea, and hypertension, were no longer associated with altered MME requirements.
Table 4: Multivariable Regression Analysis of Post-Operative Opioid Use (POD 0-3) Original table
|
Factor
|
Beta
|
95% Confidence Interval
|
p value
|
Epidural
|
94.1
|
42.5 145.8
|
<0.01
|
Pre-op Opioids
|
52.0
|
23.8 80.1
|
<0.01
|
Pre-op Abdominal Pain
|
45.2
|
19.4 71.1
|
<0.01
|
Current Smoker within one year
|
44.4
|
14.9 73.9
|
<0.01
|
Age (unit = 1)
|
-3.7
|
-4.6 -2.8
|
<0.01
|
Female
|
-41.6
|
-65.7 -17.4
|
<0.01
|
Number of psychiatric medications (1 compared to 0)
|
30.1
|
-0.3 60.6
|
0.11
|
Number of psychiatric medications (2+ compared to 0)
|
23.4
|
-13.3 60.1
|
Post-op NSAID
|
21.8
|
-7.28 50.9
|
0.14
|
Insulin dependent diabetes mellitus
|
13.9
|
-47.0 74.9
|
0.50
|
Non-insulin dependent diabetes mellitus
|
-21.1
|
-61.3 19.1
|
Open Incision (vs MIS)
|
5.8
|
-19.07 30.7
|
0.65
|
Steroid use for chronic condition
|
2.3
|
-31.0 35.6
|
0.89
|
Hypertension requiring medication
|
-10.4
|
-38.1 17.3
|
0.46
|
Dyspnea with moderate exertion
|
-45.7
|
-102.3 10.9
|
0.11
|
On multivariable analysis, patients who did not receive preoperative lidocaine had an associated average MME increase of 29.4 units (β = 29.4, 95% CI 3.6 - 55.3, p=0.03). Preoperative abdominal pain was associated with an average MME increase of 45.2 units (β = 45.2, 95% CI 19.4 - 71.1, p<0.01). Preoperative opioid use was associated with an average MME increase of 52.0 units (β = 52.0, 95% CI 23.8 - 80.1, p<0.01). Application of an epidural was associated with an average MME increase of 94.1 units (β = 94.1, 95% CI 42.5 - 145.8, p<0.01). However, postoperative NSAID use (p=0.14) and incision type (p=0.65) were not associated with an influence in MME requirements.