Prescription and consumption of opioids after bariatric surgery: a multicenter prospective cohort study.

INTRODUCTION: In the current opioid crisis, bariatric surgical patients are at increased risk of harms related to postoperative opioid overprescribing. This study aimed to assess the extent to which opioids prescribed at discharge after bariatric surgery are consumed by patients. METHODS: This multicenter prospective cohort study included adult patients (≥ 18yo) undergoing laparoscopic bariatric surgery. Preoperative assessments included demographics and patient-reported measures. Information regarding surgical and perioperative care interventions (including discharge prescriptions) was obtained from medical records. Self-reported opioid consumption was assessed weekly up to 30 days post-discharge. Number of opioid pills prescribed and consumed was compared using Wilcoxon signed-rank test. Zero-inflated negative binomial regression was used to identify predictors of post-discharge opioid consumption. RESULTS: We analyzed 351 patients (mean age 44 ± 11 years, BMI 45 ± 8.0 kg/m2, 77% female, 71% sleeve gastrectomy, length of stay 1.6 ± 0.6 days). The quantity of opioids prescribed at discharge (median 15 pills [IQR 15-16], 112.5 morphine milligram equivalents (MMEs) [IQR 80-112.5]) was significantly higher than patient-reported consumption (median 1 pill [IQR 0-5], 7.5 MMEs [IQR 0-37.5]) (p < 0.001). Overall, 37% of patients did not take any opioids post-discharge and 78.5% of the opioid pills prescribed were unused. Increased post-discharge opioid consumption was associated with male sex (IRR 1.54 [95%CI 1.14 to 2.07]), higher BMI (1.03 [95%CI 1.01 to 1.05]), preoperative opioid use (1.48 [95%CI 1.04 to 2.10]), current smoking (2.32 [95%CI 1.44 to 3.72]), higher PROMIS-29 depression score (1.03 [95% CI 1.01 to 1.04]), anastomotic procedures (1.33 [95%CI 1.01 to 1.75]), and number of pills prescribed (1.04 [95%CI 1.01 to 1.06]). CONCLUSION: This study supports that most opioid pills prescribed to bariatric surgery patients at discharge are not consumed. Patient and procedure-related factors may predict opioid consumption. Individualized post-discharge analgesia strategies with minimal or no opioids may be feasible and should be further investigated in future research.

Predictors of post-discharge pain and satisfaction with pain management after laparoscopic bariatric surgery: a prospective cohort study.

BACKGROUND: Pain management after bariatric surgery remains challenging given the risk for analgesia-related adverse events (e.g., opioid use disorder, marginal ulcers). Identifying modifiable factors associated with patient-reported pain outcomes may improve quality of care. We evaluated the extent to which patient and procedural factors predict 7-day post-discharge pain intensity, pain interference, and satisfaction with pain management after bariatric surgery. METHODS: This prospective cohort study included adults undergoing laparoscopic bariatric surgery at two university-affiliated hospitals and one private clinic. Preoperative assessments included demographics, Pain Catastrophizing Scale (score range 0-52), Patient Activation Measure (low [< 55.1] vs. high [≥ 55.1]), pain expectation (0-10), and Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29) anxiety and depression scales. At 7 days post-discharge, assessments included PROMIS-29 pain intensity (0-10) and pain interference scales (41.6-75.6), and satisfaction with pain management (high [10-9] vs. lower [8-0]). Linear and logistic regression were used to assess the association of pain outcomes with potential predictors. RESULTS: Three hundred and fifty-one patients were included (mean age = 44 ± 11 years, BMI = 45 ± 8 kg/m2, 77% female, 71% sleeve gastrectomy). At 7 days post-discharge, median (IQR) patient-reported pain intensity was 2.5 (1-5), pain interference was 55.6 (52.0-61.2), and 76% of patients reported high satisfaction with pain management. Pain intensity was predicted by preoperative anxiety (ß + 0.04 [95% CI + 0.01 to + 0.07]) and pain expectation (+ 0.15 [+ 0.05 to + 0.25]). Pain interference was predicted by preoperative anxiety (+ 0.22 [+ 0.11 to + 0.33]), pain expectation (+ 0.47 [+ 0.10 to + 0.84]), and age (- 0.09 [- 0.174 to - 0.003]). Lower satisfaction was predicted by low patient activation (OR 1.94 [1.05-3.58]), higher pain catastrophizing (1.03 [1.003-1.05]), 30-day complications (3.27 [1.14-9.38]), and age (0.97 [0.948-0.998]). CONCLUSION: Patient-related factors are important predictors of post-discharge pain outcomes after bariatric surgery. Our findings highlight the value of addressing educational, psychological, and coping strategies to improve postoperative pain outcomes.

Baseline MRI findings as predictors of hypopituitarism in patients with non-functioning pituitary adenomas.

Hypopituitarism tends to occur in large pituitary adenomas. However, similar tumors could present with strikingly different hormonal deficiencies. In this study, we looked at MRI characteristics in non-functioning pituitary adenomas (NFPA), which could predict secondary adrenal insufficiency (SAI) and central hypothyroidism (CHT). We reviewed the files of patients with NFPA attending our clinic. Tumor size, invasiveness, MR-signal intensity, and gadolinium enhancement in preoperative MRI were recorded along with documented presurgical hypopituitarism profile. Logistic regression was used to predict SAI, CHT, or both (SAI/CHT) based on MRI and demographic parameters. Receiver operating characteristic curves were used to determine their diagnostic utility. One hundred twenty-one patients were included in the study. Older age (P = 0.021), male sex (P = 0.043), stalk deviation (P < 0.0001), contrast enhancement (P = 0.029), and optic chiasma compression (P = 0.012) were associated with SAI/CHT. Adenoma vertical height, largest diameter, and estimated volume were also strongly associated with SAI/CHT (P < 0.0001). These associations remained significant in a multivariate analysis. No tumor smaller than 12 mm in vertical height, 17 mm in largest diameter, or 0.9 cm3 in volume was associated with SAI/CHT. At cut-off ≥18 mm for vertical height, ≥23 mm for largest diameter, and ≥3.2 cm3 the sensitivity was around 90-92% for detecting SAI/CHT. Only vertical height was significantly associated with any one or more pituitary hormonal deficit (P = 0.001). In conclusion, adenoma size, independent of the measurement used, remains the best predictor of SAI/CHT in NFPA. Dynamic testing to rule out SAI is probably indicated in adenomas larger than 18 mm vertical height, 23 mm largest diameter and 3.2 cm3 adenoma volume.

Serum Levels of Valproic Acid and Carbamazepine Do Not Correlate Well with End-Organ Dysfunction.

BACKGROUND: Serum levels of anticonvulsants are commonly ordered; however, the clinical utility of these laboratory tests is unclear. Clarifying the significance of anticonvulsant drug levels is essential to allow physicians to make appropriate management decisions. We aimed to determine to what extent elevated serum levels of valproic acid (VPA) and carbamazepine (CBZ) correlate with laboratory indications of end-organ dysfunction. METHODS: We reviewed a consecutive sample of patients 0-18 years of age who, over a 2-year period, had at least one blood collection in which (1) serum [VPA] or [CBZ] was tested; and (2) at least one of the following tests was performed: alanine aminotransferase (ALT), aspartate aminotransferase (AST), platelets, white blood cells (WBC), ammonia, sodium. RESULTS: 913 and 300 blood collections met criteria for VPA and CBZ, respectively. A slight increased frequency of having any abnormal laboratory value for elevated [VPA] compared to low/normal [VPA] was observed (p = 0.02; relative risk 1.27), while there was no difference in frequency of having any abnormal lab value for CBZ, nor were there significant differences for the individual lab values. When ALT and AST were plotted against [VPA] and [CBZ], no significant correlation was observed. CONCLUSION: Serum [VPA] and [CBZ] are poor indicators of risk for drug-induced end-organ dysfunction. There are likely other, individualized risk factors that explain why certain patients develop adverse effects from these medications.

A Comprehensive Clinical Care Pathway for Microvascular Maxillofacial Reconstructive Surgery.

PURPOSE: Clinical care pathways (CCPs) for major surgical procedures are less developed. We describe the development of a comprehensive microvascular maxillofacial reconstruction CCP and evaluate the impact. MATERIALS AND METHODS: Our team developed a comprehensive CCP for patients undergoing microvascular free flap reconstruction for benign or malignant tumors. Patient data before (n = 48) and after (n = 47) implementation of the CCP were used to evaluate the impact. Bayesian negative binomial and logistic regression analyses were used to estimate the associations between the CCP and clinical outcomes (length of stay [LOS], readmission to the operating room, and readmission within 3 months of discharge). RESULTS: The average total hospital LOS was high in the pre-CCP group (16.9 days) compared with the post-CCP group (9.8 days). Being in the post-CCP group reduced the LOS in the intensive care unit and surgical ward and reduced the risk of readmission to the operating room. CONCLUSION: Our results underscore the importance of standardized evidence-based patient care through CCPs for complex patient populations.

Effect of Exercise and Nutrition Prehabilitation on Functional Capacity in Esophagogastric Cancer Surgery: A Randomized Clinical Trial.

Importance: Preserving functional capacity is a key element in the care continuum for patients with esophagogastric cancer. Prehabilitation, a preoperative conditioning intervention aiming to optimize physical status, has not been tested in upper gastrointestinal surgery to date. Objective: To investigate whether prehabilitation is effective in improving functional status in patients undergoing esophagogastric cancer resection. Design, Setting, and Participants: A randomized clinical trial (available-case analysis based on completed assessments) was conducted at McGill University Health Centre (Montreal, Quebec, Canada) comparing prehabilitation with a control group. Intervention consisted of preoperative exercise and nutrition optimization. Participants were adults awaiting elective esophagogastric resection for cancer. The study dates were February 13, 2013, to February 10, 2017. Main Outcomes and Measures: The primary outcome was change in functional capacity, measured with absolute change in 6-minute walk distance (6MWD). Preoperative (end of the prehabilitation period) and postoperative (from 4 to 8 weeks after surgery) data were compared between groups. Results: Sixty-eight patients were randomized, and 51 were included in the primary analysis. The control group were a mean (SD) age, 68.0 (11.6) years and 20 (80%) men. Patients in the prehabilitation group were a mean (SD) age, 67.3 (7.4) years and 18 (69%) men. Compared with the control group, the prehabilitation group had improved functional capacity both before surgery (mean [SD] 6MWD change, 36.9 [51.4] vs -22.8 [52.5] m; P < .001) and after surgery (mean [SD] 6MWD change, 15.4 [65.6] vs -81.8 [87.0] m; P < .001). Conclusions and Relevance: Prehabilitation improves perioperative functional capacity in esophagogastric surgery. Keeping patients from physical and nutritional status decline could have a significant effect on the cancer care continuum. Trial Registration: ClinicalTrials.gov Identifier: NCT01666158.

Nasotracheal Intubation: The Preferred Airway in Oral Cavity Microvascular Reconstructive Surgery?

PURPOSE: We aimed to describe the safety and effectiveness of nasotracheal intubation (NTI) in a cohort of patients undergoing reconstruction of oral cavity defects with free tissue transfer (FTT). MATERIALS AND METHODS: We implemented a retrospective cohort study and enrolled a sample composed of consecutive patients undergoing FTT reconstruction of oral cavity, maxillary, or mandibular defects between 2013 and 2017. These patients were all subject to a newly developed enhanced recovery-after-surgery protocol. The primary outcome measurement was hospital length of stay (LOS). The secondary outcome variables were the duration of mechanical ventilation, intensive care unit (ICU) LOS, need for gastrostomy, and airway-related complications directly associated with either NTI or tracheostomy. Descriptive statistics and a multivariate logistic regression analysis were completed. RESULTS: The sample was composed of 141 patients who had undergone oral cavity FTT for both benign and malignant diseases (NTI, n = 111; tracheostomy, n = 30). Patients managed with NTI had a statistically significantly shorter hospital LOS (8 days vs 15.5 days, P < .0001) and ICU LOS (1 day vs 2 days, P = .0006), as well as a decreased requirement for gastrostomy (17.1% vs 76.7%, P < .0001). Airway-related complications were rare in both the tracheostomy (13.3%) and NTI (3.6%) groups. Multivariate analysis showed that patients undergoing tracheostomy were 3.14 (P = .004) times more likely to have a prolonged hospitalization and 10.4 (P < .0001) times more likely to require a gastrostomy. A sensitivity analysis of only patients with malignant diagnoses had similar statistically significant results. The delayed tracheostomy rate in the NTI group was 3.6%. CONCLUSIONS: To date, this is the largest study to evaluate the use of NTI in patients undergoing oral cavity reconstruction with FTT. Our results suggest that in the appropriate institutional setting, most patients can be safely managed with NTI. This approach results in a decreased hospital LOS and ICU LOS and an earlier resumption of oral intake with less need for gastrostomy.

Maximizing patient adherence to prehabilitation: what do the patients say?

PURPOSE: Multimodal prehabilitation programs (exercise, nutrition, and anxiety reduction) have been shown to be successful for enhancing patients' physical function prior to surgery, although adherence remains a challenge. Given the short pre-operative period, maintaining adherence is critical to maximize program effectiveness. This study was designed to better understand patients' perspectives of prehabilitation and to identify factors related to program adherence. METHODS: A qualitative descriptive study was conducted based on 52 cancer patients enrolled in a prehabilitation program at the Montreal General Hospital, Montreal, Canada. Data was collected with a structured questionnaire designed to evaluate the program. RESULTS: Patients enjoyed their experience in prehabilitation, especially the exercise program and training sessions. The primary motivating factor for participation was to be physically prepared for the surgery. The most challenging exercise component was resistance training, while the most enjoyed was the aerobic training. Approximately 50% of patients were interested in group fitness classes as opposed to supervised individual training sessions for reasons related to social support. The preferred methods for exercise program delivery were home-based and one supervised exercise session per week. The biggest barrier to participation was related to transportation. CONCLUSIONS: These findings highlight the need to make prehabilitation programs more patient-centered. This is critical when designing more effective therapeutic strategies tailored to meet patients' specific needs while overcoming program non-adherence.

Evaluation of supervised multimodal prehabilitation programme in cancer patients undergoing colorectal resection: a randomized control trial.

BACKGROUND: Prehabilitation has been previously shown to be more effective in enhancing postoperative functional capacity than rehabilitation alone. The purpose of this study was to determine whether a weekly supervised exercise session could provide further benefit to our current prehabilition program, when comparing to standard post-surgical rehabilitation. METHODS: A parallel-arm single-blind randomized control trial was conducted in patients scheduled for non-metastatic colorectal cancer resection. Patients were assigned to either a once weekly supervised prehabilitation (PREHAB+, n = 41) or standard rehabilitation (REHAB, n = 39) program. Both multimodal programs were home-based program and consisted of moderate intensity aerobic and resistance exercise, nutrition counseling with daily whey protein supplementation and anxiety-reduction strategies. Perioperative care was standardized for both groups as per enhanced recovery after surgery (ERAS®) guidelines. Functional exercise capacity, as determined by the 6-minute walk test distance (6MWD), was the primary outcome. Exercise quantity, intensity and energy expenditure was determined by the CHAMPS questionnaire. RESULTS: Both groups were comparable for baseline walking capacity (PREHAB+: 448 m [IQR 375-525] vs. REHAB: 461 m [419-556], p=.775) and included a similar proportion of patients who improved walking capacity (>20 m) during the preoperative period (PREHAB+: 54% vs. REHAB: 38%, p = .222). After surgery, changes in 6MWD were also similar in both groups. In PREHAB+, however, there was a significant association between physical activity energy expenditure and 6MWD (p < .01). Previously inactive patients were more likely to improve functional capacity due to PREHAB+ (OR 7.07 [95% CI 1.10-45.51]). CONCLUSIONS: The addition of a weekly supervised exercise session to our current prehabilitation program did not further enhance postoperative walking capacity when compared to standard REHAB care. Sedentary patients, however, seemed more likely to benefit from PREHAB+. An association was found between energy spent in physical activity and 6MWD. This information is important to consider when designing cost-effective prehabilitation programs.

Ductal carcinoma in situ--the influence of the radiotherapy boost on local control.

PURPOSE: Local recurrence (LR) of ductal carcinoma in situ (DCIS) is reduced by whole-breast irradiation after breast-conserving surgery (BCS). However, the benefit of adding a radiotherapy boost to the surgical cavity for DCIS is unclear. We sought to determine the impact of the boost on LR in patients with DCIS treated at the McGill University Health Centre. METHODS AND MATERIALS: A total of 220 consecutive cases of DCIS treated with BCS and radiotherapy between January 2000 and December 2006 were reviewed. Of the patients, 36% received a radiotherapy boost to the surgical cavity. Median follow-up was 46 months for the boost and no-boost groups. Kaplan-Meier survival analyses and Cox regression analyses were performed. RESULTS: Compared with the no-boost group, patients in the boost group more frequently had positive and <0.1-cm margins (48% vs. 8%) (p < 0.0001) and more frequently were in higher-risk categories as defined by the Van Nuys Prognostic (VNP) index (p = 0.006). Despite being at higher risk for LR, none (0/79) of the patients who received a boost experienced LR, whereas 8 of 141 patients who did not receive a boost experienced an in-breast LR (log-rank p = 0.03). Univariate analysis of prognostic factors (age, tumor size, margin status, histological grade, necrosis, and VNP risk category) revealed only the presence of necrosis to significantly correlate with LR (log-rank p = 0.003). The whole-breast irradiation dose and fractionation schedule did not affect LR rate. CONCLUSIONS: Our results suggest that the use of a radiotherapy boost improves local control in DCIS and may outweigh the poor prognostic effect of necrosis.