Outcomes of an enhanced recovery after surgery (ERAS) program to limit perioperative opioid use in outpatient minimally invasive GI and hernia surgeries.

BACKGROUND: Perioperative pain management is important for patient satisfaction while returning to homeostasis in the safest way possible. Studies show that patients don't require as much opioids as once thought. The benefits of ERAS pathways extend beyond enhancement of patients' perioperative experience, and include reducing opioid prescriptions in the face of the ongoing nationwide opioid crisis and evidence of prescription opioids as a contributor. METHODS: We performed a retrospective cohort study of patients undergoing same day minimally invasive surgery (MIS) procedures for GI and hernia disease using a minimal-opioid ERAS protocol at two community hospitals between January 2020 and May 2022. We included elective laparoscopic cholecystectomy (LC), laparoscopic appendectomy (LA) for acute appendicitis without perforation, and minimally invasive (laparoscopic and robotic) inguinal and ventral hernia repair or abdominal wall reconstruction (AWR). Primary outcome was postoperative opioid use. RESULTS: A total of 509 patients were included, undergoing procedures of MIS hernia repair (52.5%), LC (43.6%), and LA (7.9%). Only 9.4% of patients received opioid prescriptions at discharge, with no difference between groups. Among the patients receiving a prescription at discharge, there was a significant difference in morphine milligram equivalents (MME) prescribed (25.0 ± 0.0 in the LA group, 65.0 ± 41.4 in the LC group, 100.6 ± 46.2 in the MIS hernia/AWR group; P = 0.015). Nine percent of patients called with pain management concerns postoperatively. ASA score ≥ 3 was associated with increased odds for postoperative opioid prescription (OR 2.084; P = 0.014). CONCLUSIONS: We demonstrate that an opioid-sparing ERAS program effectively manages pain for patients undergoing multiple outpatient MIS GI/hernia procedures, and suggests generalizability across a diverse range of operations. Therefore, the use of ERAS may safely and effectively expand beyond inpatient MIS and open surgeries that target reduced length of stay to also minimize opioids for outpatient procedures.

Does routine postoperative contrast radiography improve outcomes for patients with perforated peptic ulcer? A multicenter retrospective cohort study.

BACKGROUND: Perforated peptic ulcer is a morbid emergency general surgery condition. Best practices for postoperative care remain undefined. Surgical dogma preaches practices such as peritoneal drain placement, prolonged nil per os, and routine postoperative enteral contrast imaging despite a lack of evidence. We aimed to evaluate the role of postoperative enteral contrast imaging in postoperative perforated peptic ulcer care. Our primary objective was to assess effects of routine postoperative enteral contrast imaging on early detection of clinically significant leaks. METHODS: We conducted a multicenter retrospective cohort study of patients who underwent repair of perforated peptic ulcer between July 2016 and June 2018. We compared outcomes between those who underwent routine postoperative enteral contrast imaging and those who did not. RESULTS: Our analysis included 95 patients who underwent primary/omental patch repair. The mean age was 60 years, and 54% were male. Thirteen (14%) had a leak. Eighty percent of patients had a drain placed. Nine patients had leaks diagnosed based on bilious drain output without routine postoperative enteral contrast imaging. Use of routine postoperative enteral contrast imaging varied significantly between institutions (30%-87%). Two late leaks after initial normal postoperative enteral contrast imaging were confirmed by imaging after a clinical change triggered the second study. Two patients had contained leaks identified by routine postoperative enteral contrast imaging but remained clinically well. Duration of hospital stay was longer in those who received routine postoperative enteral contrast imaging (12 vs 6 days, median; P = .000). CONCLUSION: Routine postoperative enteral contrast imaging after perforated peptic ulcer repair likely does not improve the detection of clinically significant leaks and is associated with increased duration of hospital stay.

Outcomes of Laparoscopic vs Open Repair of Perforated Peptic Ulcers: An ACS-NSQIP Study.

BACKGROUND: Perforated peptic ulcer (PPU) is a surgical emergency needing swift operative resolution. While laparoscopic and open approaches are viable options, it remains unclear whether laparoscopic repair has significantly improved outcomes. We use a national surgical database to compare perioperative and 30-d postoperative (30POP) outcomes. MATERIALS AND METHODS: The 2016-2018 ACS-NSQIP database was used to create the patient cohort, using ICD-10 and CPT codes. An unmatched analysis identified factors that likely contributed to the laparoscopic versus open treatment allocation. Propensity score matching (PSM) was used to identify outcomes that were not explained by underlying differences in the patient cohorts. RESULTS: A total of 3475 patients were included: 3135 in open group (OG), 340 (~10%) in laparoscopic group (LG). After PSM to control for comorbidities and illness severity that differed between groups on univariate analysis, 288 patients remained in each group. Analysis of the matched cohorts revealed no statistically significant difference in mortality (5.9% OG versus 3.8% LG, P = 0.245). The LG had significantly longer operative times (92 versus 79 min, P = 0.003), shorter hospital stays (8.2 versus 9.4 d, P = 0.044) and higher probability of being discharged home (81% versus 73%, P = 0.017). 30POP outcomes were largely equivalent, except that OG had higher risk for bleeding (14.6% versus 8%, P = 0.012) and pneumonia (8.7% versus 4.5%, P = 0.044). CONCLUSIONS: While laparoscopic repairs take longer, they lead to shorter hospital stays and higher likelihood of discharge home. Further study to identify patients that are candidates for this technique is warranted.

Mutational landscape of basal cell carcinomas by whole-exome sequencing.

Recent advances in sequencing technology allow genome-scale approaches to cancer mutation discovery. Such data-intensive methods have been applied to cutaneous squamous cell carcinomas (SCCs) and melanomas but have not, to our knowledge, been applied to basal cell carcinomas (BCCs). We used whole-exome sequencing to characterize the mutational landscape of sporadic BCCs. We show that BCCs are the most mutated type of human cancer. Tumors from anatomical regions with chronic UV exposure were associated with higher mutation rates than those with intermittent exposure. The majority of all mutations (75.7%) were UV signature. Using a conventional binomial probability model, several genes were found mutated significantly. However, this model assumes a uniform distribution of mutations throughout the genome. We also used a more stringent approach called InVEx that uses a permutation-based framework to pick drivers from passengers. After correction for multiple hypothesis testing, InVEx identified only PTCH1 (Patched 1) as having a significant functional mutation burden. We also found three genes, STAT5B, CRNKL1, and NEBL, with mutational hot spots at a single base in 3 of 12 tumors sequenced. Our findings support the central role of PTCH1 mutations in BCC genesis. Moreover, our discovery of the uniquely high number of mutations in this tumor may lend insight into its biological behavior.