Impact of Intraoperative Dexamethasone on Surgical and Oncologic Outcomes for Patients with Resected Pancreatic Ductal Adenocarcinoma.

BACKGROUND: Administration of dexamethasone to mitigate postoperative nausea and vomiting has been suggested to improve short- and long-term outcomes after pancreatic ductal adenocarcinoma (PDAC) resection. This study aimed primarily to evaluate these hypotheses in a contemporary patient cohort treated with multimodality therapy. METHODS: The clinicopathologic and perioperative characteristics of consecutive resected PDAC patients (July 2011 to October 2018) were analyzed from a prospectively maintained database. Intraoperative administration of dexamethasone (4-10 mg) was retrospectively abstracted from the electronic medical record. RESULTS: The majority of 373 patients (59.8%) received intraoperative dexamethasone. Most of these patients underwent neoadjuvant therapy (75.3%), were potentially resectable at presentation (69.7%), and underwent pancreaticoduodenectomy (79.9%). Women were more likely to receive dexamethasone than men (69.9 vs 30.1%; p < 0.001). The cohorts were otherwise clinically similar. Intraoperative dexamethasone was not associated with differences in postoperative major complications (PMCs) (21.1 vs 19.3%; p = 0.68), postoperative pancreatic fistulas (6.3 vs 6.7%; p = 0.88), or composite infectious complications (28.7 vs 24.7%; p = 0.39). Dexamethasone was not associated with any improvement in median recurrence-free survival (RFS) (17 vs 17 months; p = 0.99) or overall survival (OS) (46 vs 43 months; p = 0.90). After adjustment for clinical factors including margin status, clinical classification, tumor size, and dexamethasone, the only factors independently associated with OS were pathologic node-positivity (hazard ratio [HR], 1.80, 95% confidence interval [CI], 1.32-2.47), perineural invasion (HR, 2.02; 95% CI, 1.23-3.31), multimodality therapy (HR, 0.30; 95% CI, 0.13-0.70), and PMCs (HR, 1.64; 95% CI, 1.17-2.29) (all p < 0.006). CONCLUSIONS: Dexamethasone failed to demonstrate any protective advantage in terms of mitigating short-term PMCs or infectious complications, or to confer any long-term survival benefit. Tumor biology, multimodality therapy, and PMCs remain the main prognostic factors after PDAC resection.

Postoperative acute pain challenges in patients with cancer.

It is expected that the number of surgical procedures to diagnose, treat, and palliate cancers will increase in the near future. While many of those interventions can be performed with minimally invasive techniques, others require surgical large incisions and in some instances, they involve multiple areas of the body (i.e., tumor resections with flap reconstructions). Pain after major oncological procedures can be severe and many times difficult to treat as patients can present to the operating room with several conditions including preoperative pain (i.e., rapidly growing tumors and painful neuropathies), opioid tolerance, and contraindications to nonopioid analgesics or regional anesthesia. Inadequately treated postoperative pain is associated with activation of the sympathetic system, postoperative complications, large perioperative opioid use, and an increased risk of developing postoperative persistent pain. Furthermore, it has been theorized that poorly treated pain is associated with cancer recurrence and a reduced survival. Lastly, recent research questions the oncological safety of robotic surgery in gynecological procedures and indicates the need of open surgeries, which will be associated with an increased risk in moderate-to-severe postoperative pain. In conclusion, the management of acute postoperative pain in patients with cancer can be challenging.

Patterns and predictors of outpatient opioid use after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy.

Background: Long-term opioid use is a well-known complication after surgery. In this retrospective study of adults who had undergone cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC), we sought to determine the rates and factors associated with outpatient opioid use within the sixth and twelfth postoperative months. Methods: Records of 288 opioid-naïve patients were included. Logistic regression models were used to determine factors prognostic of outpatient opioid use. Results: The median patient age was 54 years, and 63% were female. Rates of outpatient opioid use within the sixth and twelfth postoperative months were 21 and 13%, respectively. In the multivariate analysis, every doubling in the amount of in-hospital postoperative opioid consumption was associated with a 44% increase in odds of opioid use within the sixth postoperative month (OR 1.44, 95% CI 1.11-1.87, p = .006) and a 70% increase within the twelfth postoperative month (OR 1.70, 95% CI 1.70-2.37, p = .001). Other factors associated with opioid use within the sixth postoperative month included physical status (OR 5.26, 95% CI 1.08-25.55, p = .039) and recent additional surgery (OR 23.02, 95% CI 2.03-261.30, p = .011). Age (OR 4.39, 95% CI 1.77-10.89, p = .001) and tumor grade (OR 3.31, 95% CI 1.31-8.41, p = .012) were associated with opioid use within the twelfth postoperative month. Conclusion: In this study, the amount of in-hospital postoperative opioid consumption was an important contributory factor to outpatient opioid use in the sixth and twelfth postoperative months. Synopsis In this study of adults who had undergone CRS-HIPEC, higher postoperative opioid consumption during hospitalization was associated with higher odds of opioid use within the sixth and twelfth postoperative months.

Determining the Safety and Efficacy of Enhanced Recovery Protocols in Major Oncologic Surgery: An Institutional NSQIP Analysis.

BACKGROUND: Enhanced-recovery (ER) protocols are increasingly being utilized in surgical practice. Outside of colorectal surgery, however, their feasibility, safety, and efficacy in major oncologic surgery have not been proven. This study compared patient outcomes before and after multispecialty implementation of ER protocols at a large, comprehensive cancer center. METHODS: Surgical cases performed from 2011 to 2016 and captured by an institutional NSQIP database were reviewed. Following exclusion of outpatient and emergent surgeries, 2747 cases were included in the analyses. Cases were stratified by presence or absence of ER compliance, defined by preoperative patient education and electronic medical record order set-driven opioid-sparing analgesia, goal-directed fluid therapy, and early postoperative diet advancement and ambulation. RESULTS: Approximately half of patients were treated on ER protocols (46%) and the remaining on traditional postoperative (TP) protocols (54%). Treatment on an ER protocol was associated with decreased overall complication rates (20% vs. 33%, p < 0.0001), severe complication rates (7.4% vs. 10%, p = 0.010), and median hospital length of stay (4 vs. 5 days, p < 0.0001). There was no change in readmission rates (ER vs. TP, 8.6% vs. 9.0%, p = 0.701). Subanalyses of high magnitude cases and specialty-specific outcomes consistently demonstrated improved outcomes with ER protocol adherence, including decreased opioid use. CONCLUSIONS: This assessment of a large-scale ER implementation in multispecialty major oncologic surgery indicates its feasibility, safety, and efficacy. Future efforts should be directed toward defining the long-term oncologic benefits of these protocols.

Subcostal Transverse Abdominis Plane Block for Acute Pain Management: A Review.

The subcostal transverse abdominis plane (SCTAP) block is the deposition of local anesthetic in the transverse abdominis plane inferior and parallel to the costal margin. There is a growing consensus that the SCTAP block provides better analgesia for upper abdominal incisions than the traditional transverse abdominis plane block. In addition, when used as part of a four-quadrant transverse abdominis plane block, the SCTAP block may provide adequate analgesia for major abdominal surgery. The purpose of this review is to discuss the SCTAP block, including its indications, technique, local anesthetic solutions, and outcomes.