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Demonstrating the Benefits of Multimodal Pain Control on Patient Outcomes in Laparoscopic Colorectal Surgery: Review of 200 Consecutive Cases
Deborah Keller*1,2, Sergio Ibarra2, Juan R. Flores2, Eric M. Haas1,2
1Colorectal Surgery, Houston Methodist Hospital, Houston, TX; 2Colorectal Surgical Associates, Houston, TX

Background: Enhanced Recovery Pathways (ERPs) are well established, and multimodal opioid-sparing pain management protocols are a cornerstone of ERP principles. However, the ideal agents and protocol are yet to be determined. The goal of this study was to evaluate the outcomes of a standardized multimodal pain management regimen added to an established ERP in a large series of laparoscopic colorectal resections.
Methods: A prospective departmental database was reviewed for 200 consecutive patients undergoing elective laparoscopic colorectal resection by a single surgeon using a multimodal pain management protocol- including intraoperative Transversus Abdominus Plane (TAP) and local wound infiltration using long-acting liposomal bupivacaine- as part of a standardized ERP. Demographic, perioperative, and postoperative outcomes were analyzed. The main outcomes measures were length of stay (LOS), return of bowel function, morbidity, and total hospital costs using the multimodal pain management protocol and comparing outcomes in this series to the 200 prior laparoscopic cases without the protocol.
Results: Between 6/1/15 and 10/15/15, 200 cases were performed with the pain management protocol. The main operative indications were colorectal cancer (30.5%) and diverticulitis (25.5%). The mean age was 55.3 (SD 15.9) years and 57% were male. The mean BMI was 30.4 kg/m2. The main procedures performed were segmental colectomy (45.5%) and low anterior resection (26.5%). Mean operative time was 183 minutes. Two cases (1.0%) were converted to open. The mean return of bowel function was on postoperative day (POD) 2.13 (SD 0.92) for flatus. The mean and median LOS were 3.6 (SD 2.0) and 3 days (range, 1-18), respectively. 50 patients were discharged by POD 2 (25%), 135 by POD 3 (62.5%), and 188 patients (94%) by POD 7. Twenty-eight patients had complications (14%); there was no ileus using the protocol, while there were 9 cases of ileus in the 200 patients prior. The 30-day readmission rate was 4.0% (n=8). There were two unplanned reoperation and no mortalities. The mean total costs were ,704 (SD ,274). Compared to the 200 prior consecutive elective resections, trends in faster return of bowel function, shorter LOS, and significantly lower total costs resulted with the protocol (Table 1).
Conclusions: Adding TAP and local wound infiltration with long-acting liposomal bupivacaine to an established ERP facilitated faster return of bowel function, shorter LOS, and lower total costs of care. The multimodal enhanced recovery pathway may be an efficient and cost effective method for improving clinical and financial after laparoscopic colorectal surgery.

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