L. R. Franko2, C. M. Gilbert2, A. A. Brescia1, J. Caceres2, L. Azzouz2, A. A. Mazurek2, A. C. Chang1, P. W. Carrott1, J. Lin1, W. R. Lynch1, M. B. Orringer1, R. M. Reddy1, K. H. Lagisetty1 1University Of Michigan,Thoracic Surgery,Ann Arbor, MI, USA 2University Of Michigan,Medical School,Ann Arbor, MI, USA
Introduction:
Transhiatal esophagectomy (THE) can be performed via an open or robotic-assisted (RA) approach. The reported benefits of RA THE include more complete lymph node sampling and direct visualization during dissection. However, the impact of RA THE on postoperative acute pain management is unknown. This study compares the impact of RA THE versus open THE on postoperative pain management.
Methods:
All patients undergoing THE at our institution between 03/2017-03/2018 were identified (n=57). Retrospective chart review and our institutional STS database were utilized to collect data regarding surgical approach, demographics, complications and pain management. Patients undergoing McKeown or Ivor Lewis esophagectomies were excluded. Pain management strategy and utilization, including opioids, adjuncts, epidural, and patient controlled analgesia (PCA), were recorded from postoperative day (POD) 0-10 as well as day prior to discharge. The mean oral morphine equivalents (OMEs) per POD were based on OMEs taken (oral and IV rescue dose) after epidural, PCA, or opioid infusion was discontinued. Descriptive data were analyzed, and 2-tailed t-test or Chi-squared was utilized as appropriate.
Results:
Open THE was performed in 41 patients with 3 conversions to open. RA THE was successful in 16 patients. An epidural was utilized in 38 (92.7%) of open patients versus only 1 (6.3%) RA patient (p<0.001). Of note, 15 (93.8%) RA patients received a PCA compared to 18 (43.9%) open (p<0.001), 3 of whom did not also receive an epidural. PCA and/or epidural was discontinued on POD 4.6 for open and 3.8 for RA patients (p=0.003). Mean daily OME use from POD 3-10 on average trended higher in RA patients with only POD 8 showing a significant difference (p=0.015; Figure 1). On the day prior to discharge, mean OME per patient was significantly higher in the RA group (35.1) versus open (17.3; p=0.029). Age, procedure time, length of stay, postoperative event rate, prior benzodiazepine or opioid use, number of adjunct doses per day, gabapentin or lidocaine patch use, discharge prescription OME, and number of patients requiring refills did not differ.
Conclusion:
This study demonstrated mean daily OME use for the first ten PODs after THE did not differ between the open or RA; however, day prior to discharge OME use was higher in the RA cohort. This suggests that opioid use following RA THE may equal or exceed opioid use following open THE. Further investigation with a larger cohort of patients is needed to identify risk factors for higher use in RA patients, such as lack of epidural use.
