Top

Published in:

01-02-2024 | Methadone | Peritoneal Surface Malignancy

Continuous Wound Irrigation and Intraoperative Methadone Decreases Opioid Use and Shortens Length of Stay After CRS/HIPEC

Authors: Markus A. Boesl, MD, Noah Brown, MD, Josh Bleicher, MD, Tyler Call, MD, Donald H. Lambert, MD, Laura A. Lambert, MD

Published in: Annals of Surgical Oncology | Issue 6/2024

Abstract

Background

Epidural analgesia is resource and labor intense and may limit postoperative management options and delay discharge. This study compared postoperative outcomes after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) with epidural analgesia versus continuous wound infusion system (CWIS) with/without intraoperative methadone.

Methods

A single-institution, retrospective chart review was performed including all patients undergoing open CRS/HIPEC from 2018 to 2021. Patient demographics, surgical characteristics, length of stay, and in-hospital analgesic use were reviewed. In-hospital opioid exposure in morphine milligram equivalents (MME) was calculated. Multivariate analysis (MVA) for mean total and daily opioid exposure was conducted.

Results

A total of 157 patients were included. Fifty-three (34%) had epidural analgesia, 96 (61%) had CWIS, and 79 (50%) received methadone. Length of stay was significantly shorter with CWIS + methadone versus epidural (7 vs. 8 days, p < 0.01). MVA showed significantly lower mean total and daily opioid exposure with CWIS+methadone versus epidural (total: 252.8 ± 17.7 MME vs. 486.8 ± 86.6 MME; odds ratio [OR] 0.72, 95% confidence interval [CI] 0.52–0.98, p = 0.04; Daily: 32.8 ± 2.0 MME vs. 51.9 ± 5.7 MME, OR 0.72, 95% CI 0.52–0.99, p ≤ 0.05). The CWIS-only group (n = 17) had a significantly lower median oral opioid exposure versus epidural (135 MME vs. 7.5 MME, p < 0.001) and longer length of stay versus CWIS + methadone (9 vs. 7 days, p = 0.04), There were no CWIS or methadone-associated complications and one epidural abscess.

Conclusions

CWIS + methadone safely offers better pain control with less in-hospital opioid use, shorter length of stay, and decreased resource utilization compared with epidural analgesia in patients undergoing CRS-HIPEC.

Available only for authorised users

Wang X, Li T. Postoperative pain pathophysiology and treatment strategies after CRS + HIPEC for peritoneal cancer. World J Surg Oncol. 2020;18(1):62. https://doi.org/10.1186/s12957-020-01842-7.CrossRefPubMedPubMedCentral

Webb C, Day R, Velazco CS, et al. Implementation of an enhanced recovery after surgery (eras) program is associated with improved outcomes in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Ann Surg Oncol. 2020;27(1):303–12. https://doi.org/10.1245/s10434-019-07900-z.CrossRefPubMed

Webb CAJ, Weyker PD, Moitra VK, Raker RK. An overview of cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion for the anesthesiologist. Anesth Analg. 2013;116(4):924–31. https://doi.org/10.1213/ANE.0b013e3182860fff.CrossRefPubMed

Raspe C, Piso P, Wiesenack C, Bucher M. Anesthetic management in patients undergoing hyperthermic chemotherapy. Curr Opin Anaesthesiol. 2012;25(3):348–55. https://doi.org/10.1097/ACO.0b013e32835347b2.CrossRefPubMed

Piccioni F, Casiraghi C, Fumagalli L, et al. Epidural analgesia for cytoreductive surgery with peritonectomy and heated intraperitoneal chemotherapy. Int J Surg Lond Engl. 2015;16(Pt A):99–106. https://doi.org/10.1016/j.ijsu.2015.02.025.CrossRef

Lu PW, Fields AC, Shabat G, et al. Cytoreductive surgery and HIPEC in an enhanced recovery after surgery program: a feasibility study. J Surg Res. 2020;247:59–65. https://doi.org/10.1016/j.jss.2019.10.042.CrossRefPubMed

Bhandoria G, Solanki SL, Bhavsar M, et al. Enhanced recovery after surgery (ERAS) in cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC): a cross-sectional survey. Pleura Peritoneum. 2021;6(3):99–111. https://doi.org/10.1515/pp-2021-0117.CrossRefPubMedPubMedCentral

Martin RC, Marshall BM, Philips P, Egger M, McMasters KM, Scoggins CR. Enhanced recovery after surgery is safe for cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. Am J Surg. 2020;220(6):1428–32. https://doi.org/10.1016/j.amjsurg.2020.08.041.CrossRefPubMedPubMedCentral

Hübner M, Kusamura S, Villeneuve L, et al. Guidelines for Perioperative Care in Cytoreductive Surgery (CRS) with or without hyperthermic IntraPEritoneal chemotherapy (HIPEC): enhanced Recovery After Surgery (ERAS®) Society Recommendations—part II: postoperative management and special considerations. Eur J Surg Oncol. 2020;46(12):2311–23. https://doi.org/10.1016/j.ejso.2020.08.006.CrossRefPubMed

10.

White B, Dahdaleh F, Naffouje SA, et al. Impact of enhanced recovery after surgery on postoperative outcomes for patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Ann Surg Oncol. 2021;28(9):5265–72. https://doi.org/10.1245/s10434-020-09476-5.CrossRefPubMed

11.

Song J, Choi N, Kang M, Ji SM, Kim DW, Kwon MA. Analgesic effects of ultrasound-guided fourquadrant transversus abdominis plane in patients with cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: a prospective, randomized, controlled study. Anesth Pain Med. 2022;17(1):75–86. https://doi.org/10.17085/apm.21094.CrossRef

12.

Koh FH, Ng JY, Seow CS, Keh CH. ON-Q pain relief system insertion technique: intraoperative insertion of a pre-peritoneal catheter for continuous local anaesthetic infusion. Ann R Coll Surg Engl. 2020;102(2):160–1. https://doi.org/10.1308/rcsann.2019.0159.CrossRefPubMed

13.

Baig MK, Zmora O, Derdemezi J, Weiss EG, Nogueras JJ, Wexner SD. Use of the ON-Q pain management system is associated with decreased postoperative analgesic requirement: double blind randomized placebo pilot study. J Am Coll Surg. 2006;202(2):297–305. https://doi.org/10.1016/j.jamcollsurg.2005.10.022.CrossRefPubMed

14.

Murphy GS, Szokol JW. Intraoperative methadone in surgical patients: a review of clinical investigations. Anesthesiology. 2019;131(3):678–92. https://doi.org/10.1097/ALN.0000000000002755.CrossRefPubMed

15.

Tabbara AK, Krishnan S, Vaynberg E, Spence NZ, Lambert DH. Intraoperative methadone: proceed with care. J Opioid Manag. 2022;18(4):377–83. https://doi.org/10.5055/jom.2022.0730.CrossRefPubMed

16.

Lee SH, Gwak MS, Choi SJ, et al. Prospective, randomized study of ropivacaine wound infusion versus intrathecal morphine with intravenous fentanyl for analgesia in living donors for liver transplantation. Liver Transpl. 2013;19(9):1036–45. https://doi.org/10.1002/lt.23691.CrossRefPubMed

17.

Soliz JM, Gebhardt R, Feng L, Dong W, Reich M, Curley S. Comparing epidural analgesia and ON-Q infiltrating catheters for pain management after hepatic resection. Open J Anesthesiol. 2013;3(1):3–7. https://doi.org/10.4236/ojanes.2013.31002.CrossRefPubMedPubMedCentral

18.

Lee B, Kim K, Ahn S, et al. Continuous wound infiltration system for postoperative pain management in gynecologic oncology patients. Arch Gynecol Obstet. 2017;295(5):1219–26. https://doi.org/10.1007/s00404-017-4342-8.CrossRefPubMed

19.

[The effects of the administration of subfacial levobupivacaine infusion with the ON-Q pain pump system on postoperative analgesia and tramadol consumption in cesarean operations] - PubMed. Accessed July 19, 2022. https://pubmed.ncbi.nlm.nih.gov/20582749/

20.

Forastiere E, Sofra M, Giannarelli D, Fabrizi L, Simone G. Effectiveness of continuous wound infusion of 0.5% ropivacaine by On-Q pain relief system for postoperative pain management after open nephrectomy. Br J Anaesth. 2008;101(6):841–7. https://doi.org/10.1093/bja/aen309.CrossRefPubMed

21.

Chung D, Lee YJ, Jo MH, et al. The ON-Q pain management system in elective gynecology oncologic surgery: management of postoperative surgical site pain compared to intravenous patient-controlled analgesia. Obstet Gynecol Sci. 2013;56(2):93–101. https://doi.org/10.5468/OGS.2013.56.2.93.CrossRefPubMedPubMedCentral

22.

Gebhardt R, Mehran RJ, Soliz J, Cata JP, Smallwood AK, Feeley TW. Epidural versus ON-Q local anesthetic-infiltrating catheter for post-thoracotomy pain control. J Cardiothorac Vasc Anesth. 2013;27(3):423–6. https://doi.org/10.1053/j.jvca.2013.02.017.CrossRefPubMed

23.

Ried M, Schilling C, Potzger T, et al. Prospective, comparative study of the On-Q® PainBuster® postoperative pain relief system and thoracic epidural analgesia after thoracic surgery. J Cardiothorac Vasc Anesth. 2014;28(4):973–8.CrossRefPubMed

24.

Wheatley GH, Rosenbaum DH, Paul MC, et al. Improved pain management outcomes with continuous infusion of a local anesthetic after thoracotomy. J Thorac Cardiovasc Surg. 2005;130(2):464–8. https://doi.org/10.1016/j.jtcvs.2005.02.011.CrossRefPubMed

25.

Sotgiu ML, Valente M, Storchi R, Caramenti G, Biella GEM. Cooperative N-methyl-D-aspartate (NMDA) receptor antagonism and mu-opioid receptor agonism mediate the methadone inhibition of the spinal neuron pain-related hyperactivity in a rat model of neuropathic pain. Pharmacol Res. 2009;60(4):284–90. https://doi.org/10.1016/j.phrs.2009.04.002.CrossRefPubMed

26.

Tognoli E, Proto PL, Motta G, Galeone C, Mariani L, Valenza F. Methadone for postoperative analgesia: contribution of N-methyl-D-aspartate receptor antagonism: a randomised controlled trial. Eur J Anaesthesiol. 2020;37(10):934–43. https://doi.org/10.1097/EJA.0000000000001217.CrossRefPubMed

27.

Machado FC, Vieira JE, de Orange FA, Ashmawi HA. Intraoperative methadone reduces pain and opioid consumption in acute postoperative pain: a systematic review and meta-analysis. Anesth Analg. 2019;129(6):1723–32. https://doi.org/10.1213/ANE.0000000000004404.CrossRefPubMed

28.

Bova SE, Kruer RM, Nesbit SA, Grant MC, Jarrell AS. Perioperative methadone prescribing and association with respiratory depression. J Opioid Manag. 2020;16(6):443–9. https://doi.org/10.5055/jom.2020.0602.CrossRefPubMed

29.

Carl A, Pasman E, Broman MJ, Lister JJ, Agius E, Resko SM. Experiences of healthcare and substance use treatment provider-based stigma among patients receiving methadone. Drug Alcohol Depend Rep. 2023;6:100138. https://doi.org/10.1016/j.dadr.2023.100138.CrossRefPubMedPubMedCentral

Title: Continuous Wound Irrigation and Intraoperative Methadone Decreases Opioid Use and Shortens Length of Stay After CRS/HIPEC
Authors: Markus A. Boesl, MD
Noah Brown, MD
Josh Bleicher, MD
Tyler Call, MD
Donald H. Lambert, MD
Laura A. Lambert, MD
Publication date: 01-02-2024
Publisher: Springer International Publishing
Keywords: Methadone
Opioids
Opioids
Fentanyl
Ketamine
Published in: Annals of Surgical Oncology / Issue 6/2024
Print ISSN: 1068-9265
Electronic ISSN: 1534-4681
DOI: https://doi.org/10.1245/s10434-024-14900-1

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Continuous Wound Irrigation and Intraoperative Methadone Decreases Opioid Use and Shortens Length of Stay After CRS/HIPEC

Abstract

Background

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 6/2024

ASO Author Reflections: Advancing Early Outcome Assessment in Robot-Assisted Radical Cystectomy: RARC Tetrafecta

Laparoscopic Tracer Technique for Liver Lymphatic Drainage by Injecting Indocyanine Green into the Glisson Pedicle

ASO Visual Abstract: Impact of Tumor Size on Survival Outcome in Esophageal Squamous Cell Carcinoma After Esophagectomy Following Neoadjuvant Chemotherapy

Solid Pseudopapillary Tumor of the Pancreas: Is Enucleation Safe?

ASO Author Reflections: Advancing the Frontiers of Robotic Pancreaticoduodenectomy: Where are We Headed?

Lessons from Dr. Norton