减重手术后强化康复（ERABS）实施后阿片类药物使用减少。
Reduction of opioid use after implementation of enhanced recovery after bariatric surgery (ERABS).
机构信息
Advanced Laparoscopic Surgery Associates, University of California San Francisco-Fresno, 205 E. River Park Circle #460, Fresno, CA, 93720, USA.
Fresno Heart and Surgical Hospital, Fresno, CA, USA.
出版信息
Surg Endosc. 2020 May;34(5):2184-2190. doi: 10.1007/s00464-019-07006-3. Epub 2019 Jul 24.
BACKGROUND
Enhanced recovery after surgery (ERAS) protocols have been extensively proven in lower gastrointestinal surgery to decrease postoperative physiologic stress and length of stay (LOS). ERAS in bariatric surgery (ERABS) varies immensely from each program with inconsistent results with a predominant goal of reducing LOS. Our focus in implementing enhanced recovery after bariatric surgery (ERABS) protocols is aimed at reducing postoperative pain and opioid use.
METHODS
This is a retrospective review of patients who underwent laparoscopic Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (VSG) at a single high-volume center from June 2016 to October 2017. Patients on previous standard protocol were categorized into "Pre-Liposomal Bupivacaine (LB) group." After routine use of Exparel™, patients were grouped into "LB group." After ERABS protocol was initiated, patients were categorized into "ERABS/LB group." Postoperative opioids were converted to morphine equivalents units (MEU); pain scores, LOS, and 30-day outcomes were analyzed using combination of t test and Mann-Whitney U.
RESULTS
A total of 1340 patients were included in the study: 304 patients in pre-LB group; 754 patients in LB group, and 282 patients in ERABS/LB group. Total hospital opioid use was 58.6 MEU in pre-LB, 40.8 MEU in LB, and 23.8 MEU in ERABS/LB (p = 0.01). ERABS/LB group found a 59.5% decline in MEU requirements compared to pre-LB (p < 0.001) and 44.9% of patients did not require any additional narcotics on the floor compared to 0% in pre-LB group (p < 0.001). ERABS/LB LOS was an average of 1.48 days compared to 1.54 days in pre-LB group (p = 0.03) with an overall decrease of 3.74% in readmission rates (p = 0.03).
CONCLUSIONS
Implementation of ERABS significantly reduced postoperative opioid use, LOS, and readmissions. With ERABS, a more profound effect was observed than simply adding Exparel™ to preexisting protocols. Almost half of these patients did not require narcotics while recovering on the surgical floor. More studies are required to assess the true effect of ERABS without use of Exparel™.
背景
加速康复外科（ERAS）方案已在胃肠道下部手术中得到广泛验证，可减少术后生理应激和住院时间（LOS）。减重手术中的 ERAS（ERABS）因每个项目而异，结果不一致，主要目标是减少 LOS。我们实施减重手术后强化康复（ERABS）方案的重点是减少术后疼痛和阿片类药物的使用。
方法
这是对 2016 年 6 月至 2017 年 10 月在一家高容量中心接受腹腔镜 Roux-en-Y 胃旁路术（RYGB）或袖状胃切除术（VSG）的患者进行的回顾性研究。接受先前标准方案的患者被归类为“预脂质体布比卡因（LB）组”。在常规使用 ExparelTM 后，患者被分为“LB 组”。在启动 ERABS 方案后，患者被分为“ERABS/LB 组”。术后阿片类药物转换为吗啡等效单位（MEU）；使用 t 检验和曼-惠特尼 U 检验分析疼痛评分、LOS 和 30 天结局。
结果
共有 1340 例患者纳入研究：预 LB 组 304 例；LB 组 754 例，ERABS/LB 组 282 例。预 LB 组总住院阿片类药物用量为 58.6 MEU，LB 组为 40.8 MEU，ERABS/LB 组为 23.8 MEU（p=0.01）。与预 LB 组相比，ERABS/LB 组的 MEU 需求下降了 59.5%（p<0.001），与预 LB 组 0%的患者无需额外使用任何阿片类药物相比，44.9%的患者无需在病房使用任何阿片类药物（p<0.001）。ERABS/LB 的 LOS 平均为 1.48 天，预 LB 组为 1.54 天（p=0.03），总体再入院率下降 3.74%（p=0.03）。
结论
实施 ERABS 可显著减少术后阿片类药物使用、LOS 和再入院率。通过 ERABS，与仅在现有方案中添加 ExparelTM 相比，效果更为显著。这些患者中几乎有一半在手术楼层恢复时无需使用阿片类药物。需要更多的研究来评估不使用 ExparelTM 的 ERABS 的真正效果。
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