30 Aug Nerve Block after Surgery Reduced Narcotic Usage, Shortened Hospital Stays
MedicalResearch.com Interview with:
Conor P. Delaney, MD MCh PhD FRCSI FACS FASCRS
The Jeffrey L. Ponsky Professor of Surgical Education | Chief, Division of Colorectal Surgery | Vice-Chair, Department of Surgery | Director, CWRU Center for Skills and Simulation | Surgical Director, Digestive Health Institute | University Hospitals Case Medical Center | Case Western Reserve University | 11100 Euclid Avenue Cleveland, OH 44106-5047
MedicalResearch.com: What are the main findings of the study?
Answer: Our goal was to see whether the transversus abdominis plane (TAP) block reduced complications and shortened the hospital stay of patients undergoing colorectal operations. The TAP block is a nerve block injection given at the conclusion of the operation which reduces pain in the operative area. Results showed that the mean hospital stay dropped to less than 2.5 days after the surgical procedure, significantly lower than the 3.7 days which the University Hospitals Case Medical Center Care pathway had already described for more than 1,000 consecutive patients. In our new study, we employed the TAP block and the Enhanced Recovery Pathway (ERP) on 100 patients. We found that 27 patients went home the next day and another 35 went home 48 hours after their operations. That is considerably better than the five or six days patients usually stay in the hospital after laparoscopic colorectal procedures, and certainly better than nine days often seen after an open operation. With a third of patients leaving the day after colorectal resection, we feel these results are significant.
We also found that the TAP block allows patients to bypass or at least reduce the amount of narcotics they are often given after an operation. Though narcotics can help reduce pain, these agents also can slow down recovery. The TAP block wears off just in time for patients to skip the worst of the pain that occurs immediately after the operation, and the block does not appear to pose any significant risks to patients.
MedicalResearch.com: Were any of the findings unexpected?
Answer: The old thinking was that if patients went home early, they have a higher chance of readmission, but the data continue to show that is not the case. Patients who went home earliest had the lowest readmission rate. Although my group has seen this in previous studies, the new study affirms those findings. There were no mortalities, and patients who stayed longer in hospital tended to have more complications.
Of the eight patients with complications, such as urinary tract infections, gastrointestinal bleeds or small bowel obstructions, only two of this group were discharged within 48 hours. Those patients who had complications or required a longer stay were probably more high-risk patients anyway, because of advanced age or additional health conditions. Standardized criteria for discharge from hospital also play an important role in these results.
MedicalResearch.com: What should clinicians and patients take away from your report?
Answer: I predict that Enhanced Recovery Pathways (ERP) will become standard practice for colorectal surgical patients in the next five years, although some health care organizations are already using them to a variable extent. The ERP protocol counters traditional conventions about how patients should prepare for, and recover from, colorectal operations. These standardized steps—which have been shown to speed recovery and improve outcomes—include letting patients eat the day after the procedure instead of waiting several days, encouraging them to walk around after procedures instead of staying in bed, optimizing analgesia, and controlling intravenous fluid volumes.
Using a TAP block to reduce hospital stay and narcotics use also has implications for reducing health care costs. In addition to the cost of each day in hospital, painkillers and other medications for colorectal surgical patients can cost many hundreds of dollars for each patient. The TAP block costs just $20 per patient. There are so many things we have to be careful of and cost is one of them. This is a low cost way to help patients feel better and recover sooner.
However, TAP blocks in the ERP protocol will require more evidence from further studies, such as a randomized clinical trial.
MedicalResearch.com: What recommendations do you have for future research as a result of this study?
Answer: The next step is a randomized clinical trial. In fact, my research team has already initiated a randomized double-blinded trial to compare a group of colorectal surgical patients who receive the TAP block with another group who will not.
If things continue to go well, my expectation is that we’ll eventually be giving the TAP to everyone, because it helps with reducing the pain. As quality and outcomes improve, we will also continue to see an increasing percentage of patients who are fit to be discharged the day after colorectal resection.
Outcomes of Discharge after Elective Laparoscopic Colorectal Surgery with Transversus Abdominis Plane Blocks and Enhanced Recovery Pathway
Favuzza J, Delaney CP.
Division of Colorectal Surgery, University Hospitals Case Medical Center, Cleveland, OH.
J Am Coll Surg. 2013 Sep;217(3):503-6. doi: 10.1016/j.jamcollsurg.2013.03.030. Epub 2013 Jun 28.