Obese Patients Who Receive an Opioid-Sparing Enhanced Recovery After Surgery (ERAS) Protocol are at Increased Risk of Pe
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ORIGINAL ARTICLE – BREAST ONCOLOGY
Obese Patients Who Receive an Opioid-Sparing Enhanced Recovery After Surgery (ERAS) Protocol are at Increased Risk of Persistent Pain After Breast Surgery Claudya Morin, MD1, Munazza Javid, MD1, Yamini Patel, MD1, Peter Flom, PhD2, Charusheela Andaz, MD1, Donna-Marie Manasseh, MD1, Patrick I. Borgen, MD1, and Kristin E. Rojas, MD1 1
Department of Surgery Maimonides Medical Center, Brooklyn, NY; 2Peter Flom Statistical Consulting, New York City, NY
ABSTRACT Background. Obese patients are at increased risk of persistent pain and chronic opioid dependence after surgery. We sought to evaluate the impact of an Enhanced Recovery After Surgery (ERAS) protocol in breast surgery patients to determine whether multimodal analgesia was effective for both obese and non-obese patients. Methods. A prospective cohort of patients undergoing breast surgery who received an opioid-sparing ERAS protocol was compared with patients who did not receive ERAS, including a historical cohort. Pain scores were compared with respect to body mass index (BMI). Obesity was defined as BMI C 30, and moderate to severe pain was defined as 4–10 of a 10-point scale. Postoperative day one and week one pain scores were compared using the Kruskal–Wallis test. Results. A combined contemporary and historical cohort of 1353 patients underwent lumpectomy and mastectomy without reconstruction. The present analysis comprises 622 patients with pain scores who did and did not receive ERAS between 2015 and 2018. The two groups were demographically similar. The day after surgery, those who received ERAS reported lower rates of moderate to severe pain, regardless of BMI (obese: 46.3% vs. 21.8%, p \ 0.001; non-obese: 36.3% vs. 19.4%, p = 0.002). One week after surgery, obese patients who received ERAS had
Ó Society of Surgical Oncology 2020 First Received: 14 May 2020 Accepted: 30 June 2020 K. E. Rojas, MD e-mail: [email protected]
higher rates of persistent pain compared with non-obese patients (18.6% vs. 11.1%, p = 0.042). Conclusions. An opioid-sparing ERAS protocol utilizing multimodal analgesia significantly improved postoperative pain control for obese and non-obese patients. However, it appears that obese patients are still at relatively greater risk for persistent pain after surgery.
Patients who undergo breast cancer surgery are at risk of chronic postoperative pain, which may be refractory to treatment and result in impaired function.1,2 Acute postsurgical pain has been well-established as a predictor for developing chronic pain after breast surgery.2 Enhanced Recovery After Surgery (ERAS) protocols using multimodal analgesia have gained traction across surgical subspecialties with improved outcomes, such as shorter hospital stays and quicker return to functionality.3–5 Furthermore, there has been a collective effort to optimize perioperative pain control to reduce superfluous opioid prescriptions in the midst of an ongoing opioid crisis. Identifying factors that put patients at risk for poorlycontrolled pain
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