Postoperative Opioid Utilization and Patient Satisfaction in General Surgery Procedures: A Prospective Observational Study

Background Wide variation of opioid prescribing persists despite attempts to quantify number of opioids utilized postoperatively. We aim to prospectively determine number of opioids used after common surgery procedures to guide future prescribing. Methods A prospective observational trial was performed of opioids prescribed and used postoperatively. Patients filled out pre- and postoperative surveys, and number of opioids utilized was captured at postoperative visit. Results One-hundred-and-thirteen patients met inclusion. Median opioids prescribed exceeded number of opioids taken for all procedures. Median number of opioids taken postoperatively was fewer than 10 for all categories of procedures: simple skin/soft tissue 2 (IQR 1-4), complex skin/soft tissue 1.5 (IQR 0-14), simple laparoscopy 1 (IQR 0-20) and complex laparoscopy 4 (IQR 0-20), laparotomy 0 (IQR 0-26), and open inguinal hernia 2 (IQR 0-2). Nearly 80% of patients had leftover opioids, and 31% planned to keep them. There was little difference between preoperative and postoperative level of satisfaction with a pain control regimen. Discussion Postoperatively, patients utilize opioids less frequently than prescribed and often keep leftover pills. Patient pain control satisfaction is unrelated to number of opioids prescribed and taken postoperatively.

Causative Factors for Complications in Transpalatal Advancement

Introduction: Transpalatal advancement (TPA) is a procedure that is used when modern variants of uvulopharyn-gopalatoplasty are unable to provide enough anterior traction. Although successful in reduction of obstructive sleep apnea (OSA) parameters, it also comes with procedure-specific risks. Formation of an oro-nasal fistula (ONF) is a complication that results in significant morbidity and a protracted treatment course. Methods: After approval from the University of Wollongong Health Research Ethics Committee, a retrospective chart review of all cases undergoing TPA performed by a single surgeon over a 10-year period from 2008 to 2018 was performed. Patients underwent pre- and postoperative level 1 or 2 polysomnography. Factors potentially contributing to palatal complications, as well as pre- and postoperative polysomnographic parameters, subjective sleep questionnaires, and body mass index (BMI) were statistically analyzed where a P value <.05 was considered a significant result. Results: A total of 59 patients were included. Overall palatal complication rate was 25.4% (15/59), with the most common being transient velo-palatal insufficiency (VPI) (8/59, 13.6%). ONF developed in 4/59 (6.8%) of patients. None of the analyzed contributing factors for palatal complications were statistically significant, except the presence of a high-arched palate and development of ONF. All analyzed sleep parameters, as well as BMI, were significantly different when comparing pre- to postoperative results. Conclusion: This study suggests that TPA has a role in current sleep surgery paradigms and can significantly improve both objective and subjective outcome measures of OSA. Surgeons contemplating TPA on patients with high-arched hard palates should do so with caution.

Use and Misuse of IOPTH Levels During Parathyroidectomy

Objective The combined use of localization and intraoperative parathyroid hormone assay (IOPTH) has facilitated the performance of targeted or minimally invasive parathyroidectomy. The precise algorithm of the use of IOPTH has been debated. We sought to clarify the optimal sequence of testing. Methods After IRB approval was obtained, demographic data and intraoperative laboratory and surgical findings from patients undergoing parathyroidectomy were prospectively gathered and analyzed. Specific attention was paid to the value of pre-excision (P-E) values and the 5-minute postoperative (5-min) levels and their impact on intraoperative decision-making. In the first 49 consecutive patients, a P-E baseline value was sought; in all cases a 5-min value was obtained when possible. Results 112 patients underwent parathyroidectomy during the study period. 30 of these were for secondary or tertiary hyperparathyroidism and were excluded. 78 (95.1%) of the patients were eucalcemic. In 4 cases (4.9%), the incorporation of the pre-excision baseline value represented a false positive, and surgery was aborted prematurely. In no case did the P-E value change what was otherwise destined to be a successful result based on pre-incision value. In 47 cases (57.3%), operative time was conserved as the procedure was correctly stopped after the 5-min level. Conclusions Pre-excision baseline levels, while logical in their original proposal, appear to play virtually no role in determining the completeness of an exploration, and may in fact be misleading. A 5-minute postoperative level adds value in over one-half of cases by allowing earlier termination of the operation.