title: Comprehensive enhanced recovery pathway significantly reduces postoperative length of stay and opioid usage in elective laparoscopic colectomy.
abstract: BACKGROUND
  A comprehensive enhanced recovery pathway (ERP) was implemented in patients undergoing laparoscopic colectomy in an attempt to reduce postoperative opioid consumption. We hypothesized that improved local analgesia and increased use of non-opioid pain medication, combined with earlier feeding and ambulation, would allow for earlier return of bowel function and shorter postoperative length of stay (LOS).
  
  
  METHODS
  We retrospectively reviewed 89 patients who underwent elective partial laparoscopic colectomy with our ERP fully integrated compared to a historical control group of 162 patients. Differences between the ERP and control groups average return of bowel function, postoperative LOS, opioid medication usage, and complications were compared statistically using the student's t-test and Fisher exact test. Pain was controlled with the laparoscope-guided transversus abdominis plane (TAP), scheduled doses of non-narcotic medications, and reserved use of opioids. Patient, nursing and resident education regarding all aspects of the ERP was emphasized.
  
  
  RESULTS
  Patients in the ERP group had a significant decrease of opioid usage, earlier return of bowel function, and shorter postoperative hospital LOS. Opioid use was reduced from 75 to 19 mg I.V. morphine (p = 0.0001). Patients had an average return of bowel function of 0.66 days earlier from postoperative day (POD) 2.99 to POD 2.33 (p = 0.0001) and were discharged from the hospital 1 day sooner on POD 2.7 compared with POD 3.7 (p = 0.0013). There was no statistically significant difference in postoperative complications between the control and ERP groups.
  
  
  CONCLUSIONS
  The new ERP, including TAP block and postoperative pain medication protocol limiting I.V. narcotics, is effective in controlling pain in elective partial laparoscopic colectomy. Pain control management together with regimented early feeding and ambulation allow for significantly earlier return of bowel function and shorter postoperative LOS.
authors.affiliation: Department of Surgery, Abington Memorial Hospital, 1200 Old York Road, Price Bldg, Suite 604, Abington, PA, 19001, USA, malvarez@amh.org.
authors.forename: Martin P
authors.initials: MP
authors.lastname: Alvarez
authors.forename: Katherine E
authors.initials: KE
authors.lastname: Foley
authors.forename: D Mark
authors.initials: DM
authors.lastname: Zebley
authors.forename: Steven A
authors.initials: SA
authors.lastname: Fassler
mesh_terms: D000368:Aged; D000701:Analgesics, Opioid / Q000627:therapeutic use*; D000762:Anesthesia Recovery Period; D003082:Colectomy / Q000379:methods*; D017558:Elective Surgical Procedures / Q000379:methods*; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009407:Nerve Block / Q000379:methods; D010149:Postoperative Pain / Q000188:drug therapy*; D010351:Patient Discharge / Q000639:trends*; D011184:Postoperative Period; D012189:Retrospective Studies
chemical_list: D000701:Analgesics, Opioid