E101: Opioid-free ERAS protocol compared to conventional ERAS protocol in colorectal surgery: A single-institution experience

Introduction: Standardized postoperative care in the form of enhanced recovery after surgery (ERAS) has improved patient outcomes, but frequently includes opioid medications. In addition, it frequently focusses on the postoperative period whilst ignoring the intraoperative period. We devised an opioid-free perioperative ERAS protocol and compared this to patients receiving a conventional opioid-containing ERAS protocol.

Methods: A single-center retrospective cohort study was conducted including all patients undergoing colorectal surgery from January 2022 to July 2023. Patients undergoing emergency or ambulatory surgeries, multivisceral resections, or had planned post-operative epidural anesthesia were excluded. Demographic, procedural and postoperative data were collected and analyzed using SPSS.  

Results: A total of 204 patients were eligible for analysis. 103 patients received the opioid-free intra-operative protocol (OFIOP), whereas 101 patients received opioid-containing anesthesia and standard opioid-containing ERAS protocols. Of the 103 patients who underwent OFIOP, 77 (74.8%) completed full opioid-free perioperative ERAS protocol while 26 (25.2%) did require opioids in the post-operative setting. Using intention-to-treat analysis, patients’ daily maximum pain score did not significantly differ between the two groups  (PACU: 4.63 vs 4.51;  POD1: 4.96 vs 4.56 ; POD2: 3.78 vs. 3.69; POD3: 2.53 vs 3.08; all p = NS) with the exception of POD0 in favor of OFIOP group (5.48 vs. 4.55 , p = 0.037). The OFIOP group used significantly less opioids on POD 0, POD1 and POD2 (p< 0.001; p< 0.001;p=0.003). The effect was no longer measurable on POD3 (p=0.193) due to an overall decrease in opioid intake and patient discharges. The use of OFIOP was significantly associated with not requiring an opioid prescription on discharge (15.5% vs. 51.5%, p< 0.001). When analyzing patients who completed the entire opioid-free ERAS protocol this effect became more pronounced (9.1% vs. 50.0%, p< 0.001). The use of OFIOP was not associated with less use of anti-emetics, either within the first 24 hours after surgery or after, or the rate of post-operative ileus (p = NS). In addition, the use of OFIOP was not associated with the rate or severity of complications (including AKI) or rate of readmission.
 

Conclusions: A completely opioid-free ERAS protocol is feasible with low failure rates, leads to comparable postoperative pain scores and decreases both inpatient and outpatient opioid use compared to conventional opioid-containing ERAS protocols.