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 ≥ 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 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.
Similar content being viewed by others
References
Wang L, Guyatt GH, Kennedy SA, Romerosa B, Kwon HY, Kaushal A, Chang Y, Craigie S, De Almeida CB, Couban RJ, Parascandalo SR, Izhar Z, Reid S, Khan JS, McGillion M, Busse JW. Predictors of persistent pain after breast cancer surgery: a systematic review and meta-analysis of observational studies. CMAJ. 2016;188(14):E352–61.
Katz J, Poleshuck EL, Andrus CH, Hoganb LA, Jungf BF, Kulickg DI, Dworkin RH. Risk factors for acute pain and its persistence following breast cancer surgery. Pain. 2005;119(1–3):16–25.
Chiu C, Aleshi P, Esserman LJ, Inglis-Arkell C, Yap E, Whitlock EL, Harbell MW. BMC Anesthesiology. 2018;18(41):1–9.
Oh C, Moriarty J, Borah BF, Mara KC, Harmsen WS, Saint-Cyr M, Lemaine V. Cost analysis of Enhanced Recovery After Surgery in microvascular breast reconstruction. JPRAS. 2018;71:819–26.
Rojas K, Manasseh DM, Flom PL, Agbroko S, Bilbro N, Andaz C, Borgen PI. A pilot study of a breast surgery Enhanced Recovery After Surgery (ERAS) protocol to eliminate narcotic prescription at discharge. Breast Cancer Res Treat. 2018;171(3):621–6.
Van Helmond N, Van Timmerman H, Van Dasselaar NT, Van de Pol CC, Olesen SS, Drewes AM, Vissers KC, Wilder-Smith OH, Steegers MA. High body mass index is a potential risk factor for persistent postoperative pain after breast cancer treatment. Pain Physician. 2017;20:E661–E671.
Gonzalez-Callejas C, Aparicio VA, Teresa CD, Nestares T. Association of body mass index and serum markers of tissue damage with postoperative pain: the role of lactate dehydrogenase for postoperative pain prediction. Pain Med. 2019;0(0):1–8.
Rojas K, Fortes T, Flom PL, Manasseh DM, Andaz C, Borgen PI. Mastectomy is no longer an indication for postoperative opioid prescription at discharge. Am J Surg. 2019;218(4):700–5.
Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research Electronic Data Capture (REDCap) – A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-81.
Harris PA, Taylor R, Minor BL, Elliott V, Fernandez M, O’Neal L, McLeod L, Delacqua G, Delacqua F, Kirby J, Duda SN, REDCap Consortium. The REDCap consortium: building an international community of software partners. J Biomed Inform. 2019;95:103208.
Guideline Resources: CDC Opioid Guideline Mobile App. CDC.gov. 29 July 2019.
Ding YY, Yao P, Wu L, Han ZK, Hong T, Zhu YQ, Li, HX. Body Mass Index and persistent pain after breast cancer surgery: findings from the women’s healthy eating and living study and a meta-analysis. Oncotarget. 2017;8(26):43332–43.
Tasmuth T, Kataja M, Blomqvist C, von Smitten K, Kalso E. Treatment-related factors predisposing to chronic pain in patients with breast cancer: a multivariate approach. Acta Oncol. 1997;36:625–30.
Fecho K, Miller NR, Merritt SA, Klauber-DeMore N, Hultman CS, Blau WS. Acute and persistent postoperative pain after breast surgery. Am Academy Pain Med. 2009;10(4):708–15.
Meretoja TJ, Leidenius MH, Tasmuth T, Sipila R, Kalso E. Pain at 12 months after surgery for breast cancer. JAMA. 2014;311:90–2.
Blokh Kerpel A, Tiosano S, Amital D, Comaneshter D, Cohen AD, Amital H. Association of obesity, smoking and socioeconomic strata with the fibromyalgia syndrome. Harefuah. 2019;158(9):583–6.
Ip HY, Abrishami A, Peng PW, Wong J, Chung F. Predictors of postoperative pain and analgesic consumption: a qualitative systematic review. Anesthesiology. 2009;111(3):657–77.
Wright LJ, Schur E, Noonan C, Ahumada S, Buchwald D, Afari N. Chronic pain, overweight, and obesity: findings from a community-based twin registry. J Pain. 2010;11(7):628–35.
Karasu SR. Of mind and matter: psychological dimensions in obesity. Am J Psychother. 2012;66(2):111–28.
Tang Z, Wang J, Zhang H, Sun L, Tang F, Deng Q, Yu J. Associations between Diabetes and Quality of Life among Breast Cancer Survivors. PLoS ONE. 2016;11(6):e0157791.
Leitner DR, Frühbeck G, Yumuk V, Schindler K, Micic D, Woodward E, Toplak H. Obesity and Type 2 Diabetes: Two Diseases with a Need for Combined Treatment Strategies - EASO Can Lead the Way. Obes Facts. 2017;10(5):483–92.
Oliveira RR, Nascimento SL, Pace do Amaral MT, Pinto Silva MP, Freire Oliveira MM. Influence of Body Mass Index on the frequency of lymphedema and other complications after surgery for breast cancer. Fisioter Pesq. 2016;23(1):84–90.
Gartner R, Jensen MB, Nielsen J, Ewertz M, Kroman N, Kehlet H. Prevalence of and factors associated with persistent pain following breast cancer surgery. JAMA. 2009;302:1985–92.
Volkow ND, McLellan AT. Opioid abuse in chronic pain: misconceptions and mitigation strategies. N Engl J Med. 2016;374(13):1253–63.
Acknowledgments
The authors acknowledge the Maimonides Medical Center anesthesiologists, perioperative staff, general surgery residents, anesthesia residents, pharmacists, physician assistants, and the administrative staff of the Maimonides Breast Center.
Funding
This research did not receive any funding from agencies in the public, commercial, or not-for-profit sectors.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Disclosure
Dr. P. Borgen and Dr. K. Rojas have received speaker’s honoraria from Pacira Pharmaceuticals, Inc. All other authors report no relevant commercial, financial, consultant, or institutional conflict of interest.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Morin, C., Javid, M., Patel, Y. et al. Obese Patients Who Receive an Opioid-Sparing Enhanced Recovery After Surgery (ERAS) Protocol are at Increased Risk of Persistent Pain After Breast Surgery. Ann Surg Oncol 27, 4802–4809 (2020). https://doi.org/10.1245/s10434-020-08894-9
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1245/s10434-020-08894-9