Discussion

Presenter: Dr Karishma Kodia Dr Linda W. Martin (Charlottesville, Va). I want to thank the American Association for Thoracic Surgery, Dr Varughese, and Dr Duncan for inviting me to discuss this paper. And I want to congratulate the authors, Dr Kodia and Dr Nguyen, on this excellent paper and thank them for submitting it ahead of time, and that it got into the top abstracts for this category. This is an important paper. It looks at a transition in an enhanced recovery program in thoracic surgery from the first 18 months of institution to the most recent calendar year and some changes that were made along the way. I applaud the authors for that continuous process improvement, which is a very key component of any enhanced recovery program. You can't rest on your laurels once you start these programs, you have to keep looking at how to make it better. I also want to point out that for those of you who don't know, thoracotomy is the most painful incision that we do in all of surgery, but the second most painful incision is minimally invasive thoracic surgery, so video-assisted thoracoscopic surgery and robotic surgery sounds like it's a much lesser evil, but it is right up there. And so, any movement we can make on opioid use is critically important. And finally, I want to point out how critical this opioid reduction is. Not only for short-term patient outcomes for the risk of addiction in those patients, which has been shown to be as high as 25% in this population as well as the opioid flow into the community, but another area that's less well known is the effect interaction of opioids on cancer progression—something I've been researching myself but there will be a paper in Lung Cancer Three session on Sunday morning that talks about that more. I'd like to ask a few questions of Dr Kodia and Dr Nguyen. And the first question is, Can you please describe in more detail the time and technique of your injection? I think this is very critical in the success of this approach. Dr. Karishma Kodia (Miami, Fla). Absolutely. Thank you so much for having me. The technique that we use is that we take the anterior robotic arm, and we take a 25-gauge butterfly needle and we inject either Exparel (Exparel; Pacira Pharmaceuticals Inc) or the combination of the bupivacaine and Exparel into the subpleural space from the second intercostal space to the 10th intercostal space. Dr Martin has a previous paper that talks about doing a wide injection, which I think is important, so we inject into this subpleural space to hit the perineural fibers and we do it upon entrance into the cavity under direct visualization; before placing our ports we infiltrate the skin wound sites as well. Dr Martin. Yes. I think that's important to do it at the very beginning and broadly, because when we've tried other techniques it's hard to show that it's an impactful approach. The onset of Exparel is quite slow, as much as an hour or more, and I think the addition of the short-acting bupivacaine was a good move that probably helps overcome that limitation. And the next question I have is, How did you decide what to discharge patients in terms of narcotics? I see most of your patients leave on day 2 or 3, and I've looked at the pharmacokinetics of this drug, it lasts for 3 to 4 days. You can get sort of duped into thinking that they have no pain. They go home and all of a sudden, they feel it and they start calling because they're feeling it as the Exparel wears off. Could you tell us a little bit about how you calculate your discharge opioids? Dr Kodia. Yes, we have a protocol in place that essentially looks at, on the day of discharge, the use of narcotics that patients have, and based on what they're using in the hospital we then discharge them accordingly. But I think it's also in line with Enhanced Recovery after Thoracic Surgery where you're still using other medications, like gabapentin and Tylenol (Johnson & Johnson Inc) to also provide pain control that's not just narcotic-based. Dr Martin. Yes. And again, I think that's an area we're all trying to figure out better, is how best to do the discharge. Another question: I saw that a lot of your nonanatomic resections were wedge resections and most of them were for what sounds like metastatic disease. In my experience those patients are so-called professional patients. They've had usually a laparotomy for liver resection and colon resection. They've sometimes had multiple lung resections for nodules and they're very sensitized to traumatic experiences and where some patients might need a little medicine, they seem to need more. Have you had to adjust your approach with those patients at all? Dr Kodia. In some cases. I think it's also important, like in your preoperative counseling, to set up expectations for what patients will experience postoperatively. And with that counseling they do a little bit better, at least in our experience. Dr Martin. Yes. I think the counseling definitely helps, but I would say with some of those people I've sometimes adjusted the protocol a little bit because they're more sensitized. I'm wondering if some of the tremendous improvement you've seen from the first cohort to the second cohort might be the greatness of your protocol. We hope. But it might also be that there's a philosophical change going on in society and a greater recognition of the problem of opioids, and patients' acceptance and willingness to try to be opioid sparing might be better. And I'm wondering if you think that's at play here. Dr Kodia. I think that might be at play. I think that it all ties into the same concept, which is that a lot of patients end up with prescriptions that they don't end up using and then they don't end up storing them appropriately anyway. So, some of that is from the patient end and some of that is from our end, but essentially both forces kind of work synergistically so that at a societal level and individual level we're using fewer narcotics for our patients. Dr Martin. Great. I've noticed one of the things I find to be most useful with Enhanced Recovery and the protocol that we use, which is similar to yours, is that if you have a need to convert to thoracotomy there's really no change in your pain management protocol. It's a very seamless thing to go from video-assisted thoracoscopic surgery or robotic to open. And we found that our pain scores and our narcotic use are similar between those groups. I was wondering why you chose to exclude your converted patients. Dr Kodia. I think we parse out a lot of our Estimated Recovery after Thoracic Surgery data into thoracotomy patients only or robotic patients only. So, essentially just inputting these patients into different groups from our data set and then including them in different papers was the reason to do so. Dr Martin. Okay, great. Congratulations on a great paper.