Inpatient Opioid Utilization After Robot-assisted versus Laparoscopic Bariatric Surgery

doi:10.21203/rs.3.rs-4953013/v1

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Research Article

Inpatient Opioid Utilization After Robot-assisted versus Laparoscopic Bariatric Surgery

https://doi.org/10.21203/rs.3.rs-4953013/v1

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Introduction: Robotic platforms are increasingly utilized in bariatric surgery to overcome technical limitations of traditional laparoscopy. However, the impact of robotics on postoperative pain control is not fully understood. The present study aimed to compare pain control outcomes following primary bariatric surgery performed via robot-assisted approaches versus conventional laparoscopy.

Methods: This was an IRB-approved retrospective investigation of all adults who underwent primary bariatric surgeries at a single institution from August 2016 to January 2019. Multivariable generalized linear and ordinal logistic regression models were fitted to test predictive associations of the (robotic vs laparoscopic) surgical technique with post-operative, in-hospital opioids consumption and pain intensity ratings, independent of co-varying risk factors.

Results: A total of 340 patients (201 undergoing robotic, 139 laparoscopic procedures) were included in the study. Baseline preoperative characteristics were similar between comparison groups, except mean BMI was significantly higher among robotic surgery recipients (47.7 vs 44.0 kg/m²; p<0.001). Postoperative in-hospital opioid consumption did not significantly differ among recipients of robotic versus laparoscopic bariatric surgery. No difference was detected between comparison cohorts in total inpatient opioid use (p=0.300), opioid use in PACU (p=0.977), nor average opioid use per inpatient day (p=0.178). Similarly, in multivariable ordinal logistic regression models of postoperative day 0 and postoperative day 1 pain ratings, perceived pain intensity was not significantly higher following robotic versus laparoscopic primary bariatric surgeries, after accounting for other risk factors.

Conclusion: Compared to conventional laparoscopy, robotic primary bariatric procedures did not independently increase post-operative, in-hospital opioid utilization nor pain intensity.

Inpatient opioid utilization after robotic bariatric surgery was similar to laparoscopy
Pain intensity was similar between robotic and laparoscopic bariatric procedures
Robotic bariatric surgery may not lead to inferior pain control postoperatively

Obesity has reached epidemic proportions in the United States (U.S.), with its incidence among adults projected to rise from 41–42% in 2017,[1, 2] to 49% by 2030.[3] Obesity accounts for approximately $173 billion in medical expenditures nationwide.[4] Studies repeatedly show that bariatric surgery is the most effective therapy for obesity [5–7] and its related illnesses.[8–12] Increasing numbers of obese American adults now undergo weight loss surgery, with bariatric operations rising from 158,000 in 2011 to 256,000 in 2019, followed by a pandemic-era fall to 199,000 in 2020,[13] then bouncing back to 263,000 by 2021,[14] and 280,000 by 2022.[15] Laparoscopy has hitherto been the gold standard for bariatric surgery, as it is associated with fewer complications, faster recovery, and shorter hospital stays, compared to open surgery.[16] Nevertheless, laparoscopy also has limitations including limited rotational motion, reduced depth perception, 2-dimensional visualization, and ergonomic difficulties. Robotic surgery platforms overcome these technical limitations via improved instrument dexterity, three-dimensional visualization, and superior ergonomics.[17–19] Despite increasing popularity in bariatric operations and theorized advantages,[20, 21] robotic platforms have undergone deep scrutiny due to poor haptic feedback, increased costs, and longer operative times.[22] Their comparability with standard laparoscopy regarding costs, leak rates, stricture rates, operative time, hospital stay length, and conversion to open surgery has recently improved.[23–26] Hence, the upward trend in utilization of robotic bariatric surgery.[27–29]

A concurrent phenomenon in the U.S. is the opioid dependency epidemic.[30] Bariatric surgery recipients experience higher pre- and post-operative risks of chronic pain, anxiety, depression, and bipolar disorder,[31–33] all precursors of opioid dependency.[33, 34] From 4–6% [35–37] to 6–9% [38] of opioid naïve patients become new chronic opioid users after bariatric surgery. Over prescription of opioids after bariatric surgery is widespread,[39, 40] despite recipients being at greater risk of complications such as obstructive sleep apnea,[41] which is linked to opioid-induced respiratory depression.[42] Thus, Enhanced Recovery After Bariatric Surgery (ERABS) protocols nowadays incorporate strategies to lessen opioid use,[43, 44] with studies reporting their effectiveness.[45–47] However, opioid use after robotic versus laparoscopic bariatric surgeries is rarely compared among adults. One retrospective study found no significant differences in in-patient opioid utilization or pain scores after robotic versus laparoscopic Roux-en-Y gastric bypass (RYGB) surgery.[48] A recent retrospective study also found that in-patient, postoperative opioid usage and pain scores did not significantly differ after robotic versus laparoscopic sleeve gastrectomies (SG).[49] In order to strengthen the evidence base, more studies comparing postoperative opioid utilization and pain control between these two minimally invasive approaches to bariatric surgery are needed.

The present study addresses this gap in evidence by examining both postoperative opioid utilization and pain control after robot-assisted versus laparoscopic primary bariatric surgeries. We hypothesized that patients who undergo robotic bariatric surgery would not experience increased in-hospital/pre-discharge opioid use nor pain intensity compared to those who underwent bariatric surgery with traditional laparoscopy. Based on anecdotal experience, we hypothesized that robotic surgery recipients would have similar pain control outcomes when compared to laparoscopy recipients. The present study also investigated factors that have a significant, independent predictive association with short-term opioid usage and pain intensity following primary bariatric surgery, and whether these differed for robotic versus laparoscopic procedures.

Study Design/Participant Selection:

This is a retrospective observational study. Eligible participants were adult patients (aged ≥ 18 years) with obesity who underwent primary weight loss surgery performed by a team led by a single bariatric surgeon at a single high-volume center between August 2016 and January 2019. Only primary bariatric surgeries performed via either the laparoscopic or robotic approach were sampled. Patients aged below 18 years and revisional bariatric surgeries, defined as re-operations after a prior primary surgery, were excluded. Participant demographics and clinical encounter data were extracted from the hospital’s EPIC® (© Epic Systems Corporation, Verona, Wisconsin) electronic medical record (EMR) system. Participants were categorized into two comparator cohorts based on the operative technique employed in the bariatric surgery: laparoscopic versus robotic.

Study Variables:

Primary Outcome

The principal endpoint is the quantity of in-hospital/pre-discharge opioid medications used (expressed in milligram morphine equivalents [MME]).[50, 51] Both the overall total and average daily quantity of opioid medications were examined.

Secondary Outcome

Perceived pain intensity after surgery is the other endpoint outcome. At our institution, pain intensity is scored by nurses using the visual analog scale for pain (VASP) according to a 0 (no pain) – 10 (maximum, unbearable pain) rating spectrum. Each pain score and the exact time of its assessment were abstracted from the EMR. Bariatric surgery recipients are typically discharged in one day or less.[52, 53] Thus, postoperative, inpatient opioid use and pain data were mostly available for the day of surgery (POD0) and the day after surgery (POD1).

Covariates

The analysis adjusted for potential confounding factors, which included patient demographics such as age (in years), sex, race/ethnicity (white, black, or other), body mass index (BMI, expressed in kg/m²); surgical operation (RYGB, SG, or duodeno-ileal switch [DS]); duration of the operation (in minutes); preoperative American Society of Anesthesiologists (ASA) physical status classification; history of smoking, comorbid illnesses (e.g., chronic obstructive pulmonary disease [COPD], chronic pain, arthritis, neuropathy, anxiety, depression, back pain); and preoperative medications (e.g., anxiolytics, antidepressants, muscle relaxants, nonsteroidal anti–inflammatory drugs [NSAIDs], Gabapentin/Pregabalin, opioids).

Statistical Analysis:

Continuous variables with a normal distribution are summarized as means ± standard deviations (SD), non-normally distributed continuous variables as medians (interquartile range: Q1–Q3), and discrete variables as percentages (%). Group differences in continuous variables were assessed via Student’s t-test in case of a normal distribution, and the Mann-Whitney or Wilcoxon rank sum test in case of a skewed distribution. Unadjusted differences in binary/categorical variables were analyzed using Pearson’s chi-square test or Fisher’s exact test, as appropriate.

Multivariable generalized linear regression models were fitted to test risk-adjusted associations of the operative technique with opioid medications utilization after surgery and before discharge. Continuous risk factors were fitted with restricted cubic splines, which are robust to violations of regression models’ assumptions of linearity.[54, 55] Variability in distribution of residuals was examined for violations of the assumption of normal distribution. Quantile–quantile plots of the residuals followed a straight line, suggesting that violation of the normality assumption did not threaten statistical conclusion validity. Multivariable models of post-operative opioid usage (i) over the full hospital stay, (ii) averaged per hospital day, (iii) in the post-anesthesia care unit (PACU), (iv) on the day of surgery (POD0), and (v) the first day after surgery (POD1) were fitted.

Risk-adjusted associations of the operative technique with VASP ratings were evaluated using multivariate ordinal logistic regressions. The proportional odds assumption was tested via standard graphical techniques.[56] Separate models for pain on POD 0 and POD 1 were fitted, adjusting for demographics (age, sex, race) and clinical covariates (BMI, ASA class, surgical operation, duration of operation, comorbidities). The multivariable model for pain on POD 1 also adjusted for baseline pain (i.e., on POD 0). Statistical analyses were performed using R software version 4.0.3 (R Development Core Team, Vienna, Austria). All statistical tests were two-sided with the statistical significance threshold set at p < 0.05.

A total of 340 patients received primary bariatric surgery during the study period, of whom 201 (59.12%) underwent robot-assisted procedures while 139 (40.88%) underwent laparoscopy. SG (79.4%) were most frequent, versus RYGB (15.0%) and DS (5.6%) surgeries. SG operations were more likely to be performed via laparoscopy, while more RYGB and all DS operations were robot-assisted. The overall sample was 72.9% female, 27.1% male, 66.8% white, and 37.0% aged 55 years or older; 73.7% had class III (extreme or morbid) obesity (BMI ≥ 40 kg/m²) before surgery. In regards to preoperative mental illness, 32.6% suffered from depression and 31.5% had anxiety. Likewise, 37.1% were taking antidepressants while 15.6% were on anxiolytics before surgery. One of five patients were already taking opioid medications, one of seven were on Gabapentin/Pregabalin, and another one of seven on NSAIDs, before surgery. Median (interquartile range) in-hospital stay after surgery was only 1.0(1.0–1.0) days. Detailed baseline characteristics of the sample are illustrated in Table 1, comparing robotic versus laparoscopic bariatric surgery recipients. The two comparison cohorts did not differ on baseline characteristics (p > 0.05) except for: (a) preoperative BMI, which was significantly higher for robot-assisted versus laparoscopic surgery recipients [mean (± SD) of 47.7 (± 10.4) vs 44.0 (± 8.1) kg/m², respectively]; and (b) duration of surgery, also higher for robotic procedures [mean (± SD) of 120.7 (± 51.9) vs 83.9 (± 69.4) minutes; p < 0.001)].

Total in-hospital, pre-discharge opioid utilization after surgery for the overall sample reached a mean (± SD) of 28.0 (± 23.8) MMEs. Daily opioid analgesia administration in the postoperative, pre-discharge period averaged 23.1 (± 16.1) MMEs per day. Mean (± SD) usage increased from 6.4 (± 7.2) in the PACU to 11.3 (± 11.6) on the first day then, for those still admitted, to 15.5 (± 14.6) MMEs by the third day after surgery. As shown in Table 2, postoperative in-hospital opioid consumption did not significantly differ among recipients of robotic versus laparoscopic bariatric surgery. In the multivariable risk-adjusted model of average daily opioid utilization, male sex (β=-4.43; [95% CI: -8.49, -0.36]; p = 0.034), older age (β=-6.77; [CI: -11.76, -1.78]; p = 0.041), depression (β=-6.24; [CI: -11.03, -1.46]; p = 0.011), and being on NSAIDs before surgery (β=-6.11; [CI: -11.29, -0.94]; p = 0.021) were protective factors. Conversely, back pain (β = 4.87; [CI: -0.18, 9.91]; p = 0.058) and being on opioids (β = 8.04; [CI: 3.13, 12.95]; p = 0.001), or Gabapentin (β = 7.44; [CI: 2.15, 12.73]; p = 0.006) at baseline were exacerbators. Figure 1 illustrates these findings. In the multivariable model of the total postoperative, predischarge opioid consumption, being depressed (β=-10.17; [CI: -17.11, -3.22]; p = 0.004) and on NSAIDs at baseline (β=-7.75; [CI: -15.29, -0.22]; p = 0.044) were protective while having back pain (β = 9.47; [CI: 2.14, 16.780]; p = 0.012) and being on opioids before surgery (β = 14.74; [95% CI: 7.61, 21.86]; p < 0.001) exacerbated the risk of greater usage. This model is depicted by Fig. 2.

In multivariable ordinal logistic regression models of POD0 and POD1 VASP scores, perceived pain intensity was NOT significantly higher for patients undergoing robotic versus laparoscopic primary bariatric surgeries, after accounting for other risk factors. In these models, male sex (OR = 0.59; [CI: 0.33, 1.04]; p = 0.07), higher BMI (OR = 0.97; [CI: 0.94,1.00]) and older age (OR = 0.96; [CI: 0.94, 0.98]; p = 0.001) were associated with reduced odds of greater pain intensity on POD1, and being a smoker at the baseline with increased odds (OR = 6.88; [CI: 2.36, 20.10]; p < 0.001) of higher pain intensity on POD1, independent of other risk factors. DS (versus SG) operations were associated with lower odds (OR = 0.14; [CI: 0.04, 0.42]; p = 0.001) of higher pain ratings on POD0, independent of covarying factors. Odds ratios from the multivariable ordinal logistic regression models are summarized in Table 3.

While there have been many studies evaluating the clinical benefits of robotic surgery, the impact on postoperative pain outcomes has remained uncertain. The present study aimed to fill that gap in the literature by comparing short-term postoperative pre-discharge consumption of opioid analgesics, plus perceived pain intensity, among adults with obesity who underwent robotic versus laparoscopic primary bariatric surgery at a single institution. In multivariable analyses, the quantity of opioids utilized in the days after surgery did not significantly differ between the two comparison groups. Moreover, the predicted risk of postoperative pain intensity did not significantly differ between recipients of robotic versus laparoscopic primary bariatric surgeries, independent of covarying risk factors.

Our findings correspond with Dudash et al. (2022), who found that short-term postoperative inpatient opioid usage did not significantly differ between 462 recipients of laparoscopic and 111 recipients of robotic RYGB surgery;[48] and with Saleh et al. (2024)’s similar findings for 286 recipients of laparoscopic and 82 recipients of robotic SG surgery.[49] Authors are not aware of any other study comparing adult inpatient opioid usage in primary robotic versus laparoscopic bariatric surgery. A small study by Joselyn et al. (2015) among 28 severely obese adolescents and youths found similar inpatient opioid usage after laparoscopic versus robotic SG surgery.[57] There is available literature evaluating similar outcomes following general surgery procedures. Recent studies comparing robotic versus laparoscopic inguinal hernia repair find no significant differences in perioperative opioid usage[58] nor pain intensity.[59] Regarding cholecystectomies, studies comparing outcomes following robotic versus laparoscopic approaches have reported mixed findings.[60, 61] Subject to confirmation by future studies, our findings imply that inpatient opioid utilization is similar between patients undergoing primary bariatric surgery via the robotic approach and traditional laparoscopy.

Patients whose primary bariatric surgeries were performed via robot-assisted procedures did not rate their pain after surgery as significantly different from that of their counterparts who underwent laparoscopy. This finding again corroborates existing literature suggesting that pain control following robotic bariatric surgery is either similar or slightly improved in the initial postoperative period when compared to laparoscopy. The study by Saleh et al. (2024) found that, while inpatient pain scores were similar after primary robotic versus laparoscopic SG surgery, a smaller proportion of robotic SG recipients were prescribed opioids at discharge.[49] The study by Joselyn et al. (2015) demonstrated that laparoscopic and robotic SG recipients had similar inpatient pain scores throughout the postoperative period despite lower intraoperative opioid analgesia administration during robot-assisted procedures.[57] This trend could be due to the improved ergonomics of robotic platforms as dexterity of the wristed instruments enhances bend and rotation, reducing traction on port sites and decreasing pain over time.[22] It is noteworthy that these studies were each restricted to one type of bariatric procedure, while our study sampled RYGB, SG, and DS procedures. Altogether, both the current literature and this study’s findings suggest that robot-assisted primary bariatric surgery results in equivalent pain control outcomes vis-à-vis traditional laparoscopy. Further research is needed to conclusively resolve the question of whether postoperative pain control outcomes significantly differ following robotic versus laparoscopic bariatric surgery.

Multivariate analyses revealed some notable independent risk factors. Male sex and older age were associated with improved pain control outcomes, while preoperative pain and preexisting opioid use were associated with worse pain control outcomes. This corroborates prior literature associating female sex, pre-existing pain, and younger age with severe postoperative pain.[62] Interestingly, preexisting NSAID use was found to be protective against increased opioid utilization. A recent Cochrane review concluded that pre-emptive NSAIDs reduce morphine consumption and pain following certain surgeries.[63] Although they should not be administered long-term postoperatively due to complications such as marginal ulceration, perioperative use meets patient safety standards and may help reduce postoperative pain.[64] Our finding of increased odds of higher postoperative pain intensity among smokers corroborates previous studies that associated smoking with worse postoperative pain control due to its adverse effects on pain perception.[65, 66] Surprisingly, being depressed was independently associated with reduced opioid consumption. One plausible explanation for this paradoxical result is that a pre-existing diagnosis of depression was confounded with reception of anti-depressants, in this study. A recent meta-analysis linked anti-depressant medication use to reduced postoperative opioid consumption.[67]

Our findings should be interpreted with caution, as the present study had notable limitations. First, the retrospective design implies that only inferences about associations, and not causation, can be drawn. There is potential for confounding between the effect of the operative technique and underlying effects of a contemporaneous downward trend in opioid prescribing. À priori standardization of perioperative analgesia regimens or pain assessment schedules across the compared cohorts is not possible in a retrospective study. The sample was limited to patients at a single institution whose bariatric surgeries were performed by a team supervised by a single attending surgeon. Generalizability of findings to different clinical settings or patient populations requires further investigation. Data were abstracted exclusively from the EMR. The study team had no access to administrative data such as health insurance claims. We also did not assess post-discharge opioid utilization since the follow-up period was limited to postoperative in-hospital days. The study hypotheses merit further investigation in prospective, multi-center observational cohort studies or in a pragmatic clinical trial.

In a retrospective single-institution study, no significant differences were observed in short-term inpatient opioid utilization after robotic versus laparoscopic primary bariatric surgeries. Pain intensity was not observed to be significantly higher among recipients of robotic versus laparoscopic bariatric procedures on the day of surgery or the first day after surgery. This study suggests that the rise in primary bariatric surgeries performed via robotic procedures instead of traditional laparoscopy might not necessarily result in higher opioid utilization nor inferior pain control in the immediate aftermath of surgery. Further research is needed to test this preliminary evidence further.

Disclosures:

Author 6 is a consultant for intuitive. The other authors have no conflicts of interest nor funding sources to disclose. There was no funding provided or used for this research.

Author Contribution

LF, JK, AW, BB, GO, and DD contributed to study conception, study design, and data acquisition. GO performed data analysis and interpretation. LF, AW, JK, GO, and DD drafted the original manuscript. All authors provided final approval of the submitted version of the manuscript.

Acknowledgement

We acknowledge the assistance of Christine Sanchez, Anella Bittle, Emerald Piña, and Syed Harris Bokhari from the Baylor Research Institute for their administrative management of this study and data acquisition.

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Tables 1 to 3 are available in the Supplementary Files section.

No competing interests reported.

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Inpatient Opioid Utilization After Robot-assisted versus Laparoscopic Bariatric Surgery

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Abstract

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INTRODUCTION

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RESULTS

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Supplementary Files

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