114. Outcomes of an enhanced recovery after surgery (ERAS) program for patients with metastatic spine tumors

BACKGROUND CONTEXT Metastatic spine tumor surgery generally consists of palliative operations performed on frail patients with multiple medical comorbidities. Perioperative complications that may arise can mitigate any potential benefit in this vulnerable patient cohort. Enhanced recovery after surgery (ERAS) programs involve an evidence-based multidisciplinary approach to improve perioperative outcomes. While ERAS programs have been shown to be beneficial in other surgical fields, literature evaluating the feasibility, implementation, and outcomes of an ERAS program dedicated to metastatic spine tumor surgery is limited. PURPOSE We present the metastatic spine tumor ERAS pathway and describe the clinical outcomes of the program. STUDY DESIGN/SETTING The metastatic spine tumor ERAS program went into effect in April 2019. This protocol focused on multimodality analgesia, including preoperative gabapentinoid, NSAID, and acetaminophen administration in combination with local field blocks with liposomal bupivacaine, to minimize opioid consumption; intraoperative goal-directed fluid management, early advancement of diet, and early ambulation with physical therapy. PATIENT SAMPLE A total of 177 consecutive patients undergoing metastatic spine tumor surgery enrolled in the ERAS program were compared to 213 consecutive pre-ERAS patients. OUTCOME MEASURES Outcomes measured included: length of hospitalization stay, time to ambulation, urinary catheter duration, time to regular diet, total intraoperative fluid intake, estimated blood loss, intraoperative opioid use, and cumulative postop day 0-5 opioid use. Methods Single institution, retrospective review of prospectively collected data. Results While the case duration was similar in the ERAS vs pre-ERAS cohort (265 min vs 274 min, p = 0.22), the ERAS cohort had less estimated blood loss (157 mL vs 215 mL, p = 0.003), less postop day 0-5 cumulative opioid use (178 MME vs 396 MME, p < 0.0001), earlier ambulation (34 hours vs 57 hours, p = 0.0001), earlier discontinued urinary catheter (36 hours vs 56 hours, p < 0.001), and had a shorter length of stay (5.4 days vs 7.5 days, p < 0.0001), in comparison to the pre-ERAS cohort. The rates of ER visits, readmissions, and reoperations were not significantly different between the two cohorts. The increased utilization of minimally invasive procedures in the ERAS vs pre-ERAS cohort (46% vs 33%) was not a confounding factor for these outcome improvements. Conclusions To date, this is the largest study focusing on outcomes of an ERAS program specifically for patients undergoing metastatic spine tumor surgery. The implementation of an evidence-based multidisciplinary ERAS program has led to a significant reduction in postoperative opioid consumption, improved clinical quality metrics, and shorter hospitalization. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. Metastatic spine tumor surgery generally consists of palliative operations performed on frail patients with multiple medical comorbidities. Perioperative complications that may arise can mitigate any potential benefit in this vulnerable patient cohort. Enhanced recovery after surgery (ERAS) programs involve an evidence-based multidisciplinary approach to improve perioperative outcomes. While ERAS programs have been shown to be beneficial in other surgical fields, literature evaluating the feasibility, implementation, and outcomes of an ERAS program dedicated to metastatic spine tumor surgery is limited. We present the metastatic spine tumor ERAS pathway and describe the clinical outcomes of the program. The metastatic spine tumor ERAS program went into effect in April 2019. This protocol focused on multimodality analgesia, including preoperative gabapentinoid, NSAID, and acetaminophen administration in combination with local field blocks with liposomal bupivacaine, to minimize opioid consumption; intraoperative goal-directed fluid management, early advancement of diet, and early ambulation with physical therapy. A total of 177 consecutive patients undergoing metastatic spine tumor surgery enrolled in the ERAS program were compared to 213 consecutive pre-ERAS patients. Outcomes measured included: length of hospitalization stay, time to ambulation, urinary catheter duration, time to regular diet, total intraoperative fluid intake, estimated blood loss, intraoperative opioid use, and cumulative postop day 0-5 opioid use. Single institution, retrospective review of prospectively collected data. While the case duration was similar in the ERAS vs pre-ERAS cohort (265 min vs 274 min, p = 0.22), the ERAS cohort had less estimated blood loss (157 mL vs 215 mL, p = 0.003), less postop day 0-5 cumulative opioid use (178 MME vs 396 MME, p < 0.0001), earlier ambulation (34 hours vs 57 hours, p = 0.0001), earlier discontinued urinary catheter (36 hours vs 56 hours, p < 0.001), and had a shorter length of stay (5.4 days vs 7.5 days, p < 0.0001), in comparison to the pre-ERAS cohort. The rates of ER visits, readmissions, and reoperations were not significantly different between the two cohorts. The increased utilization of minimally invasive procedures in the ERAS vs pre-ERAS cohort (46% vs 33%) was not a confounding factor for these outcome improvements. To date, this is the largest study focusing on outcomes of an ERAS program specifically for patients undergoing metastatic spine tumor surgery. The implementation of an evidence-based multidisciplinary ERAS program has led to a significant reduction in postoperative opioid consumption, improved clinical quality metrics, and shorter hospitalization.