1
|
Ayyala HS, Assel M, Aloise J, Serafin J, Tan KS, Mehta M, Puttanniah V, McCormick P, Malhotra V, Vickers A, Matros E, Lin E. Paravertebral and erector spinae plane blocks decrease length of stay compared with local infiltration analgesia in autologous breast reconstruction. Reg Anesth Pain Med 2024:rapm-2023-105031. [PMID: 38336375 DOI: 10.1136/rapm-2023-105031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 01/20/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND Autologous breast reconstruction is associated with significant pain impeding early recovery. Our objective was to evaluate the impact of replacing surgeon-administered local infiltration with preoperative paravertebral (PVB) and erector spinae plane (ESP) blocks for latissimus dorsi myocutaneous flap reconstruction. METHODS Patients who underwent mastectomy with latissimus flap reconstruction from 2018 to 2022 were included in three groups: local infiltration, PVB, and ESP blocks. Block effect on postoperative length of stay (LOS) and the association between block status and pain, opioid consumption, time to first analgesic, and postoperative antiemetic administration were assessed. RESULTS 122 patients met the inclusion criteria for this retrospective cohort study: no block (n=72), PVB (n=26), and ESP (n=24). On adjusted analysis, those who received a PVB block had a 20-hour shorter postoperative stay (95% CI 11 to 30; p<0.001); those who received ESP had a 24-hour (95% CI 15 to 34; p<0.001) shorter postoperative stay compared with the no block group, respectively. Using either block was associated with a reduction in intraoperative opioids (23 morphine milligram equivalents (MME)), 95% CI 14 to 31, p<0.001; ESP versus no block: 23 MME, 95% CI 14 to 32, p<0.001). CONCLUSIONS Replacing surgical infiltration with PVB and ESP blocks for autologous breast reconstruction reduces LOS. The comparable reduction in LOS suggests that ESP may be a viable alternative to PVB in patients undergoing latissimus flap breast reconstruction following mastectomy. Further research should investigate whether ESP or PVB have better patient outcomes in complex breast reconstruction.
Collapse
Affiliation(s)
- Haripriya S Ayyala
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Melissa Assel
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Joseph Aloise
- Department of Operational Excellence, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Joanna Serafin
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Kay See Tan
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Meghana Mehta
- Digital Informatics & Technology Solutions Department, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Vinay Puttanniah
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Patrick McCormick
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Vivek Malhotra
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Andrew Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Evan Matros
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Emily Lin
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| |
Collapse
|
2
|
Tokita HK, Assel M, Simon BA, Lin E, Sarraf L, Masson G, Pilewskie M, Vingan P, Vickers A, Nelson JA. Regional Blocks Benefit Patients Undergoing Bilateral Mastectomy with Immediate Implant-Based Reconstruction, Even After Discharge. Ann Surg Oncol 2024; 31:316-324. [PMID: 37747581 PMCID: PMC11200308 DOI: 10.1245/s10434-023-14348-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 09/05/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND There is limited evidence that regional anesthesia reduces pain in patients undergoing mastectomy with immediate implant-based reconstruction. We sought to determine whether regional blocks reduce opioid consumption and improve post-discharge patient-reported pain in this population. METHODS We retrospectively reviewed patients who underwent bilateral mastectomy with immediate implant-based reconstruction with and without a regional block. We tested for differences in opioid consumption by block receipt using multivariable ordinal regression, and also assessed routinely collected patient-reported outcomes (PROs) for 10 days postoperatively and tested the association between block receipt and moderate or greater pain. RESULTS Of 754 patients, 89% received a block. Non-block patients had an increase in the odds of requiring a higher quartile of postoperative opioids. Among block patients, the estimated probability of being in the lowest quartile of opioids required was 25%, compared with 15% for non-block patients. Odds of patient-reported moderate or greater pain after discharge was 0.54 times lower in block patients than non-block patients (p = 0.025). Block patients had a 49% risk of moderate or greater pain compared with 64% in non-block patients on postoperative day 5. There was no indication of any reason for these differences other than a causal effect of the block. CONCLUSION Receipt of a regional block resulted in reduced opioid use and lower risk of self-reported moderate and higher pain after discharge in bilateral mastectomy with immediate implant-based reconstruction patients. Our use of PROs suggests that the analgesic effects of blocks persist after discharge, beyond the expected duration of a 'single shot' block.
Collapse
Affiliation(s)
- Hanae K Tokita
- Department of Anesthesiology and Critical Care Medicine, Josie Robertson Surgery Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Melissa Assel
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Brett A Simon
- Department of Anesthesiology and Critical Care Medicine, Josie Robertson Surgery Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Emily Lin
- Department of Anesthesiology and Critical Care Medicine, Josie Robertson Surgery Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Leslie Sarraf
- Department of Anesthesiology and Critical Care Medicine, Josie Robertson Surgery Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Geema Masson
- Department of Anesthesiology and Critical Care Medicine, Josie Robertson Surgery Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Perri Vingan
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrew Vickers
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jonas A Nelson
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| |
Collapse
|
3
|
Doan LV, Yoon J, Chun J, Perez R, Wang J. Pain associated with breast cancer: etiologies and therapies. FRONTIERS IN PAIN RESEARCH 2023; 4:1182488. [PMID: 38148788 PMCID: PMC10750403 DOI: 10.3389/fpain.2023.1182488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 11/27/2023] [Indexed: 12/28/2023] Open
Abstract
Pain associated with breast cancer is a prevalent problem that negatively affects quality of life. Breast cancer pain is not limited to the disease course itself but is also induced by current therapeutic strategies. This, combined with the increasing number of patients living with breast cancer, make pain management for breast cancer patients an increasingly important area of research. This narrative review presents a summary of pain associated with breast cancer, including pain related to the cancer disease process itself and pain associated with current therapeutic modalities including radiation, chemotherapy, immunotherapy, and surgery. Current pain management techniques, their limitations, and novel analgesic strategies are also discussed.
Collapse
Affiliation(s)
- Lisa V. Doan
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY, United States
| | - Jenny Yoon
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY, United States
| | - Jeana Chun
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY, United States
| | - Raven Perez
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY, United States
| | - Jing Wang
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY, United States
- Department of Neuroscience and Physiology, NYU Grossman School of Medicine, New York, NY, United States
| |
Collapse
|
4
|
Ozonur VA, Salviz EA, Sivrikoz N, Kozanoglu E, Karaali S, Gokduman HC, Polat H, Emekli U, Tugrul MK, Orhan-Sungur M. Single and double injection paravertebral block comparison in reduction mammaplasty cases: a randomized controlled study. Anesth Pain Med (Seoul) 2023; 18:421-430. [PMID: 37919926 PMCID: PMC10635849 DOI: 10.17085/apm.23029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 06/29/2023] [Accepted: 07/03/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND This study compares the analgesic effects and dermatomal blockade distributions of single and double injection bilateral thoracic paravertebral block (TPVB) techniques in patients undergoing reduction mammaplasty. METHODS After obtaining ethics committee approval, 60 patients scheduled for bilateral reduction mammaplasty were included in the study. Preoperatively, the patients received one of single (Group S: T3-T4) or double (Group D: T2-T3 & T4-T5) injection bilateral TPVBs using bupivacaine 0.375% 20 ml per side. All patients were operated under general anesthesia. The T3-T6 dermatomal blockade distributions on the midclavicular line were followed by pin-prick test for 30 min preoperatively and 48 h postoperatively. All patients received paracetamol 1 g when numeric rating scale (NRS) pain score was ≥ 4, and also tramadol 1 mg/kg when NRS was ≥ 4 again after 1 h. The primary endpoint was NRS pain scores at postoperative 12th h. The secondary endpoints were dermatomal blockade distributions and NRS scores through the postoperative first 48 h, time until first pain and the analgesic consumption on days 1 and 2. RESULTS Fifty-two patients completed the study. The NRS pain scores at 12th h were similar (right side: P = 0.100, left side: P = 0.096). The remaining NRS scores and other parameters were also comparable within the groups (P ≥ 0.05). Only single injection TPVB application time was shorter (P < 0.001). CONCLUSIONS The single injection TPVB technique provided sufficient dermatomal distribution and analgesic efficacy with the advantages of being faster and less invasive.
Collapse
Affiliation(s)
- Vecih Anil Ozonur
- Department of Anesthesiology and Reanimation, Liv Hospital Vadİstanbul, Istanbul, Turkiye
| | - Emine Aysu Salviz
- Department of Anesthesiology, Washington University in St Louis, School of Medicine, St Louis, MO, USA
| | - Nukhet Sivrikoz
- Department of Anesthesiology and Reanimation, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkiye
| | - Erol Kozanoglu
- Department of Plastic, Reconstructive and Aesthetic Surgery, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkiye
| | - Soner Karaali
- Department of Plastic, Reconstructive and Aesthetic Surgery, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkiye
| | - Huru Ceren Gokduman
- Department of Anesthesiology and Reanimation, Basaksehir Cam and Sakura State Hospital, Istanbul, Turkiye
| | - Hacer Polat
- Department of Anesthesiology and Reanimation, Sancaktepe State Hospital, Istanbul, Turkiye
| | - Ufuk Emekli
- Department of Plastic, Reconstructive and Aesthetic Surgery, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkiye
| | - Mehmet Kamil Tugrul
- Department of Anesthesiology and Reanimation, Liv Hospital Vadİstanbul, Istanbul, Turkiye
| | - Mukadder Orhan-Sungur
- Department of Anesthesiology and Reanimation, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkiye
| |
Collapse
|
5
|
Paffile J, McGuire C, Bezuhly M. Systematic Review of Patient Safety and Quality Improvement Initiatives in Breast Reconstruction. Ann Plast Surg 2022; 89:121-136. [PMID: 35749815 DOI: 10.1097/sap.0000000000003062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Improving patient care and safety requires high-quality evidence. The objective of this study was to systematically review the existing evidence for patient safety (PS) and quality improvement initiatives in breast reconstruction. METHODS A systematic review of the published plastic surgery literature was undertaken using a computerized search and following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Publication descriptors, methodological details, and results were extracted. Articles were assessed for methodological quality and clinical heterogeneity. Descriptive statistics were completed, and a meta-analysis was considered. RESULTS Forty-six studies were included. Most studies were retrospective (52.2%) and from the third level of evidence (60.9%). Overall, the scientific quality was moderate, with randomized controlled trials generally being higher quality. Studies investigating approaches to reduce seroma (28.3% of included articles) suggested a potential benefit of quilting sutures. Studies focusing on infection (26.1%) demonstrated potential benefits to prophylactic antibiotics and drain use under 21 days. Enhanced recovery after surgery protocols (10.9%) overall did not compromise PS and was beneficial in reducing opioid use and length of stay. Interventions to increase flap survival (10.9%) demonstrated a potential benefit of nitroglycerin on mastectomy skin flaps. CONCLUSIONS Overall, studies were of moderate quality and investigated several worthwhile interventions. More validated, standardized outcome measures are required, and studies focusing on interventions to reduce thromboembolic events and bleeding risk could further improve PS.
Collapse
Affiliation(s)
| | - Connor McGuire
- Division of Plastic Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Michael Bezuhly
- Division of Plastic Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| |
Collapse
|
6
|
Nerve Blocks in Breast Plastic Surgery: Outcomes, Complications, and Comparative Efficacy. Plast Reconstr Surg 2022; 150:1e-12e. [PMID: 35499513 DOI: 10.1097/prs.0000000000009253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND As plastic surgeons continue to evaluate the utility of nonopioid analgesic alternatives, nerve block use in breast plastic surgery remains limited and unstandardized, with no syntheses of the available evidence to guide consensus on optimal approach. METHODS A systematic review was performed to evaluate the role of pectoralis nerve blocks, paravertebral nerve blocks, transversus abdominus plane blocks, and intercostal nerve blocks in flap-based breast reconstruction, prosthetic-based reconstruction, and aesthetic breast plastic surgery, independently. RESULTS Thirty-one articles reporting on a total of 2820 patients were included in the final analysis; 1500 patients (53 percent) received nerve blocks, and 1320 (47 percent) served as controls. Outcomes and complications were stratified according to procedures performed, blocks employed, techniques of administration, and anesthetic agents used. Overall, statistically significant reductions in opioid consumption were reported in 91 percent of studies evaluated, postoperative pain in 68 percent, postanesthesia care unit stay in 67 percent, postoperative nausea and vomiting in 53 percent, and duration of hospitalization in 50 percent. Nerve blocks did not significantly alter surgery and/or anesthesia time in 83 percent of studies assessed, whereas the overall, pooled complication rate was 1.6 percent. CONCLUSIONS Transversus abdominus plane blocks provided excellent outcomes in autologous breast reconstruction, whereas both paravertebral nerve blocks and pectoralis nerve blocks demonstrated notable efficacy and versatility in an array of reconstructive and aesthetic procedures. Ultrasound guidance may minimize block-related complications, whereas the efficacy of adjunctive postoperative infusions was proven to be limited. As newer anesthetic agents and adjuvants continue to emerge, nerve blocks are set to represent essential components of the multimodal analgesic approach in breast plastic surgery.
Collapse
|
7
|
Mohan SC, Siegel E, Tran H, Ozcan L, Alban R, Shariff S, Mirocha J, Chung A, Giuliano A, Dang C, Anand K, Shane R, Amersi F. Effects of paravertebral blocks versus liposomal bupivacaine on hospital utilization after mastectomy with reconstruction. Am J Surg 2022; 224:938-942. [DOI: 10.1016/j.amjsurg.2022.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 04/13/2022] [Accepted: 04/19/2022] [Indexed: 11/25/2022]
|
8
|
The Role of Maximal Locoregional Block in Autologous Breast Reconstruction. Ann Plast Surg 2022; 88:612-616. [PMID: 35276709 DOI: 10.1097/sap.0000000000003134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) has become the standard of care in microsurgical breast reconstruction. The current literature provides overwhelming evidence of the benefit of ERAS pathways in improving quality of recovery, decreasing length of hospital stay, and minimizing the amount of postoperative narcotic use in these patients. However, there are limited data on the role of using maximal locoregional anesthetic blocks targeting both the abdomen and chest as an integral part of an ERAS protocol in abdominally based autologous breast reconstruction. The aim of this study is to compare the outcomes of implementing a comprehensive ERAS protocol with and without maximal locoregional nerve blocks to determine any added benefit of these blocks to the standard ERAS pathway. METHODS Forty consecutive patients who underwent abdominally based autologous breast reconstruction in the period between July 2017 and February 2020 were included in this retrospective institutional review board-approved study. The goal was to compare patients who received combined abdominal and thoracic wall locoregional blocks as part of their ERAS pathway (study group) with those who had only transversus abdominis plane blocks. The primary end points were total hospital length of stay, overall opioids consumption, and overall postoperative complications. RESULTS The use of supplemental thoracic wall block resulted in a shorter hospital length of stay in the study group of 3.2 days compared with 4.2 days for the control group (P < 0.01). Postoperative total morphine equivalent consumption was lower at 38 mg in the study group compared with 51 mg in the control group (P < 0.01). Complications occurred in 6 cases (15%) in the control group versus one minor complication in the thoracic block group. There was no difference between the 2 groups in demographics, comorbidities, and type of reconstruction. CONCLUSION The maximal locoregional nerve block including a complete chest wall block confers added benefits to the standard ERAS protocol in microvascular breast reconstruction.
Collapse
|
9
|
Williams L, Iteld L. Moving Toward Opioid-Free Breast Surgery: Regional Blocks and a Novel Technique. Clin Plast Surg 2020; 48:123-130. [PMID: 33220899 DOI: 10.1016/j.cps.2020.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Perioperative pain control is of increasing importance as awareness regarding the risks of under-controlled pain and opioid abuse rise. Enhanced recovery protocols and multimodal analgesia, including regional blocks, are useful tools for the plastic surgeon. The thoracic paravertebral block, pectoralis nerve I and pectoralis nerve II blocks, and proximal intercostal blocks are 3 described methods that provide regional anesthesia for breast surgery. The widespread use of these methods may be limited by the requirements for ultrasound equipment and anesthesiologists skilled in regional blocks. This article describes a novel technique of the intercostal field block under direct visualization that is safe and efficient.
Collapse
Affiliation(s)
- Lydia Williams
- Plastic & Reconstructive Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Lawrence Iteld
- Plastic & Reconstructive Surgery, University of Chicago Medicine, Chicago, IL, USA; Iteld Plastic Surgery, 939 West North Avenue, Suite 600, Chicago, IL 606042, USA.
| |
Collapse
|
10
|
King CA, Perez‐Alvarez IM, Bartholomew AJ, Bozzuto L, Griffith K, Sosin M, Thibodeau R, Gopwani S, Myers J, Fan KL, Tousimis EA. Opioid‐free anesthesia for patients undergoing mastectomy: A matched comparison. Breast J 2020; 26:1742-1747. [DOI: 10.1111/tbj.13999] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 07/14/2020] [Accepted: 07/15/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Caroline A. King
- Department of Surgery Division of Breast Surgery MedStar Georgetown University Hospital Washington DC USA
| | - Idanis M. Perez‐Alvarez
- Department of Surgery Division of Breast Surgery MedStar Georgetown University Hospital Washington DC USA
| | - Alex J. Bartholomew
- Department of Surgery Division of Breast Surgery MedStar Georgetown University Hospital Washington DC USA
| | - Laura Bozzuto
- Department of Surgery Division of Breast Surgery MedStar Georgetown University Hospital Washington DC USA
| | - Kayla Griffith
- Department of Surgery Division of Breast Surgery MedStar Georgetown University Hospital Washington DC USA
| | - Michael Sosin
- Department of Surgery Division of Breast Surgery MedStar Georgetown University Hospital Washington DC USA
| | - Renee Thibodeau
- Department of Surgery Division of Breast Surgery MedStar Georgetown University Hospital Washington DC USA
| | - Sumeet Gopwani
- Department of Anesthesia MedStar Georgetown University Hospital Washington DC USA
| | - Joseph Myers
- Department of Anesthesia MedStar Georgetown University Hospital Washington DC USA
| | - Kenneth L. Fan
- Department of Plastic and Reconstructive Surgery MedStar Georgetown University Hospital Washington DC USA
| | - Eleni A. Tousimis
- Department of Surgery Division of Breast Surgery MedStar Georgetown University Hospital Washington DC USA
| |
Collapse
|
11
|
Persing S, Manahan M, Rosson G. Enhanced Recovery After Surgery Pathways in Breast Reconstruction. Clin Plast Surg 2020; 47:221-243. [DOI: 10.1016/j.cps.2019.12.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
12
|
Abstract
There has been a shift in recent years toward a growing popularity of implant-based breast reconstruction, especially in the setting of increased frequency of concurrent contralateral prophylactic mastectomy. Advancements in implant safety and technology have also allowed for an expanding implant reconstruction practice across the country. The traditional approach is immediate two-stage implant reconstruction with placement of a tissue expander within a subpectoral pocket. The introduction of acellular dermal matrix has revolutionized implant-based breast reconstruction, allowing surgeons the opportunity to minimize morbidity while maximizing aesthetic outcomes. There have also been advances in the management of postoperative pain control as well as secondary revision surgery.
Collapse
Affiliation(s)
- Christine Oh
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Sebastian J Winocour
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | | |
Collapse
|
13
|
Non-narcotic Perioperative Pain Management in Prosthetic Breast Reconstruction During an Opioid Crisis: A Systematic Review of Paravertebral Blocks. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2299. [PMID: 31624690 PMCID: PMC6635209 DOI: 10.1097/gox.0000000000002299] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 04/24/2019] [Indexed: 12/27/2022]
Abstract
Background: Alternatives to postoperative, narcotic pain management following implant-based, postmastectomy breast reconstruction (IBR) must be a focus for plastic surgeons and anesthesiologists, especially with the current opioid epidemic. Paravertebral blocks (PVBs) are a regional technique that has demonstrated efficacy in patients undergoing a variety of breast cancer–related surgeries. However, a specific understanding of PVB’s efficacy in pain management in patients who undergo IBR is lacking. Methods: A systematic search of PubMed, EMBASE, and Cochrane Library electronic database was conducted to examine PVB administration in mastectomy patients undergoing IBR. Data were abstracted regarding: authors, publication year, study design, patient demographics, tumor laterality, tumor stage, type, and timing of reconstruction. The primary outcome was PVB efficacy, represented as patient-reported pain scores. Secondary outcomes of interest include narcotic consumption, postoperative nausea and vomiting, antiemetic use, and length of stay. Results: The search resulted in 1,516 unique articles. After title and abstract screening, 29 articles met the inclusion criteria for full-text review. Only 7 studies were included. Of those, 2 studies were randomized control trials and 5 were retrospective cohort studies. Heterogeneity of included studies precluded a meta-analysis. Overall, PVB patients had improved pain control, and less opioid consumption. Conclusion: PVBs are a regional anesthesia technique which may aid in pain management in the breast reconstructive setting. Evidence suggests that PVBs aid in controlling acute postoperative pain, reduce opioid consumption, and improve patient length of stay. However, some conflicting findings demonstrate a need for continued research in this area of pain control.
Collapse
|
14
|
Sharif-Askary B, Hompe E, Broadwater G, Anolik R, Hollenbeck ST. The Effect of Enhanced Recovery after Surgery Pathway Implementation on Abdominal-Based Microvascular Breast Reconstruction. J Surg Res 2019; 242:276-285. [PMID: 31125841 DOI: 10.1016/j.jss.2019.04.062] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 02/23/2019] [Accepted: 04/24/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Although Enhanced Recovery after Surgery (ERAS) pathways are becoming the standard of care in microvascular breast reconstruction, evidence supporting their use is limited or based on small sample sizes. We hypothesized that improvements in postoperative outcomes would persist when examining the largest cohort of patients undergoing abdominal-based microvascular breast reconstruction, to date. MATERIALS AND METHODS Data were retrospectively reviewed for 276 consecutive patients who underwent abdominal-based free flap breast reconstruction before and after ERAS implementation (pre-ERAS, n = 138 patients; post-ERAS, n = 138 patients). Primary outcomes were postoperative opioid use measured in oral morphine equivalents (OMEs), median hospital length of stay (LOS) in days, and incidence of postoperative complications. RESULTS Postoperative opioid requirements were significantly lower in the post-ERAS cohort compared with the pre-ERAS cohort (57.3 OME, [interquartile range 20.0-115.5] versus 297.3 OME [interquartile range 138.6-437.7], P < 0.0001). There was no significant difference in hospital LOS when controlling for variables that differed between the groups. In addition, there were no differences in the rate of postoperative complications, return to operating room, or readmission after ERAS pathway implementation. CONCLUSIONS ERAS improves specific aspects of recovery for patients undergoing microvascular breast reconstruction, most notably postoperative opioid use. Patient selection and a shift toward less invasive procedures may explain a nonsignificant impact on hospital LOS.
Collapse
Affiliation(s)
| | - Eliza Hompe
- Duke University School of Medicine, Durham, North Carolina
| | - Gloria Broadwater
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Rachel Anolik
- Division of Plastic and Reconstructive Surgery, Duke University Medical Center, Durham, North Carolina
| | - Scott T Hollenbeck
- Division of Plastic and Reconstructive Surgery, Duke University Medical Center, Durham, North Carolina.
| |
Collapse
|
15
|
Abstract
PURPOSE OF REVIEW Enhanced recovery pathways are a well-described perioperative healthcare program involving evidence-based interventions. Enhanced recovery is designed to standardize techniques such as drug selection and nerve blocks in order to speed recovery and reduce overall hospital costs. RECENT FINDINGS A PubMed literature search was performed for articles that included the terms enhanced recovery and breast reconstruction surgery. The present investigation summarizes enhanced recovery literature related to breast surgery with a focus on breast reconstruction. Enhanced recovery considerations discussed in this review include patient education, preadmission optimization, perforator flap planning, anesthetic techniques, optimized fasting, venous thrombosis prophylaxis, early mobilization, and antimicrobial prophylaxis.
Collapse
|
16
|
Evaluating Postoperative Narcotic Use in Prepectoral Versus Dual-plane Breast Reconstruction Following Mastectomy. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2082. [PMID: 30881831 PMCID: PMC6416120 DOI: 10.1097/gox.0000000000002082] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Accepted: 10/26/2018] [Indexed: 12/03/2022]
Abstract
Background: The majority of postmastectomy breast reconstruction performed in the United States is device-based. Typically, a tissue expander or implant is placed in the dual-plane (ie, subpectoral). Prepectoral breast reconstruction with acellular dermal matrices following mastectomy is a relatively new technique that has favorable outcomes with minimal complications and satisfactory aesthetic results. Few studies have compared opioid use between the 2 approaches. This study compares duration of postoperative opioid use among patients undergoing prepectoral device-based breast reconstruction with those in whom dual-plane devices were placed. Methods: We reviewed the records of adult female patients aged 18 years or older who underwent prepectoral or dual-plane device-based breast reconstructions following mastectomy by one of the 2 plastic surgeons (A.M. or M.V.) from 2015 to 2017 at a large tertiary care hospital. Patients with a history of substance abuse, chronic pain, or who were already receiving opioid medication were excluded. Electronic medical records were reviewed and patient surveys were conducted during postoperative visits to determine postoperative opioid requirements. Results: During the study period, 58 patients underwent dual-plane breast reconstruction and 94 underwent prepectoral reconstruction. Demographics and comorbidities of the groups were similar. By multivariate regression analysis, the prepectoral reconstruction group required 33% fewer days on opioid analgesic medication (P = 0.016) and were 66% less likely to require opioid prescription refills (P = 0.027). There were no statistically significant differences in other outcomes or complications. Conclusion: Patients undergoing prepectoral tissue expander or implant-based reconstruction required fewer days of opioid pain medication than those managed with the dual-plane technique.
Collapse
|
17
|
Parikh RP, Myckatyn TM. Paravertebral blocks and enhanced recovery after surgery protocols in breast reconstructive surgery: patient selection and perspectives. J Pain Res 2018; 11:1567-1581. [PMID: 30197532 PMCID: PMC6112815 DOI: 10.2147/jpr.s148544] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The management of postoperative pain is of critical importance for women undergoing breast reconstruction after surgical treatment for breast cancer. Mitigating postoperative pain can improve health-related quality of life, reduce health care resource utilization and costs, and minimize perioperative opiate use. Multimodal analgesia pain management strategies with nonopioid analgesics have improved the value of surgical care in patients undergoing various operations but have only recently been reported in reconstructive breast surgery. Regional anesthesia techniques, with paravertebral blocks (PVBs) and transversus abdominis plane (TAP) blocks, and enhanced recovery after surgery (ERAS) pathways have been increasingly utilized in opioid-sparing multimodal analgesia protocols for women undergoing breast reconstruction. The objectives of this review are to 1) comprehensively review regional anesthesia techniques in breast reconstruction, 2) outline important components of ERAS protocols in breast reconstruction, and 3) provide evidence-based recommendations regarding each intervention included in these protocols. The authors searched across six databases to identify relevant articles. For each perioperative intervention included in the ERAS protocols, the literature was exhaustively reviewed and evidence-based recommendations were generated using the Grading of Recommendations, Assessment, Development, and Evaluation system methodology. This study provides a comprehensive evidence-based review of interventions to optimize perioperative care and postoperative pain control in breast reconstruction. Incorporating evidence-based interventions into future ERAS protocols is essential to ensure high value care in breast reconstruction.
Collapse
Affiliation(s)
- Rajiv P Parikh
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St Louis, MO, USA,
| | - Terence M Myckatyn
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St Louis, MO, USA,
| |
Collapse
|
18
|
Abstract
This paper is the thirty-ninth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2016 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia, stress and social status, tolerance and dependence, learning and memory, eating and drinking, drug abuse and alcohol, sexual activity and hormones, pregnancy, development and endocrinology, mental illness and mood, seizures and neurologic disorders, electrical-related activity and neurophysiology, general activity and locomotion, gastrointestinal, renal and hepatic functions, cardiovascular responses, respiration and thermoregulation, and immunological responses.
Collapse
Affiliation(s)
- Richard J Bodnar
- Department of Psychology and CUNY Neuroscience Collaborative, Queens College, City University of New York, Flushing, NY 11367, United States.
| |
Collapse
|
19
|
Offodile AC, Aycart MA, Segal JB. Comparative Effectiveness of Preoperative Paravertebral Block for Post-Mastectomy Reconstruction: A Systematic Review of the Literature. Ann Surg Oncol 2017; 25:818-828. [DOI: 10.1245/s10434-017-6291-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Indexed: 11/18/2022]
|
20
|
Intraoperative Techniques for the Plastic Surgeon to Improve Pain Control in Breast Surgery. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1522. [PMID: 29263948 PMCID: PMC5732654 DOI: 10.1097/gox.0000000000001522] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 08/21/2017] [Indexed: 11/26/2022]
Abstract
Supplemental Digital Content is available in the text. In recent years, there has been a growing emphasis placed on reducing length of hospital stay and health costs associated with breast surgery. Adequate pain control is an essential component of enhanced recovery after surgery. Postoperative pain management strategies include use of narcotic analgesia, non-narcotic analgesia, and local anesthetics. However, these forms of pain control have relatively brief durations of action and multiple-associated side effects. Intraoperative regional blocks have been effectively utilized in other areas of surgery but have been understudied in breast surgery. The aim of this article was to review various intraoperative techniques for regional anesthesia and local pain control in breast surgery and to highlight areas of future technique development.
Collapse
|
21
|
Consensus Review of Optimal Perioperative Care in Breast Reconstruction: Enhanced Recovery after Surgery (ERAS) Society Recommendations. Plast Reconstr Surg 2017; 139:1056e-1071e. [PMID: 28445352 DOI: 10.1097/prs.0000000000003242] [Citation(s) in RCA: 190] [Impact Index Per Article: 27.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Enhanced recovery following surgery can be achieved through the introduction of evidence-based perioperative maneuvers. This review aims to present a consensus for optimal perioperative management of patients undergoing breast reconstructive surgery and to provide evidence-based recommendations for an enhanced perioperative protocol. METHODS A systematic review of meta-analyses, randomized controlled trials, and large prospective cohorts was conducted for each protocol element. Smaller prospective cohorts and retrospective cohorts were considered only when higher level evidence was unavailable. The available literature was graded by an international panel of experts in breast reconstructive surgery and used to form consensus recommendations for each topic. Each recommendation was graded following a consensus discussion among the expert panel. Development of these recommendations was endorsed by the Enhanced Recovery after Surgery Society. RESULTS High-quality randomized controlled trial data in patients undergoing breast reconstruction informed some of the recommendations; however, for most items, data from lower level studies in the population of interest were considered along with extrapolated data from high-quality studies in non-breast reconstruction populations. Recommendations were developed for a total of 18 unique enhanced recovery after surgery items and are discussed in the article. Key recommendations support use of opioid-sparing perioperative medications, minimal preoperative fasting and early feeding, use of anesthetic techniques that decrease postoperative nausea and vomiting and pain, use of measures to prevent intraoperative hypothermia, and support of early mobilization after surgery. CONCLUSION Based on the best available evidence for each topic, a consensus review of optimal perioperative care for patients undergoing breast reconstruction is presented. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, V.
Collapse
|
22
|
Fentie DY, Gebremedhn EG, Denu ZA, Gebreegzi AH. Efficacy of single-injection unilateral thoracic paravertebral block for post open cholecystectomy pain relief: a prospective randomized study at Gondar University Hospital. Local Reg Anesth 2017; 10:67-74. [PMID: 28744155 PMCID: PMC5513842 DOI: 10.2147/lra.s133946] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Cholecystectomy can be associated with considerable postoperative pain. While the benefits of paravertebral block (PVB) on pain after thoracotomy and mastectomy have been demonstrated, not enough investigations on the effects of PVB on pain after open cholecystectomy have been conducted. We tested the hypothesis that a single-injection thoracic PVB reduces pain scores, decreases opioid consumption, and prolongs analgesic request time after cholecystectomy. Methods Of 52 patients recruited, 50 completed the study. They were randomly allocated into two groups: the paravertebral group and the control group. The outcome measures were the severity of pain measured on numeric pain rating scale, total opioid consumption, and first analgesic request time during the first postoperative 24 hours. Result The main outcomes recorded during 24 hours after surgery were Numerical Rating Scale (NRS) pain scores (NRS, 0–10), cumulative opioid consumption, and the first analgesic request time. Twenty four hours after surgery, NRS at rest was 4 (3–6) vs 5 (5–7) and at movement 4 (4–7) vs 6 (5–7.5) for the PVB and control groups, respectively. The difference between the groups over the whole observation period was statistically significant (P<0.05). Twenty-four hours after surgery, median (25th–75th percentile) cumulative morphine consumption was 0 (0–2) vs 2.5 (2–4) mg (P<0.0001) and cumulative tramadol consumption was 200 (150–250) mg vs 300 (200–350) mg in the paravertebral and in the control group, respectively (P=0.003). After surgery, the median (25th–75th percentile) first analgesic requirement time was prolonged in the PVB group in statistically significant fashion (P<0.0001). Conclusion and recommendations Single-shot thoracic PVB as a component of multi-modal analgesic regimen provided superior analgesia when compared with the control group up to 24 postoperative hours after cholecystectomy, and we recommend this block for post cholecystectomy pain relief.
Collapse
Affiliation(s)
- Demeke Yilkal Fentie
- Department of Anesthesia, School of Medicine, Gondar College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Endale Gebreegziabher Gebremedhn
- Department of Anesthesia, School of Medicine, Gondar College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Zewditu Abdissa Denu
- Department of Anesthesia, School of Medicine, Gondar College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Amare Hailekiros Gebreegzi
- Department of Anesthesia, School of Medicine, Gondar College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| |
Collapse
|