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Alghamdi M, Alsayed B, Albenmousa F, Salleh SB, Alqaysi L, Alfayez J, Mandoorah J, Alanzi R, Alshayeqe G, Albaqmi S, Sabi A, Arif S, Mortada H. Local Anesthetic Infiltration for Pain Control in Aesthetic Breast Reduction Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Aesthetic Plast Surg 2024:10.1007/s00266-024-04249-x. [PMID: 38977458 DOI: 10.1007/s00266-024-04249-x] [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: 04/24/2024] [Accepted: 07/02/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND Aesthetic breast surgeries, including breast reduction, are commonly performed surgical procedures associated with postoperative pain. Pain control is essential to patient comfort, satisfaction, and early recovery. This systematic review is the first to conduct both qualitative and quantitative analysis to evaluate the efficacy and safety of local anesthetic infiltration in reducing pain after breast reduction surgeries. METHODS This systematic review is registered in PROSPERO, assessed for bias using the RoB2 tool, and follows the PRISMA guidelines. A full electronic search was performed in different databases for all clinical papers on adult female patients undergoing cosmetic breast reduction surgery who were given local anesthetic infiltration for postoperative pain relief. RESULTS A systematic review of five randomized clinical trials with a total of 191 patients found that local anesthetic infiltration significantly reduces postoperative pain in breast reduction surgery, reduces opioid consumption, and improves patient outcomes. A meta-analysis of two trials reported the mean VAS score for postoperative pain in the local anesthetic and placebo groups. CONCLUSION A systematic review and a meta-analysis show a significant reduction in postoperative pain following local anesthetic infiltration, but further research is needed to understand its effectiveness and potential adverse effects. LEVEL OF EVIDENCE I This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Maysaa Alghamdi
- College of Medicine, University of Jeddah, Jeddah, Saudi Arabia.
| | - Bader Alsayed
- College of Medicine, Imam Mohammed Ibn Saud Islamic University, Riyadh, Saudi Arabia
| | | | - Sumayyah Bin Salleh
- College of Pharmacy, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Luba Alqaysi
- College of Pharmacy, King Khalid University, Abha, Saudi Arabia
| | - Joud Alfayez
- College of Pharmacy, Qassim University, Buraydah, Saudi Arabia
| | - Joana Mandoorah
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Reem Alanzi
- College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Ghina Alshayeqe
- College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Sara Albaqmi
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Ahmed Sabi
- College of Medicine, Jazan University, Jazan, Saudi Arabia
| | - Sultan Arif
- Department of Plastic Surgery and Burn Unit, Security Force Hospital, Riyadh, Saudi Arabia
| | - Hatan Mortada
- Division of Plastic Surgery, Department of Surgery, King Saud University Medical City, Riyadh, Saudi Arabia
- Department of Plastic Surgery and Burn Unit, King Saud Medical City, Riyadh, Saudi Arabia
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Wallace AB, Song S, Yeh P, Kim EA. The Effect of Pectoral Nerve Blocks on Opioid Use and Postoperative Pain in Masculinizing Mastectomy: A Randomized Controlled Trial. Plast Reconstr Surg 2024; 153:570-577. [PMID: 37220393 DOI: 10.1097/prs.0000000000010707] [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: 05/25/2023]
Abstract
BACKGROUND Bilateral masculinizing mastectomy is the most common gender-affirmation operation performed. Currently, there is lack of data regarding intraoperative and postoperative pain control for this population. It is the authors' aim to study the effects of the pectoral nerve (Pecs) I and II regional nerve blocks in patients undergoing masculinizing mastectomy. METHODS A randomized, double-blind, placebo-controlled trial was performed. Patients undergoing bilateral gender-affirmation mastectomy were randomized to receive either a Pecs block with ropivacaine or placebo injection. The patient, surgeon, and anesthesia team were blinded to the allocation. Intraoperative and postoperative opioid requirements were collected and recorded as morphine milligram equivalents (MME). Participants recorded postoperative pain scores at specific time points on the day of surgery through postoperative day 7. RESULTS Fifty patients were enrolled between July of 2020 and February of 2022. Twenty-seven were randomized to the intervention group and 23 to the control group, with 43 patients undergoing analysis. There was no significant difference in intraoperative MME between the Pecs block group and the control group (9.8 versus 11.1; P = 0.29). In addition, there was no difference in postoperative MME between the groups (37.5 versus 40.0; P = 0.72). Postoperative pain scores were also similar between the groups at each specified time point. CONCLUSIONS There was no significant reduction in opioid consumption or postoperative pain scores in patients undergoing bilateral gender-affirmation mastectomy who received a regional anesthetic when compared with placebo. In addition, a postoperative opioid-sparing approach may be appropriate for patients undergoing bilateral masculinizing mastectomy. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, I.
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Affiliation(s)
- Adam B Wallace
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, San Francisco
| | - Siyou Song
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, San Francisco
| | - Peter Yeh
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, San Francisco
| | - Esther A Kim
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, San Francisco
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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.
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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
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Merchant SJ, Shellenberger JP, Sawhney M, La J, Brogly SB. Physician Characteristics Associated With Opioid Prescribing After Same-Day Breast Surgery in Ontario, Canada: A Population-Based Cohort Study. ANNALS OF SURGERY OPEN 2023; 4:e365. [PMID: 38144500 PMCID: PMC10735111 DOI: 10.1097/as9.0000000000000365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 10/28/2023] [Indexed: 12/26/2023] Open
Abstract
Background and Objectives Opioid overprescribing in patients undergoing breast surgery is a concern, as evidence suggests that minimal or no opioid is needed to manage pain. We sought to describe characteristics of opioid prescribers and determine associations between prescriber's characteristics and high opioid prescribing within 7 days of same-day breast surgery. Methods Patients ≥18 years of age who underwent same-day breast surgery in Ontario, Canada from 2012 to 2020 were identified and linked to prescriber data. The primary outcome was current high opioid prescribing defined as >75th percentile of the mean oral morphine equivalents (OME; milligrams). Prescriber characteristics including age, sex, specialty, years in practice, practice setting, and history of high (>75th percentile) opioid prescribing in the previous year were captured. Associations between prescriber characteristics and the primary outcome were estimated in modified Poisson regression models. Results The final cohort contained 56,434 patients, 3469 unique prescribers, and 58,656 prescriptions. Over half (1971/3469; 57%) of prescribers wrote ≥1 prescription that was >75th percentile of mean OME of 180 mg, of which 50% were family practice physicians. Adjusted mean OMEs prescribed varied by specialty with family practice specialties prescribing the highest mean OME (614 ± 38 mg) compared to surgical specialties (general surgery [165 ± 9 mg], plastic surgery [198 ± 10 mg], surgical oncology [154 ± 14 mg]). Whereas 73% of first and 31% of second prescriptions were provided by general surgery physicians, family practice physicians provided 2% of first and 51% of second prescriptions. Prescriber characteristics associated with a higher likelihood of high current opioid prescribing were family practice (risk ratio [RR], 1.56; 95% confidence interval [CI], 1.35-1.79 compared to general surgery), larger community practice setting (RR, 1.34; 95% CI, 1.05-1.71 compared to urban), and a previous high opioid prescribing behavior (RR, 2.28; 95% CI, 2.06-2.52). Conclusions While most studies examine surgeon opioid prescribing, our data suggest that other specialties contribute to opioid overprescribing in surgical patients and identify characteristics of physicians likely to overprescribe.
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Affiliation(s)
| | | | - Monakshi Sawhney
- Department of Anesthesiology and Perioperative Medicine, School of Nursing, Queen’s University, Kingston, Ontario, Canada
| | - Julie La
- From the Department of Surgery, Queen’s University
| | - Susan B. Brogly
- From the Department of Surgery, Queen’s University
- ICES Queen’s
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La J, Alqaydi A, Wei X, Shellenberger J, Digby GC, Brogly SB, Merchant SJ. Variation in opioid filling after same-day breast surgery in Ontario, Canada: a population-based cohort study. CMAJ Open 2023; 11:E208-E218. [PMID: 36882209 PMCID: PMC10000904 DOI: 10.9778/cmajo.20220055] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND Postoperative pain management practices in breast surgery are variable, with recent evidence that approaches for minimizing or sparing opioids can be successfully implemented. We describe opioid filling and predictors of higher doses in patients undergoing same-day breast surgery in Ontario, Canada. METHODS In this retrospective population-based cohort study, we used linked administrative health data to identify patients aged 18 years or older who underwent same-day breast surgery from 2012 to 2020. We categorized procedure types by increasing invasiveness of surgery: partial, with or without axillary intervention (P ± axilla); total, with or without axillary intervention (T ± axilla); radical, with or without axillary intervention (R ± axilla); and bilateral. The primary outcome was filling an opioid prescription within 7 or fewer days after surgery. Secondary outcomes were total oral morphine equivalents (OMEs) filled (mg, median and interquartile range [IQR]) and filling more than 1 prescription within 7 or fewer days after surgery. We estimated associations (adjusted risk ratios [RRs] and 95% confidence intervals [CIs]) between study variables and outcomes in multivariable models. We used a random intercept for each unique prescriber to account for provider-level clustering. RESULTS Of the 84 369 patients who underwent same-day breast surgery, 72% (n = 60 620) filled an opioid prescription. Median OMEs filled increased with invasiveness (P ± axilla = 135 [IQR 90-180] mg; T ± axilla = 135 [IQR 100-200] mg; R ± axilla = 150 [IQR 113-225] mg, bilateral surgery = 150 [IQR 113-225] mg; p < 0.0001). Factors associated with filling more than 1 opioid prescription were age 30-59 years (v. age 18-29 yr), increased invasiveness (RR 1.98, 95% CI 1.70-2.30 bilateral v. P ± axilla), Charlson Comorbidity Index ≥ 2 versus 0-1 (RR 1.50, 95% CI 1.34-1.69) and malignancy (RR 1.39, 95% CI 1.26-1.53). INTERPRETATION Most patients undergoing same-day breast surgery fill an opioid prescription within 7 days. Efforts are needed to identify patient groups where opioids may be successfully minimized or eliminated.
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Affiliation(s)
- Julie La
- Division of General Surgery and Surgical Oncology (La, Alqaydi, Merchant), Queen's University; ICES Queen's (Wei, Shellenberger, Brogly); Departments of Medicine (Digby) and Surgery (Brogly, Merchant), Queen's University, Kingston, Ont
| | - Anood Alqaydi
- Division of General Surgery and Surgical Oncology (La, Alqaydi, Merchant), Queen's University; ICES Queen's (Wei, Shellenberger, Brogly); Departments of Medicine (Digby) and Surgery (Brogly, Merchant), Queen's University, Kingston, Ont
| | - Xuejiao Wei
- Division of General Surgery and Surgical Oncology (La, Alqaydi, Merchant), Queen's University; ICES Queen's (Wei, Shellenberger, Brogly); Departments of Medicine (Digby) and Surgery (Brogly, Merchant), Queen's University, Kingston, Ont
| | - Jonas Shellenberger
- Division of General Surgery and Surgical Oncology (La, Alqaydi, Merchant), Queen's University; ICES Queen's (Wei, Shellenberger, Brogly); Departments of Medicine (Digby) and Surgery (Brogly, Merchant), Queen's University, Kingston, Ont
| | - Geneviève C Digby
- Division of General Surgery and Surgical Oncology (La, Alqaydi, Merchant), Queen's University; ICES Queen's (Wei, Shellenberger, Brogly); Departments of Medicine (Digby) and Surgery (Brogly, Merchant), Queen's University, Kingston, Ont
| | - Susan B Brogly
- Division of General Surgery and Surgical Oncology (La, Alqaydi, Merchant), Queen's University; ICES Queen's (Wei, Shellenberger, Brogly); Departments of Medicine (Digby) and Surgery (Brogly, Merchant), Queen's University, Kingston, Ont
| | - Shaila J Merchant
- Division of General Surgery and Surgical Oncology (La, Alqaydi, Merchant), Queen's University; ICES Queen's (Wei, Shellenberger, Brogly); Departments of Medicine (Digby) and Surgery (Brogly, Merchant), Queen's University, Kingston, Ont.
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Li ZH, Hong WJ, Guo XL, Li XR, Jiang XY, Jiang Y, Luo SK. Serratus Plane Block in Breast Cancer Surgery: A Systematic Review and Meta-Analysis. Clin Breast Cancer 2023; 23:e1-e13. [PMID: 36357268 DOI: 10.1016/j.clbc.2022.10.009] [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: 03/29/2022] [Revised: 10/10/2022] [Accepted: 10/13/2022] [Indexed: 12/27/2022]
Abstract
The serratus plane block is a regional anesthesia technique awaiting efficacy and safety evaluation in breast cancer surgery, but evidence is unclear. This meta-analysis evaluates the analgesic effectiveness of serratus plane block vis-à-vis general anesthesia and paravertebral block for breast cancer surgery. We searched for randomized controlled trials in PubMed, the Cochrane Library, and Web of Science with no language limitation, comparing the serratus plane block with multimodal analgesia or the thoracic paravertebral block in breast cancer surgery. The Hartung-Knapp-Sidik-Jonkman method in combination with a random-effects model was used to pool data. We included 12 randomized controlled trials (799 patients). Compared with multimodal analgesia, pooled outcomes favored the use of serratus plane block for effectively alleviating acute postoperative pain severity at multiple time points. The serratus plane block also resulted in decreased postoperative analgesic consumption of 28.81mg (95% confidence interval [CI]: -51.20, -6.43), decreased intraoperative fentanyl consumption of -56.46 mg (95% CI: -79.61, -33.30), increased duration of postoperative anesthesia of 243.85 min (95% CI: 104.38, 383.31), and reduced postoperative nausea and vomiting with a log relative risk of -1.07 (95% CI: -1.90, -0.24). Compared with the thoracic paravertebral block, the serratus plane block was not statically worse for all of the outcomes assessed. No adverse effects were reported. The serratus plane block effectively alleviates acute postoperative pain, reduces the rate of postoperative nausea and vomiting, and improves perioperative anesthesia outcomes in breast cancer surgery, and it may represent an alternative to thoracic paravertebral block.
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Affiliation(s)
- Zhen-Hao Li
- Jinan University, Guangzhou City, Guangdong Province, China; Department of Plastic and Reconstructive Surgery, Guangdong Second Provincial General Hospital, Guangzhou City, Guangdong Province, China
| | - Wei-Jin Hong
- Department of Plastic and Reconstructive Surgery, Guangdong Second Provincial General Hospital, Guangzhou City, Guangdong Province, China
| | - Xiao-Liang Guo
- Department of Plastic and Reconstructive Surgery, Guangdong Second Provincial General Hospital, Guangzhou City, Guangdong Province, China
| | - Xin-Rui Li
- Department of Plastic and Reconstructive Surgery, Guangdong Second Provincial General Hospital, Guangzhou City, Guangdong Province, China; The Second School of Clinical Medicine, Southern Medical University, Guangzhou City, Guangdong Province, China
| | - Xuan-Yu Jiang
- Jinan University, Guangzhou City, Guangdong Province, China; Department of Plastic and Reconstructive Surgery, Guangdong Second Provincial General Hospital, Guangzhou City, Guangdong Province, China
| | - Yu Jiang
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou City, Guangdong Province, China
| | - Sheng-Kang Luo
- Department of Plastic and Reconstructive Surgery, Guangdong Second Provincial General Hospital, Guangzhou City, Guangdong Province, China; Jinan University, Guangzhou City, Guangdong Province, China.
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Chan KY, Keogh S, Aucharaz N, Merrigan A, Tormey S. Opioid prescribing after breast surgery: A systematic review of guidelines. Surgeon 2022:S1479-666X(22)00139-1. [PMID: 36593160 DOI: 10.1016/j.surge.2022.12.004] [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: 08/30/2022] [Revised: 12/01/2022] [Accepted: 12/05/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Despite advances in opioid-sparing analgesia, opioid prescribing in breast surgery remains suboptimal. Besides delayed rehabilitation, excess post-operative opioids may contribute significantly to opioid dependence. This systematic review of guidelines evaluates current opioid-prescribing recommendations after breast surgery to identify trends in prescribing. Additionally, it compares recommendations on different non-opioid and non-pharmacological adjuncts. METHODS Electronic databases were searched systematically using terms "breast surgery", "analgesia", "opioid" and "guidelines". The grey literature was used to supplement the search. All articles that provided guidance on opioid prescribing in breast surgery were included. Quality of the guidelines were assessed using the AGREE II tool. Recommendations pertaining to opioid prescribing, analgesic adjuncts and non-pharmacological interventions were summarised and reported with descriptive statistics. RESULT Eight guidelines pertaining to mastectomies, breast conserving surgery and breast reconstructions were included in this review. Although an opioid-sparing approach was unanimous, there were conflicting recommendations on opioid doses. Opioid requirements were stratified by procedure in 3 guidelines, and by patient risk factors in 2 guidelines. There was significant variability in the recommended multimodal adjuncts. Notably, non-pharmacological interventions such as patient education were infrequently included in guidelines. CONCLUSION There is a lack of high-quality guidance on opioid prescribing after breast surgery. The optimum approach for personalised opioid prescribing remains unknown. Significant variability between guidelines provide little actionable interventions for prescribers. This could be driven by the paucity in evidence supporting a single efficacious analgesic regimen for patients undergoing breast surgery. Future guidelines should also regularly incorporate non-pharmacological adjuncts to reduce opioid prescribing.
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Affiliation(s)
- Kin Yik Chan
- Department of Breast Surgery, University Hospital Limerick, Limerick V94 F858, County Limerick, Ireland.
| | - Shane Keogh
- Department of Breast Surgery, University Hospital Limerick, Limerick V94 F858, County Limerick, Ireland
| | - Nitin Aucharaz
- Department of Breast Surgery, University Hospital Limerick, Limerick V94 F858, County Limerick, Ireland
| | - Anne Merrigan
- Department of Breast Surgery, University Hospital Limerick, Limerick V94 F858, County Limerick, Ireland
| | - Shona Tormey
- Department of Breast Surgery, University Hospital Limerick, Limerick V94 F858, County Limerick, Ireland
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Abujbarah SM, Jogerst K, Kosiorek HE, Ahmad S, Cronin PA, Casey W, Craner R, Rebecca A, Pockaj BA. Postoperative Hematomas in the Era of Outpatient Mastectomy: Is Ketorolac Really to Blame? Ann Surg Oncol 2022; 29:6395-6403. [PMID: 35849298 DOI: 10.1245/s10434-022-12141-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 06/16/2022] [Indexed: 12/17/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols following mastectomy with or without implant-based breast reconstruction (IBBR) include ketorolac for multimodal perioperative analgesia. There are concerns that ketorolac could be associated with increased risk of postoperative hematoma formation. METHODS Retrospective review of patients undergoing mastectomy with or without IBBR between January 2013 and December 2019 at a single institution. Patients received 15 mg, 30 mg, or no ketorolac depending on ERAS protocol adherence, patient characteristics, and surgeon preference. Clinically significant hematoma was defined as requiring surgical intervention on day of surgery or postoperative day 1. Patients were compared by demographics, surgical characteristics, ketorolac dose, and hematoma prevalence. Univariable and multivariable logistic regression evaluated hematoma formation odds. RESULTS Eight hundred patients met inclusion criteria: 477 received ketorolac. Those who received ketorolac were younger, had lower ASA scores, were more likely to have bilateral procedures and undergo concomitant IBBR, had longer operative times, were less likely to take antiplatelet or anticoagulation medications, had higher PACU pain scores, and had higher incidence of hematomas requiring surgical intervention. Of the cohort, 4.4% had clinically significant hematomas. The 15 mg and 30 mg ketorolac groups had similar prevalence (6.0% vs 5.8%, p = 0.95). On univariable regression, there were increased odds of hematoma formation in patients who were younger, had bilateral procedures, had longer OR times, and who received ketorolac. On multivariable regression, none of the prior variables remained significant. CONCLUSION After accounting for associations with longer operative times, concomitant IBBR, and bilateral procedures, ketorolac administration did not remain an independent risk factor for hematoma formation.
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Affiliation(s)
- Sami M Abujbarah
- Mayo Clinic Alix School of Medicine, Arizona Campus, Scottsdale, AZ, USA
| | - Kristen Jogerst
- Department of General Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Heidi E Kosiorek
- Department of Research-Biostatistics, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Sarwat Ahmad
- Department of General Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Patricia A Cronin
- Department of General Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - William Casey
- Department of Surgery, Division of Plastic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Ryan Craner
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Alanna Rebecca
- Department of Surgery, Division of Plastic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Barbara A Pockaj
- Department of General Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA.
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Ludwig K, Wexelman B, Chen S, Cheng G, DeSnyder S, Golesorkhi N, Greenup R, James T, Lee B, Pockaj B, Vuong B, Fluharty S, Fuentes E, Rao R. Home Recovery After Mastectomy: Review of Literature and Strategies for Implementation American Society of Breast Surgeons Working Group. Ann Surg Oncol 2022; 29:5799-5808. [PMID: 35503389 DOI: 10.1245/s10434-022-11799-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 04/07/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Practices regarding recovery after mastectomy vary significantly, including overnight stay versus discharge same day. Expanded use of Enhanced Recovery After Surgery (ERAS) algorithms and the recent COVID pandemic have led to increased number of patients who undergo home recovery after mastectomy (HRAM). METHODS The Patient Safety Quality Committee of the American Society of Breast Surgeons created a multispecialty working group to review the literature evaluating HRAM after mastectomy with and without implant-based reconstruction. A literature review was performed regarding this topic; the group then developed guidance for patient selection and tools for implementation. RESULTS Multiple, retrospective series have reported that patients discharged day of mastectomy have similar risk of complications compared with those kept overnight, including risk of hematoma (0-5.1%). Multimodal strategies that improve nausea and analgesia improve likelihood of HRAM. Patients who undergo surgery in ambulatory surgery centers and by high-volume breast surgeons are more likely to be discharged day of surgery. When evaluating unplanned return to care, the only significant factors are African American race and increased comorbidities. CONCLUSIONS Review of current literature demonstrates that HRAM is a safe option in appropriate patients. Choice of method of recovery should consider patient factors, such as comorbidities and social situation, and requires input from the multidisciplinary team. Preoperative education regarding pain management, drain care, and after-hour access to medical care are crucial components to a successful program. Additional investigation is needed as these programs become more prevalent to assess quality measures such as unplanned return to care, complications, and patient satisfaction.
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Affiliation(s)
- Kandice Ludwig
- Indiana University School of Medicine, Indianapolis, IN, USA.
| | | | | | - Gloria Cheng
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | | | | | - Ted James
- Harvard Medical School, Boston, MA, USA
| | | | | | - Brooke Vuong
- Kaiser Permanente Medical Center, Sacramento, CA, USA
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Singh NP, Makkar JK, Kuberan A, Guffey R, Uppal V. Efficacy of regional anesthesia techniques for postoperative analgesia in patients undergoing major oncologic breast surgeries: a systematic review and network meta-analysis of randomized controlled trials. Can J Anaesth 2022; 69:527-549. [PMID: 35102494 DOI: 10.1007/s12630-021-02183-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 11/08/2021] [Accepted: 11/10/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The optimal regional technique to control pain after breast cancer surgery remains unclear. We sought to synthesize available data from randomized controlled trials comparing pain-related outcomes following various regional techniques for major oncologic breast surgery. METHODS In a systematic review and network meta-analysis, we searched trials in PubMed, Embase Scopus, Medline, Cochrane Central and Google Scholar, from inception to 31 July 2020, for commonly used regional techniques. The primary outcome was the 24-hr resting pain score measured on a numerical rating score of 0-10. We used surface under the cumulative ranking curve (SUCRA) to establish the probability of an intervention ranking highest. The analysis was performed using the Bayesian random effects model, and effect sizes are reported as 95% credible interval (Crl). We conducted cluster-rank analysis by combining 24-hr pain ranking with 24-hr opioid use or incidence of postoperative nausea and vomiting. RESULTS Seventy-nine randomized controlled trials containing 11 different interventions in 5,686 patients were included. The SUCRA values of the interventions for 24-hr resting pain score were continuous paravertebral block (0.83), serratus anterior plane block (0.76), continuous wound infusion (0.76), single-level paravertebral block (0.68), erector spinae plane block (0.59), modified pectoral block (0.49), intercostal block (0.45), multilevel paravertebral block (0.41), wound infiltration (0.33), no intervention (0.12), and placebo (0.08). When compared with placebo, the continuous paravertebral block (mean difference, 1.26; 95% Crl, 0.43 to 2.12) and serratus anterior plane block (mean difference, 1.12; 95% Crl, 0.32 to 1.9) had the highest estimated probability of decreasing 24-hr resting pain scores. Cluster ranking analysis combining 24-hr resting pain scores and opioid use showed that most regional analgesia techniques were more effective than no intervention or placebo. Nevertheless, wound infiltration and continuous wound infusion may be the least effective active interventions for reducing postoperative nausea and vomiting. CONCLUSION Continuous paravertebral block and serratus anterior plane block had a high probability of reducing pain at 24 hr after major oncologic breast surgery. The certainty of evidence was moderate to very low. Future studies should compare different regional anesthesia techniques, including surgeon-administered techniques such as wound infiltration or catheters. Trials comparing active intervention with placebo are unlikely to change clinical practice. STUDY REGISTRATION PROSPERO (CRD42020198244); registered 19 October 2020.
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Affiliation(s)
- Narinder Pal Singh
- Department of Anaesthesia, MMIMSR, MM (DU), Mullana-Ambala, Ambala, India
| | - Jeetinder Kaur Makkar
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aswini Kuberan
- Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
| | - Ryan Guffey
- Department of Anesthesia, Washington University in St. Louis, St. Louis, MO, USA
| | - Vishal Uppal
- Department of Anesthesia, Perioperative Medicine and Pain Management, Dalhousie University, Nova Scotia Health Authority and Izaak Walton Killam Health Centre, Halifax, NS, Canada.
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11
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Abushukur Y, Cascardo C, Ibrahim Y, Teklehaimanot F, Knackstedt R. Improving Breast Surgery Outcomes Through Alternative Therapy: A Systematic Review. Cureus 2022; 14:e23443. [PMID: 35481320 PMCID: PMC9034658 DOI: 10.7759/cureus.23443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2022] [Indexed: 11/05/2022] Open
Abstract
Enhanced recovery after surgery (ERAS) protocols are the current standard of care when it comes to improving post-surgical outcomes in breast cancer patients. Compliance with all protocol items is required in order for patients to experience significant benefits. Given that the ERAS protocols involve numerous medications which each have unique side effect profiles and medication interactions, this is often difficult to accomplish. Additionally, breast cancer patients are often left with a large psychological burden, which ERAS protocols fail to address. This review aims to determine the role that alternative therapies can play in improving both the emotional and physical strains patients experience during the post-operative stage of recovery. A PubMed search was conducted using the following search terms (“alternative medicine” or “complementary medicine” or “integrative medicine” or “holistic medicine” or “natural medicine" or “mediation” or “aromatherapy” or “music” or “art” or “reiki” or “massage”) and (“surgery”) and (“pain”). Studies selected for this review include articles published or translated in English that addressed alternative medical interventions affecting pre-, peri-, or post-operative outcomes in breast biopsies, surgeries, or breast-related procedures. Eighteen articles fit the inclusion criteria, with seven addressing music, five addressing meditation, yoga, and guided imagery, five addressing massage, one addressing myofascial release, four addressing aromatherapy, two addressing acupuncture, and three addressing hypnosis. Most forms of alternative therapies offered some benefit to patients following breast-related procedures, many resulting in improvements in post-operative outcomes including pain, fatigue, energy, stress, anxiety, mood, and depression. The reviewed studies demonstrated numerous benefits to integrating alternative medicine into standardized therapy to improve postoperative outcomes. Most studies analyzed did not include placebo controls as including proper placebos was often not feasible. Future studies with larger sample sizes are needed to better quantify the benefits patients receive from these noninvasive, low-risk complementary therapies.
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12
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Pawloski KR, Sevilimedu V, Twersky R, Tadros AB, Kirstein LJ, Cody HS, Morrow M, Moo TA. Association Between Local Anesthetic Dosing, Postoperative Opioid Requirement, and Pain Scores After Lumpectomy and Sentinel Lymph Node Biopsy with Multimodal Analgesia. Ann Surg Oncol 2022; 29:1737-1745. [PMID: 34694521 PMCID: PMC11110646 DOI: 10.1245/s10434-021-10981-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 10/05/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Multimodal analgesia (MMA) during breast surgery reduces postoperative pain and opioid requirements, but the relative contribution of local anesthetic dosing as a component of MMA is not well defined among patients undergoing lumpectomy and sentinel lymph node biopsy (SLNB). PATIENTS AND METHODS We identified consecutive patients who underwent lumpectomy and SLNB with MMA from 1/2019 to 4/2020. Univariable and multivariable linear and logistic regression were used to examine associations between local anesthetics, opioid requirements in the post-anesthesia care unit (PACU), and pain scores in the PACU and on postoperative day (POD) 1. RESULTS In total, 1603 patients [median tumor size, 14 mm (interquartile range 8-20 mm)] were included. The median PACU opioid requirement was 0 morphine milligram equivalents (interquartile range 0-5). PACU maximum pain was none or mild in 58% of patients and moderate to severe in 42%; among 420 survey respondents, 56% reported no or mild pain and 44% reported moderate to severe pain on POD 1. On multivariable analysis that adjusted for routine components of MMA, increasing doses of 0.5% bupivacaine were associated with reduced PACU opioid requirements (β -0.04, 95% confidence interval -0.07 to -0.01, p = 0.011) and lower odds of moderate to severe pain (odds ratio 0.98, 95% confidence interval 0.97-0.99, p < 0.001). Local anesthetics were not associated with pain scores on POD 1. CONCLUSIONS Higher amounts of local anesthetics reduce acute postoperative pain and opioid requirement after lumpectomy and SLNB. Maximizing dosing within weight-based limits is a low-risk, cost-effective pain control strategy that can be used in diverse practice settings.
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Affiliation(s)
- Kate R Pawloski
- Department of Surgery, Breast Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Varadan Sevilimedu
- Department of Epidemiology and Biostatistics, Biostatistics Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Rebecca Twersky
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Audree B Tadros
- Department of Surgery, Breast Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Laurie J Kirstein
- Department of Surgery, Breast Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hiram S Cody
- Department of Surgery, Breast Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Department of Surgery, Breast Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Tracy-Ann Moo
- Department of Surgery, Breast Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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13
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Pawloski KR, Moo TA. ASO Author Reflection: Pain Control Can Be Optimized with Surgeon-Administered Local Anesthesia in Patients Undergoing Lumpectomy and Sentinel Lymph Node Biopsy with Multimodal Analgesia. Ann Surg Oncol 2021; 29:1746-1747. [PMID: 34713372 DOI: 10.1245/s10434-021-11004-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 10/13/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Kate R Pawloski
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Tracy-Ann Moo
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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14
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Pawloski KR, Moo TA. ASO Author Reflections: Non-Steroidal Anti-Inflammatory Drugs are Safe in the Post-Discharge Setting After Lumpectomy and Sentinel Lymph Node Biopsy with Multimodal Analgesia. Ann Surg Oncol 2021; 29:558-559. [PMID: 34387771 DOI: 10.1245/s10434-021-10580-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 05/24/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Kate R Pawloski
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Tracy-Ann Moo
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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15
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Gunasingha RMKD, Niloy IL, Wetstein BB, Learn PA, Turza LC. Keeping tabs: Reducing postoperative opioid prescriptions for patients after breast surgical procedures. Surgery 2021; 169:1316-1322. [PMID: 33413919 DOI: 10.1016/j.surg.2020.11.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/11/2020] [Accepted: 11/19/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND As the opioid crisis continues, it is critical that health care providers ensure they are not overprescribing opioid medications. At our institution (Walter Reed National Military Medical Center, Bethesda, MD), postoperative patients after breast surgeries are discharged with variable amounts of opioid medications. However, many patients report minimal opioid use. The objectives of this study were to characterize postoperative opioid usage and prescribing practices for patients undergoing various breast surgeries and to recommend the number of opioid pills for discharge for each procedure. METHODS This was a prospective, single-institution study of all patients undergoing breast surgery from October 2018 to 2019. All patients were enrolled in our institution's enhanced recovery after surgery protocol. Patients were given questionnaires at their 2-week postoperative clinic appointment that evaluated perioperative pain and use of pain medications. The electronic medical record was reviewed to obtain additional information. Appropriate parametric and nonparametric tests were used for analysis. RESULTS A total of 190 breast surgery patients completed the survey. We observed no significant differences in pain scores except between re-excision and mastectomy. Of these patients, 99% were prescribed opioids; however, only 53% of patients used them. Of those patients who were prescribed opioids, on average, all were prescribed more pills than were used. CONCLUSION Our study demonstrates that it is possible to discharge all breast surgery patients with fewer than 10 opioid pills, except for special circumstances. This is the first study to provide a set of specific recommended discharge medications. Utilization of an enhanced recovery after surgery protocol with standardized discharge opioids can be used successfully to reduce the number of opioids prescribed to patients.
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Affiliation(s)
- Rathnayaka M K D Gunasingha
- Breast Care Center, Murtha Cancer Center, General Surgery, Walter Reed National Military Medical Center, Bethesda, MD.
| | - Injamamul L Niloy
- Department of Oral Maxillofacial Surgery, Walter Reed National Military Medical Center, Bethesda, MD
| | - Berish B Wetstein
- School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Peter A Learn
- Breast Care Center, Murtha Cancer Center, General Surgery, Walter Reed National Military Medical Center, Bethesda, MD; School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Lauren C Turza
- Breast Care Center, Murtha Cancer Center, General Surgery, Walter Reed National Military Medical Center, Bethesda, MD
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16
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Eyrich NW, Sloss KR, Howard RA, Klueh MP, Englesbe MJ, Waljee JF, Brummett CM, Sabel MS, Dossett LA, Lee JS. Opioid prescribing exceeds consumption following common surgical oncology procedures. J Surg Oncol 2021; 123:352-356. [PMID: 33125747 PMCID: PMC7770117 DOI: 10.1002/jso.26272] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 09/24/2020] [Accepted: 10/11/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND AND OBJECTIVES Surgical oncology patients are vulnerable to persistent opioid use. As such, we aim to compare opioid prescribing to opioid consumption for common surgical oncology procedures. METHODS We prospectively identified patients undergoing common surgical oncology procedures at a single academic institution (August 2017-March 2018). Patients were contacted by telephone within 6 months of surgery and asked to report their opioid consumption and describe their discharge instructions and opioid handling practices. RESULTS Of the 439 patients who were approached via telephone, 270 completed at least one survey portion. The median quantity of opioid prescribed was significantly larger than consumed following breast biopsy (5 vs. 2 tablets of 5 mg oxycodone, p < .001), lumpectomy (10 vs. 2 tablets of 5 mg oxycodone, p < .001), and mastectomy or wide local excision (20 tablets vs. 2 tablets of 5 mg oxycodone, p < .001). The majority of patients reported receiving education on taking opioids, but only 27% received instructions on proper disposal; 82% of prescriptions filled resulted in unused opioids, and only 11% of these patients safely disposed of them. CONCLUSIONS This study demonstrates that opioid prescribing exceeds consumption following common surgical oncology procedures, indicating the potential for reductions in prescribing.
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Affiliation(s)
| | | | - Ryan A. Howard
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Michael P. Klueh
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI
| | - Michael J. Englesbe
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Jennifer F. Waljee
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Chad M. Brummett
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
| | - Michael S. Sabel
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Division of Surgical Oncology, University of Michigan, Ann Arbor, MI
| | - Lesly A. Dossett
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- Division of Surgical Oncology, University of Michigan, Ann Arbor, MI
| | - Jay S. Lee
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
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Chang SB. ASO Author Reflections: We Can Do It: Using Non-Opioid Regimens After Breast Surgery. Ann Surg Oncol 2020; 27:715-716. [PMID: 32815079 DOI: 10.1245/s10434-020-09036-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 08/09/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Sharon B Chang
- Department of Surgery, Kaiser Permanente Fremont Medical Center, Fremont, CA, USA.
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Brenin DR, Dietz JR, Baima J, Cheng G, Froman J, Laronga C, Ma A, Manahan MA, Mariano ER, Rojas K, Schroen AT, Tiouririne NAD, Wiechmann LS, Rao R. Pain Management in Breast Surgery: Recommendations of a Multidisciplinary Expert Panel-The American Society of Breast Surgeons. Ann Surg Oncol 2020; 27:4588-4602. [PMID: 32783121 DOI: 10.1245/s10434-020-08892-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 07/02/2020] [Indexed: 12/13/2022]
Abstract
Opioid overdose accounted for more than 47,000 deaths in the United States in 2018. The risk of new persistent opioid use following breast cancer surgery is significant, with up to 10% of patients continuing to fill opioid prescriptions one year after surgery. Over prescription of opioids is far too common. A recent study suggested that up to 80% of patients receiving a prescription for opioids post-operatively do not need them (either do not fill the prescription or do not use the medication). In order to address this important issue, The American Society of Breast Surgeons empaneled an inter-disciplinary committee to develop a consensus statement on pain control for patients undergoing breast surgery. Representatives were nominated by the American College of Surgeons, the Society of Surgical Oncology, The American Society of Plastic Surgeons, and The American Society of Anesthesiologists. A broad literature review followed by a more focused review was performed by the inter-disciplinary panel which was comprised of 14 experts in the fields of breast surgery, anesthesiology, plastic surgery, rehabilitation medicine, and addiction medicine. Through a process of multiple revisions, a consensus was developed, resulting in the outline for decreased opioid use in patients undergoing breast surgery presented in this manuscript. The final document was reviewed and approved by the Board of Directors of the American Society of Breast Surgeons.
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Affiliation(s)
- David R Brenin
- Department of Surgery, University of Virginia, Charlottesville, VA, USA.
| | - Jill R Dietz
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jennifer Baima
- Department of Physical Medicine and Rehabilitation, UMass Memorial Medical Center, Worcester, MA, USA
| | - Gloria Cheng
- Department of Anesthesia, University of Texas Southwestern, Dallas, TX, USA
| | - Joshua Froman
- Department of Surgery, Mayo Clinic, Owatonna, MN, USA
| | | | - Ayemoethu Ma
- Surgery and Integrative Medicine, Scripps Health, La Jolla, CA, USA
| | - Michele A Manahan
- Department of Plastic Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Edward R Mariano
- Department of Anesthesia, Stanford University, Stanford, CA, USA
| | - Kristin Rojas
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Anneke T Schroen
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | | | - Lisa S Wiechmann
- New York Presbyterian Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Roshni Rao
- New York Presbyterian Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
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Patel AR, Vuong B, Kuehner GE, Odele P, Low G, Savitz A, Shim V, Mentakis M, Linehan E, Chang SB. Adoption of Opioid-Sparing and Non-Opioid Regimens After Breast Surgery in a Large, Integrated Health Care Delivery System. Ann Surg Oncol 2020; 27:4835-4843. [DOI: 10.1245/s10434-020-08897-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 07/07/2020] [Indexed: 12/12/2022]
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20
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Moo TA, Pawloski KR, Sevilimedu V, Charyn J, Simon BA, Sclafani LM, Plitas G, Barrio AV, Kirstein LJ, Van Zee KJ, Morrow M. Changing the Default: A Prospective Study of Reducing Discharge Opioid Prescription after Lumpectomy and Sentinel Node Biopsy. Ann Surg Oncol 2020; 27:4637-4642. [PMID: 32734370 DOI: 10.1245/s10434-020-08886-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 06/09/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Whether routinely prescribed opioids are necessary for pain control after discharge among lumpectomy/sentinel node biopsy (Lump/SLNB) patients is unclear. We hypothesize that Lump/SLNB patients could be discharged without opioids, with a failure rate < 10%. This study prospectively examines outcomes after changing standard discharge prescription from an opioid/non-steroidal anti-inflammatory drug (NSAID) to NSAID/acetaminophen. PATIENTS AND METHODS Standard discharge pain medication orders included opioids in the first 3-month study period and were changed to NSAID/acetaminophen in the second 3-month period. Patient-reported medication consumption and pain scores were collected by post-discharge survey. Frequency of discharge with opioid, NSAID/acetaminophen failure rate, opioid use, and pain scores were examined. RESULTS From May to October 2019, 663 patients had Lump/SLNB: 371 in the opioid study period and 292 in the NSAID period. In the opioid period, 92% (342/371) of patients were prescribed an opioid at discharge; of 142 patients who documented opioid use on the survey, 86 (61%) used zero tablets. Among 56 (39%) patients who used opioids, the median number taken by POD 5 was 4. After the change to NSAID/acetaminophen, rates of opioid prescription decreased to 14% (41/292). The NSAID/acetaminophen failure rate was 2% (5/251). Among survey respondents, there was no significant difference in the maximum reported pain scores (POD 1-5) between the opioid period and the NSAID period (p = 0.7). CONCLUSIONS In Lump/SLNB patients, a change to default discharge with NSAID/acetaminophen resulted in a 78% absolute reduction in opioid prescription, with a failure rate of 2% and no difference in patient-reported pain scores. Most Lump/SLNB patients can be discharged with NSAID/acetaminophen.
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Affiliation(s)
- Tracy-Ann Moo
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kate R Pawloski
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Varadan Sevilimedu
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jillian Charyn
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Brett A Simon
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Josie Robertson Surgery Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lisa M Sclafani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - George Plitas
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrea V Barrio
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Laurie J Kirstein
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kimberly J Van Zee
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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21
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Moo TA, Morrow M. ASO Author Reflections: Discharge Without Opioids After Lumpectomy with Sentinel Node Biopsy Should be the Norm, Not the Exception. Ann Surg Oncol 2020; 27:682-683. [PMID: 32712887 DOI: 10.1245/s10434-020-08930-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 06/27/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Tracy-Ann Moo
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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22
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Rao R, Froman J. ASO Author Reflections: Overregulation Got Us into This, Only Letting Us Be Doctors Will Get Us Out. Ann Surg Oncol 2020; 27:991-992. [PMID: 32026064 DOI: 10.1245/s10434-020-08247-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Roshni Rao
- Columbia University Irving Medical Center, New York Presbyterian, New York, NY, USA.
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Cyr AE. Underutilization of Enhanced Recovery After Surgery (ERAS) in Breast Surgery: An Opportunity to Reduce Opioid Usage. Ann Surg Oncol 2020; 27:966-968. [DOI: 10.1245/s10434-020-08198-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Indexed: 12/15/2022]
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