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Knackstedt RW, Lin JH, Kakoty S. Liposomal Bupivacaine Analgesia in Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Retrospective Cohort Study. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5874. [PMID: 38855138 PMCID: PMC11161287 DOI: 10.1097/gox.0000000000005874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 04/08/2024] [Indexed: 06/11/2024]
Abstract
Background Liposomal bupivacaine (LB) can be used for postsurgical analgesia after breast reconstruction. We examined real-world clinical and economic benefits of LB versus bupivacaine after deep inferior epigastric perforator (DIEP) flap breast reconstruction. Methods This retrospective cohort study used the IQVIA claims databases to identify patients undergoing primary DIEP flap breast reconstruction in 2016-2019. Patients receiving LB and those receiving bupivacaine were compared to assess opioid utilization in morphine milligram equivalents (MMEs) and healthcare resource utilization during perioperative (2 weeks before surgery to 2 weeks after discharge) and 6-month postdischarge periods. A generalized linear mixed-effects model and inverse probability of treatment weighting method were performed. Results Weighted baseline characteristics were similar between cohorts (LB, n = 669; bupivacaine, n = 348). The LB cohort received significantly fewer mean MMEs versus the bupivacaine cohort during the perioperative (395 versus 512 MMEs; rate ratio [RR], 0.771 [95% confidence interval (CI), 0.677-0.879]; P = 0.0001), 72 hours after surgery (63 versus 140 MMEs; RR, 0.449 [95% CI, 0.347-0.581]; P < 0.0001), and inpatient (154 versus 303 MMEs; RR, 0.508 [95% CI, 0.411-0.629]; P < 0.0001) periods; postdischarge filled opioid prescriptions were comparable. The LB cohort was less likely to have all-cause inpatient readmission (odds ratio, 0.670 [95% CI, 0.452-0.993]; P = 0.046) and outpatient clinic/office visits (odds ratio, 0.885 [95% CI, 0.785-0.999]; P = 0.048) 3 months after discharge than the bupivacaine cohort; other all-cause healthcare resource utilization outcomes were not different. Conclusions LB was associated with fewer perioperative MMEs and all-cause 3-month inpatient readmissions and outpatient clinic/office visits than bupivacaine in patients undergoing DIEP flap breast reconstruction.
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Marquez JL, Chow J, Moss W, Luo J, Eddington D, Agarwal JP, Kwok AC. Outpatient Prescription Opioid Use following Discharge after Deep Inferior Epigastric Perforator Breast Reconstruction with and without an Educational Intervention. J Reconstr Microsurg 2024. [PMID: 38452802 DOI: 10.1055/a-2283-4775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
BACKGROUND There is limited evidence for appropriate postoperative opioid prescribing in autologous breast reconstruction. We sought to describe postoperative outpatient prescription opioid use following discharge after deep inferior epigastric perforator (DIEP) breast reconstruction with and without an educational video. METHODS Patients undergoing DIEP reconstruction were given a 28-day postoperative pain and medication logbook from August 2022 to June 2023. Our practice implemented an educational video upon discharge on proper opioid consumption. Descriptive statistics on patient characteristics, intraoperative and postoperative opioid consumption, and outpatient prescription opioid use after discharge were compared between the two cohorts. RESULTS A total of 53 logbooks were completed with 20 patients in the no video cohort and 33 in the video cohort. On average, the days to cessation of opiates was longer in the no video cohort (8.2 vs. 5.1 days, p = 0.003). The average number of oxycodone 5 mg equivalents consumed following discharge was 13.8 in the no video cohort and 7.8 in the video cohort, which was statistically significant (p = 0.01). Overall, the percentage of opioids prescribed that were consumed in the video cohort was 28.3% versus 67.1% in the no video cohort. CONCLUSION For patients discharging home after DIEP reconstruction, we recommend a prescription for 12 oxycodone 5 mg tablets. With the use of an educational video regarding proper opioid consumption, we were able to reduce the total outpatient opioid use to 5 oxycodone 5 mg tablets following hospital discharge.
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Affiliation(s)
- Jessica L Marquez
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Josh Chow
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Whitney Moss
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Jessica Luo
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Devin Eddington
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Jayant P Agarwal
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Alvin C Kwok
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Utah School of Medicine, Salt Lake City, Utah
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Talwar AA, Niu EF, Broach RB, Nelson JA, Fischer JP. Patient-reported outcomes: A primer for plastic surgeons. J Plast Reconstr Aesthet Surg 2023; 86:35-47. [PMID: 37688832 DOI: 10.1016/j.bjps.2023.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 07/23/2023] [Accepted: 08/13/2023] [Indexed: 09/11/2023]
Abstract
Surgical care today is no longer evaluated only on clinical outcomes but also on holistic patient wellbeing. Patient-reported outcomes (PROs) are a representation of the patient's perspective on their results and wellbeing. The aim of this review is to establish PROs as the center of healthcare and plastic surgery, to delineate important PROs in plastic surgery practice and research, to discuss the future of PROs within our discipline, and to encourage surgeons to incorporate PROs into their practice. PROs are an important parallel of clinical outcomes in that they can use the patient's perspective to 1) support clinical findings, 2) detect differences in care when there are no clear clinical differences, 3) track progress longitudinally, and 4) support systemic improvements in healthcare. Plastic surgery as a field is naturally aligned with PROs because, as a discipline, we focus on patient form and function. The emerging forefronts of plastic surgery such as lymphedema care, gender-affirming care, peripheral nerve surgery, migraine surgery, and breast implant illness are critically dependent on PROs. In the next decade, we predict that there will be a continued proliferation of robust PRO measures and integration into healthcare delivery. Outcomes research in surgery should continue to evolve as surgeons provide increasingly more benefits to improve patient wellbeing. Plastic surgeons must continue to play a prominent role in the future of PROs.
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Affiliation(s)
- Ankoor A Talwar
- Division of Plastic Surgery, University of Pennsylvania, United states
| | - Ellen F Niu
- Division of Plastic Surgery, University of Pennsylvania, United states
| | - Robyn B Broach
- Division of Plastic Surgery, University of Pennsylvania, United states
| | - Jonas A Nelson
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, United States
| | - John P Fischer
- Division of Plastic Surgery, University of Pennsylvania, United states.
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Sudduth JD, Moss WD, Clinker C, Marquez JL, Anderson E, Eddington D, Agarwal J, Kwok AC. Scheduled Postoperative Ketorolac Does Not Decrease Opiate Use following Free Flap Breast Reconstruction. J Reconstr Microsurg 2023; 39:751-757. [PMID: 37068512 DOI: 10.1055/s-0043-1768220] [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: 04/19/2023]
Abstract
BACKGROUND In the setting of the opioid crisis, managing postoperative pain without the exclusive use of opiates has become a topic of interest. Many hospitals have begun implementing enhanced recovery after surgery protocols to decrease postoperative complications, hospital costs, and opiate utilization. Ketorolac has been added to many of these protocols, but few studies have examined its effects independently. METHODS A retrospective chart review was performed on all patients that received autologous breast reconstruction from October 2020 to June 2022 at an academic institution. We identified patients who did and did not receive postoperative ketorolac. Use of ketorolac was based upon surgeon preference. The two groups were compared in basic demographics, reconstruction characteristics, length of stay, complications, reoperations, and morphine milligram equivalents (MMEs). RESULTS One-hundred ten patients were included for the analysis, with 55 receiving scheduled postoperative ketorolac and 55 who did not receive ketorolac. There were seven incidences of postoperative complications in each group (12.7%, p = 1.00). The total mean postoperative MMEs were 344.7 for the nonketorolac group and 336.5 for the ketorolac group (p = 0.81). No variable was found to be independently associated with postoperative opiate use. Ketorolac was not found to contribute significantly to any postoperative complication. CONCLUSION In this study, the use of ketorolac did not significantly reduce opiate use in a cohort of 110 patients. Surgeons should consider whether the use of ketorolac alone is the best option to reduce postoperative opiate use following free flap breast reconstruction.
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Affiliation(s)
- Jack D Sudduth
- Division of Plastic Surgery, Department of Surgery, The University of Utah Hospital, Salt Lake City, Utah
| | - Whitney D Moss
- Division of Plastic Surgery, Department of Surgery, The University of Utah Hospital, Salt Lake City, Utah
| | - Christopher Clinker
- Division of Plastic Surgery, Department of Surgery, The University of Utah Hospital, Salt Lake City, Utah
| | - Jessica L Marquez
- Division of Plastic Surgery, Department of Surgery, The University of Utah Hospital, Salt Lake City, Utah
| | - Eric Anderson
- Division of Plastic Surgery, Department of Surgery, The University of Utah Hospital, Salt Lake City, Utah
| | - Devin Eddington
- Division of Epidemiology, Department of Internal Medicine, The University of Utah Hospital, Salt Lake City, Utah
| | - Jayant Agarwal
- Division of Plastic Surgery, Department of Surgery, The University of Utah Hospital, Salt Lake City, Utah
| | - Alvin C Kwok
- Division of Plastic Surgery, Department of Surgery, The University of Utah Hospital, Salt Lake City, Utah
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Liu Z, Cheng S, Wang C, Liu X, Huang H, Zhu Y, Zhou B, Wu H, Cao M. Preoperative flurbiprofen diminishes the rate of reoperation after free flap reconstruction: A retrospective study. J Craniomaxillofac Surg 2023; 51:560-567. [PMID: 37620245 DOI: 10.1016/j.jcms.2023.08.014] [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: 03/31/2022] [Revised: 01/09/2023] [Accepted: 08/14/2023] [Indexed: 08/26/2023] Open
Abstract
This study aimed to evaluate the association between preoperative flurbiprofen, a non-selective COX inhibitor, and reoperation for flap crisis after free flap reconstruction. In this retrospective study, patients who underwent head and neck surgery with free flap reconstructions were collected. To identify risk factors for reoperation from demographic features and perioperative variables, univariate and multivariate logistic analyses were conducted. After propensity score matching (PSM), univariate and adjusted multivariate analyses were employed to explore the impact of preoperative flurbiprofen on reoperation after free flap reconstruction. This study comprised 437 patients, 33 of whom underwent reoperations for flap crisis. After multivariate analysis, radiotherapy history (P = 0.005; odds ratio [OR] = 0.225; 95% CI, 0.080-0.636) and preoperative flurbiprofen (P = 0.038; OR = 5.059; 95% CI, 1.094-23.386) were identified as independent factors for reoperation. PSM was achieved, and preoperative flurbiprofen was found to diminish the reoperation rate (P = 0.046; OR = 4.765; 95% CI, 1.029-22.202) without increasing bleeding complications. Within the limitations of the study, flurbiprofen should be administered preoperatively to reduce the rate of reoperations for flap crisis whenever appropriate.
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Affiliation(s)
- Zhongqi Liu
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shi Cheng
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chengli Wang
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiaoqing Liu
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Haoquan Huang
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yingying Zhu
- Clinical Research Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Bin Zhou
- Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Haixuan Wu
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Minghui Cao
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.
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Tay JQ. Re: Association of preoperative opioid use and postoperative complications following breast reconstruction. J Plast Reconstr Aesthet Surg 2023; 83:475-476. [PMID: 37336114 DOI: 10.1016/j.bjps.2023.05.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 05/15/2023] [Indexed: 06/21/2023]
Affiliation(s)
- Jing Qin Tay
- Plastic, Burns and Reconstructive Surgery Department, Salisbury District Hospital, Thames Valley/Wessex Deanery, UK.
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Saiga M, Nakagiri R, Mukai Y, Matsumoto H, Kimata Y. Trends and issues in clinical research on satisfaction and quality of life after mastectomy and breast reconstruction: a 5-year scoping review. Int J Clin Oncol 2023:10.1007/s10147-023-02347-5. [PMID: 37160493 DOI: 10.1007/s10147-023-02347-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 04/20/2023] [Indexed: 05/11/2023]
Abstract
Breast reconstruction (BR) aims to improve the satisfaction and quality of life (QOL) of breast cancer survivors. Clinical studies using patient-reported outcomes (PROs) can therefore provide relevant information to the patients and support decision-making. This scoping review was conducted to analyze recent trends in world regions, methods used, and factors investigated. The literature search was conducted in August 2022. Databases of PubMed, MEDLINE, and CINAHL were searched for relevant English-language studies published from 2017 to 2022. Studies involving women with breast cancer who underwent BR after mastectomy and investigated PROs after BR using BR-specific scales were included. Data on the country, publication year, study design, PRO measures (PROMs) used, time points of surveys, and research themes were collected. In total, 147 articles met the inclusion criteria. BREAST-Q was the most widely used, contributing to the increase in the number and diversification of studies in this area. Such research has been conducted mainly in North America and Europe and is still developing in Asia and other regions. The research themes involved a wide range of clinical and patient factors in addition to surgery, which could be influenced by research methods, time since surgery, and even cultural differences. Recent BR-specific PROMs have led to a worldwide development of research on factors that affect satisfaction and QOL after BR. PRO after BR may be influenced by local cultural and social features, and it would be necessary to accumulate data in each region to draw clinically useful conclusion.
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Affiliation(s)
- Miho Saiga
- Department of Plastic Surgery, Okayama University Hospital, 2-5-1, Shikata-cho, Kita-ku, Okayama City, Okayama, 700-8558, Japan.
| | - Ryoko Nakagiri
- Department of Plastic Surgery, Okayama University Hospital, 2-5-1, Shikata-cho, Kita-ku, Okayama City, Okayama, 700-8558, Japan
| | - Yuko Mukai
- Department of Plastic Surgery, Okayama Rosai Hospital, Okayama, Japan
| | - Hiroshi Matsumoto
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yoshihiro Kimata
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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Pak LM, Pawloski KR, Sevilimedu V, Kalvin HL, Le T, Tokita HK, Tadros A, Morrow M, Van Zee KJ, Kirstein LJ, Moo TA. How Much Pain Will I Have After Surgery? A Preoperative Nomogram to Predict Acute Pain Following Mastectomy. Ann Surg Oncol 2022; 29:6706-6713. [PMID: 35699814 PMCID: PMC9196152 DOI: 10.1245/s10434-022-11976-5] [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] [Received: 03/28/2022] [Accepted: 05/16/2022] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Acute postoperative pain affects time to opioid cessation and quality of life, and is associated with chronic pain. Effective screening tools are needed to identify patients at increased risk of experiencing more severe acute postoperative pain, and who may benefit from multimodal analgesia and early pain management referral. In this study, we develop a nomogram to preoperatively identify patients at high risk of moderate-severe pain following mastectomy. METHODS Demographic, psychosocial, and clinical variables were retrospectively assessed in 1195 consecutive patients who underwent mastectomy from January 2019 to December 2020 and had pain scores available from a post-discharge questionnaire. We examined pain severity on postoperative days 1-5, with moderate-severe pain as the outcome of interest. Multivariable logistic regression was performed to identify variables associated with moderate-severe pain in a training cohort of 956 patients. The final model was determined using the Akaike information criterion. A nomogram was constructed using this model, which also included a priori selected clinically relevant variables. Internal validation was performed in the remaining cohort of 239 patients. RESULTS In the training cohort, 297 patients reported no-mild pain and 659 reported moderate-severe pain. High body mass index (p = 0.042), preoperative Distress Thermometer score ≥4 (p = 0.012), and bilateral surgery (p = 0.003) predicted moderate-severe pain. The resulting nomogram accurately predicted moderate-severe pain in the validation cohort (AUC = 0.735). CONCLUSIONS This nomogram incorporates eight preoperative variables to provide a risk estimate of acute moderate-severe pain following mastectomy. Preoperative risk stratification can identify patients who may benefit from individually tailored perioperative pain management strategies and early postoperative interventions to treat pain and assist with opioid tapering.
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Affiliation(s)
- Linda M Pak
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, USA
| | - Kate R Pawloski
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, USA
| | - Varadan Sevilimedu
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hannah L Kalvin
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Tiana Le
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, USA
| | - Hanae K Tokita
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Audree Tadros
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, USA
| | - Kimberly J Van Zee
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, USA
| | - Laurie J Kirstein
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, USA
| | - Tracy-Ann Moo
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, USA.
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Mancel L, Van Loon K, Lopez AM. Role of regional anesthesia in Enhanced Recovery After Surgery (ERAS) protocols. Curr Opin Anaesthesiol 2021; 34:616-625. [PMID: 34325463 DOI: 10.1097/aco.0000000000001048] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Enhanced Recovery After Surgery (ERAS) protocols and interventional locoregional anesthesia (LRA) techniques continuously evolve. This review outlines the latest recommendations for the use of regional anesthesia in ERAS protocols and emerging interventional analgesia techniques. RECENT FINDINGS Research in ultrasound-guided regional anesthesia has led to a refinement of the traditional techniques and the introduction of a number of new approaches to complement ERAS strategies. The efficacy and versatility of LRA enable its use in an increasing number of ERAS indications. SUMMARY The implementation of ERAS protocols in different surgical procedures reduces overall complications and recovery time. Multimodal analgesia strategies with regional anesthesia techniques are some of the key interventions contributing to the improvement in postoperative outcomes.
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Affiliation(s)
- Leander Mancel
- Department of Anesthesiology, UZ Leuven, Leuven, Belgium
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