Evaluating the Efficacy of Two Regional Pain Management Modalities in Autologous Breast Reconstruction

Abstract

Background: At our institution, multimodal opiate-sparing pain management is the cornerstone of our enhanced recovery program for autologous breast reconstruction. The purpose of this study was to compare postoperative outcomes and pain control metrics following implementation of an enhanced recovery program with two different regional analgesia approaches. Methods: This retrospective cohort study identified 145 women who underwent autologous breast reconstruction from 2015 to 2017. Three groups were included: historical control patients (n = 46) and enhanced recovery patients that received multimodal pain management including a postoperative transversalis abdominis plane block with either a continuous local anesthetic catheter (n = 60) or a single-shot of liposomal bupivacaine (n = 39). The primary outcome was pain scores in the first three postoperative days. Secondary outcomes were opioid consumption in oral morphine equivalents and length of stay. Results: Postoperative pain scores were similar across all three groups until postoperative day 3. Length of stay was significantly shorter in both of the enhanced recovery cohorts (3.0 [3.0, 4.0]) compared with control patients (4.0 [4.0, 5.0], P < 0.001). Likewise, average total oral morphine equivalents consumption was significantly reduced in enhanced recovery patients (continuous catheter 215.9 (95% CI, 165.4–266.3); liposomal bupivacaine 211.0 (95% CI, 154.8–267.2); control 518.4 (95% CI 454.2–582.7), P < 0.001). Neither length of stay ( P = 0.953), nor oral morphine equivalents consumption ( P = 0.883) differed by type of regional analgesia. Conclusion: Compared with control patients, both approaches to regional transversalis abdominis plane block analgesia as part of an opiate-sparing enhanced recovery pain management strategy were successful, but neither superior to the other.

Liposomal Bupivacaine Analgesia in Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Retrospective Cohort Study

“…27 Some, but not all, previous studies reported significantly shorter length of stay for patients receiving liposomal bupivacaine via a TAP block for DIEP flap reconstruction specifically. 15,16,[21][22][23] Other studies assessing costs with liposomal bupivacaine via TAP block versus comparators in DIEP flap reconstruction have not observed substantial cost differences between groups. 21,22 Although previous breast reconstruction studies reported reduction in inpatient opioid consumption with liposomal bupivacaine, some showed no evidence of significant reduction, and how liposomal bupivacaine affected other outcomes (including postdischarge outcomes) after DIEP flap procedures is less clear.…”

“…20 In this systematic review, liposomal bupivacaine, a formulation of the local anesthetic bupivacaine enabling controlled release of bupivacaine for prolonged analgesia, was highlighted for pain management after breast reconstruction. 20 Previous studies investigated liposomal bupivacaine administered as a TAP block (including as part of an ERP protocol) for DIEP flap breast reconstruction, [15][16][17][21][22][23] with some showing reduced opioid consumption versus historical controls. 15,23 Prior studies of DIEP flap procedures found that liposomal bupivacaine was associated with lower opioid use compared with bupivacaine administered via TAP blocks.…”

“…Enhanced recovery pathways (ERPs; eg, enhanced recovery after surgery protocols) are associated with lower postoperative pain, shorter length of stay, and fewer opioid-related adverse effects. [13][14][15][16] Regional pain blocks [eg, transversus abdominis plane (TAP) blocks, paravertebral blocks, erector spinae plane blocks] may be included in ERP protocols for breast reconstruction as a component of multimodal management. [17][18][19] In a systematic review of 28 studies examining pain management for breast reconstruction, opioid consumption was reduced in all seven studies that included ERP protocols and in eight of nine studies that included TAP or paravertebral blocks.…”

“…27 Some, but not all, previous studies reported significantly shorter length of stay for patients receiving liposomal bupivacaine via a TAP block for DIEP flap reconstruction specifically. 15,16,21–23 Other studies assessing costs with liposomal bupivacaine via TAP block versus comparators in DIEP flap reconstruction have not observed substantial cost differences between groups. 21,22…”