Transversus abdominus plane blocks do not reduce rates of postoperative prolonged opioid use following abdominally based autologous breast reconstruction: a nationwide longitudinal analysis

Abstract

Background The transversus abdominus plane (TAP) block reduces postoperative donor site pain in patients undergoing autologous breast reconstruction with an abdominally based flap. This study aimed to determine the effect of TAP blocks on rates of conversion to chronic opioid use. Methods The Clinformatics Data Mart was queried from 2003 to 2019, extracting adult encounters for abdominally based free and pedicled flaps based on common procedural terminology (CPT) codes. Patients were excluded if they had filled a narcotic prescription 1 year to 30 days prior to surgery. The exposure variable—TAP block—was identified by CPT codes. Outcomes were evaluated using morphine milligram equivalents (MME) from prescriptions filled between 30 days prior to and 30 days after surgery. Chronic opioid use (COU) was defined as receiving 4 unique prescriptions or a 60-day supply between 30 and 180 days after surgery. Results Of the 4091 patients, (mean age 51.2 ± 9.0 years), 181 (4.4%) had a TAP block placed. Perioperative MMEs/day, postoperative COU, and length of stay did not differ in patients who received a TAP block (p = 0.142; p = 0.271). Significant predictors of risk of conversion to COU included younger age, pedicled abdominal flap, Elixhauser comorbidity index score > 3, filling a psychiatric medication prescription, and filling a benzodiazepine prescription. Conclusions In patients undergoing autologous breast reconstruction with abdominally based flap reconstruction, TAP blocks do not decrease perioperative MME/day, conversion to chronic opioid use, or length of stay. These data suggest that intraoperative TAP block placement may be a low-yield opioid-reduction strategy. Level of evidence: Level III, risk/prognostic study

Outpatient Prescription Opioid Use following Discharge after Deep Inferior Epigastric Perforator Breast Reconstruction with and without an Educational Intervention

“…14 Efforts to curtail inappropriate opioid prescribing and patient opioid consumption include the ERAS, including use of a local anesthetic techniques, which have been shown to reduce narcotic use and improve patients' pain scores after breast reconstruction surgery. [15][16][17][18][19] Additionally, a recent study suggests that postoperative magnesium repletion in abdominal based free-flap reconstruction led to a significant decrease in postoperative narcotic consumption, suggesting a multimodal approach in addition to patient education may help reduce opioid consumption. 20 Historical data from our institution suggest that prior to capping initial postdischarge opioid prescriptions at 20-30 oxycodone 5 mg equivalents, patients consumed more opioids on average than those who were prescribed fewer tablets.…”

An Interdisciplinary, Comprehensive Recovery Pathway Improves Microsurgical Breast Reconstruction Delivery

“…[8][9][10] Further, surgeons and patients may anticipate a more challenging recovery with longer hospital courses, outpatient rehabilitation, and prolonged opioid use. [11][12][13] Management of pain and prolonged flap monitoring protocols lead to multiday inpatient stays. Meanwhile, discharge of IBR patients before day 3 is commonplace.…”

“…In comparison to implant-based reconstruction (IBR), free flap–based breast reconstructions (FFR) are technically challenging and often require longer operations, experienced staff, and surgeon familiarity 8–10 . Further, surgeons and patients may anticipate a more challenging recovery with longer hospital courses, outpatient rehabilitation, and prolonged opioid use 11–13 . Management of pain and prolonged flap monitoring protocols lead to multiday inpatient stays.…”