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CC BY 4.0 · Arch Plast Surg 2024; 51(02): 156-162
DOI: 10.1055/s-0043-1777673
Breast/Trunk
Original Article

Comparison of Pain Management Strategies to Reduce Opioid Use Postoperatively in Free Flap Breast Reconstruction: Pain Catheter versus Nerve Block in Addition to Refinements in the Oral Pain Management Regime

Andrea B. Stefansdottir 
1   Department of Plastic and Reconstructive Surgery, Uppsala University Hospital, Uppsala, Sweden
2   Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
,
Luis Vieira 
1   Department of Plastic and Reconstructive Surgery, Uppsala University Hospital, Uppsala, Sweden
2   Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
3   Department of Plastic Surgery, Central University Hospital Center, Lisbon, Portugal
,
Arni Johnsen 
4   Department of Otorhinolaryngology, Landspitali, National University Hospital of Iceland, Reykjavik, Iceland
,
Daniel Isacson 
1   Department of Plastic and Reconstructive Surgery, Uppsala University Hospital, Uppsala, Sweden
2   Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
,
Andres Rodriguez 
1   Department of Plastic and Reconstructive Surgery, Uppsala University Hospital, Uppsala, Sweden
2   Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
,
Maria Mani 
1   Department of Plastic and Reconstructive Surgery, Uppsala University Hospital, Uppsala, Sweden
2   Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
› Author Affiliations Funding None.
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Abstract

Background Perioperative management in autologous breast reconstruction has gained focus in recent years. This study compares two pain management protocols in patients undergoing abdominal-based free flap breast reconstruction: a past protocol (PP) and a current protocol (CP)—both intended to reduce opioid consumption postoperatively. The PP entails use of a pain catheter in the abdominal wound and the CP consists of an intraoperative nerve block in addition to refinements in the oral pain management. We hypothesize that the CP reduces opioid consumption compared to PP.

Methods From December 2017 to January 2020, 102 patients underwent breast reconstruction with an abdominal-based free flap. Two postoperative pain management strategies were used during the period; from December 2017 to September 2018, the PP was used which entailed the use of a pain catheter with ropivacaine applied in the abdominal wound with continuous distribution postoperatively in addition to paracetamol orally and oxycodone orally pro re nata (PRN). From October 2018 to January 2020, the CP was used. This protocol included a combination of intraoperative subfascial nerve block and a postoperative oral pain management regime that consisted of paracetamol, celecoxib, and gabapentin as well as oxycodone PRN.

Results The CP group (n = 63) had lower opioid consumption compared to the PP group (n = 39) when examining all aspects of opioid consumption, including daily opioid usage in morphine milligram equivalents and total opioid usage during the stay (p < 0.001). The CP group had shorter length of hospital stay (LOS).

Conclusion Introduction of the CP reduced opioid use and LOS was shorter.

Keywords

free flap breast reconstruction - pain management - DIEP

Authors' Contributions

A.B.S., L.V. and M.M. conceived the ideas. A.B.S. and L.V. collected the data. A.B.S. led the writing with support from L.V. A.J. led data analysis. A.B.S., L.V., D.I., A.J., A.R. and M.M. all contributed to reviewing/editing the manuscript and interpreting data.


Ethical Approval

The study was approved by the Regional Ethical Committee (Dnr 2014/354).




Publication History

Received: 24 May 2023

Accepted: 23 October 2023

Article published online:
29 February 2024

© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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  • References

  • 1 Lagares-Borrego A, Gacto-Sanchez P, Infante-Cossio P, Barrera-Pulido F, Sicilia-Castro D, Gomez-Cia T. A comparison of long-term cost and clinical outcomes between the two-stage sequence expander/prosthesis and autologous deep inferior epigastric flap methods for breast reconstruction in a public hospital. J Plast Reconstr Aesthet Surg 2016; 69 (02) 196-205
    CrossrefPubMedGoogle Scholar
  • 2 Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg 2002; 183 (06) 630-641
    CrossrefPubMedGoogle Scholar
  • 3 Tan M, Law LSC, Gan TJ. Optimizing pain management to facilitate Enhanced Recovery After Surgery pathways. Can J Anaesth 2015; 62 (02) 203-218
    CrossrefPubMedGoogle Scholar
  • 4 Bonnet F, Marret E. Influence of anaesthetic and analgesic techniques on outcome after surgery. Br J Anaesth 2005; 95 (01) 52-58
    CrossrefPubMedGoogle Scholar
  • 5 Wheble GAC, Tan EKH, Turner M, Durrant CAT, Heppell S. Surgeon-administered, intra-operative transversus abdominis plane block in autologous breast reconstruction: a UK hospital experience. J Plast Reconstr Aesthet Surg 2013; 66 (12) 1665-1670
    CrossrefPubMedGoogle Scholar
  • 6 Mickute Z, Di Candia M, Moses M, Bailey AR, Malata CM. Analgesia requirements in patients undergoing DIEP flap breast reconstructions: rib preservation versus rib sacrifice. J Plast Reconstr Aesthet Surg 2010; 63 (12) e837-e839
    CrossrefPubMedGoogle Scholar
  • 7 Park JW, Seong IH, Woo KJ. Factors influencing postoperative abdominal pain in DIEP flap breast reconstruction. Gland Surg 2021; 10 (07) 2211-2219
    CrossrefPubMedGoogle Scholar
  • 8 Batdorf NJ, Lemaine V, Lovely JK. et al. Enhanced recovery after surgery in microvascular breast reconstruction. J Plast Reconstr Aesthet Surg 2015; 68 (03) 395-402
    CrossrefPubMedGoogle Scholar
  • 9 Hivelin M, Wyniecki A, Plaud B, Marty J, Lantieri L. Ultrasound-guided bilateral transversus abdominis plane block for postoperative analgesia after breast reconstruction by DIEP flap. Plast Reconstr Surg 2011; 128 (01) 44-55
    CrossrefPubMedGoogle Scholar
  • 10 Sindali K, Harries V, Borges A. et al. Improved patient outcomes using the enhanced recovery pathway in breast microsurgical reconstruction: a UK experience. JPRAS Open 2018; 19: 24-34
    CrossrefPubMedGoogle Scholar
  • 11 Bonde C, Khorasani H, Eriksen K, Wolthers M, Kehlet H, Elberg J. Introducing the fast track surgery principles can reduce length of stay after autologous breast reconstruction using free flaps: a case control study. J Plast Surg Hand Surg 2015; 49 (06) 367-371
    CrossrefPubMedGoogle Scholar
  • 12 McCormack HM, Horne DJ, Sheather S. Clinical applications of visual analogue scales: a critical review. Psychol Med 1988; 18 (04) 1007-1019
    CrossrefPubMedGoogle Scholar
  • 13 World Health Organization; Information NC for B. Pike USNL of M 8600 R, MD B, Usa 20894. Pharmacological Profiles and Opioid Conversion Tables. Geneva: World Health Organization; 2018. Accessed April 12, 2021 at: https://www.ncbi.nlm.nih.gov/books/NBK537482/
    Google Scholar
  • 14 Hagau N, Longrois D. Anesthesia for free vascularized tissue transfer. Microsurgery 2009; 29 (02) 161-167
    CrossrefPubMedGoogle Scholar
  • 15 Macdonald DJ. Anaesthesia for microvascular surgery. A physiological approach. Br J Anaesth 1985; 57 (09) 904-912
    CrossrefPubMedGoogle Scholar
  • 16 Schaverien MV, Butler CE. Complications in DIEP flap breast reconstruction after mastectomy for breast cancer: a prospective cohort study comparing unilateral and bilateral reconstructions. Ann Surg Oncol 2017; 24 (06) 1451-1453
    CrossrefPubMedGoogle Scholar
  • 17 Fleet JL, Dixon SN, Kuwornu PJ. et al. Gabapentin dose and the 30-day risk of altered mental status in older adults: a retrospective population-based study. PLoS ONE 2018; 13 (03) e0193134
    CrossrefPubMedGoogle Scholar
  • 18 Hurley RW, Cohen SP, Williams KA, Rowlingson AJ, Wu CL. The analgesic effects of perioperative gabapentin on postoperative pain: a meta-analysis. Reg Anesth Pain Med 2006; 31 (03) 237-247
    PubMedGoogle Scholar
  • 19 Vasigh A, Jaafarpour M, Khajavikhan J, Khani A. The effect of gabapentin plus celecoxib on pain and associated complications after laminectomy. J Clin Diagn Res 2016; 10 (03) UC04-UC08
    PubMedGoogle Scholar
  • 20 Kulkarni AR, Pusic AL, Hamill JB. et al. Factors associated with acute postoperative pain following breast reconstruction. JPRAS Open 2017; 11: 1-13
    CrossrefPubMedGoogle Scholar
  • 21 Wade RG, Marongiu F, Sassoon EM, Haywood RM, Ali RS, Figus A. Contralateral breast symmetrisation in unilateral DIEP flap breast reconstruction. J Plast Reconstr Aesthet Surg 2016; 69 (10) 1363-1373
    CrossrefPubMedGoogle Scholar
  • 22 Parrett BM, Caterson SA, Tobias AM, Lee BT. The rib-sparing technique for internal mammary vessel exposure in microsurgical breast reconstruction. Ann Plast Surg 2008; 60 (03) 241-243
    CrossrefPubMedGoogle Scholar
  • 23 Darcy CM, Smit JM, Audolfsson T, Acosta R. Surgical technique: The intercostal space approach to the internal mammary vessels in 463 microvascular breast reconstructions. J Plast Reconstr Aesthet Surg 2011; 64 (01) 58-62
    CrossrefPubMedGoogle Scholar
  • 24 Larson DW, Batdorf NJ, Touzios JG. et al. A fast-track recovery protocol improves outcomes in elective laparoscopic colectomy for diverticulitis. J Am Coll Surg 2010; 211 (04) 485-489
    CrossrefPubMedGoogle Scholar
  • 25 Damen THC, Morritt AN, Zhong T, Ahmad J, Hofer SOP. Improving outcomes in microsurgical breast reconstruction: lessons learnt from 406 consecutive DIEP/TRAM flaps performed by a single surgeon. J Plast Reconstr Aesthet Surg 2013; 66 (08) 1032-1038
    CrossrefPubMedGoogle Scholar
  • 26 Chandran GJ, Lalonde DH. A review of pain pumps in plastic surgery. Can J Plast Surg 2010; 18 (01) 15-18
    CrossrefPubMedGoogle Scholar