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Randomized Controlled Trial
. 2024 Oct 1;154(4S):52S-59S.
doi: 10.1097/PRS.0000000000011326. Epub 2024 Sep 20.

Effectiveness of Liposomal Bupivacaine Transversus Abdominis Plane Block in DIEP Flap Breast Reconstruction: A Randomized Controlled Trial

Rachel H Park  1 , Jesse Chou  1 , Robert G DeVito  1 , Aric Elmer  2 , Scott T Hollenbeck  1 , Chris A Campbell  1 , John T Stranix  1
Affiliations
Randomized Controlled Trial

Effectiveness of Liposomal Bupivacaine Transversus Abdominis Plane Block in DIEP Flap Breast Reconstruction: A Randomized Controlled Trial

Rachel H Park et al. Plast Reconstr Surg. .

Abstract

Background: Transversus abdominis plane (TAP) blocks improve pain control and reduce narcotic medication requirements in various surgical procedures. Liposomal bupivacaine may provide more sustained analgesia. This study compared pain-related outcomes between standard bupivacaine and liposomal bupivacaine TAP blocks after autologous breast reconstruction.

Methods: The authors conducted a single-center, single-blinded randomized controlled trial between March of 2021 and December of 2022. Patients undergoing deep inferior epigastric perforator flap breast reconstruction in a standardized enhanced recovery after surgery pathway were randomized to receive intraoperative TAP blocks with either bupivacaine and epinephrine (control group) or liposomal bupivacaine, bupivacaine, and epinephrine (experimental group). Primary outcome was postoperative narcotic medication requirements, with secondary outcomes of pain scores, length of stay, and narcotic medication refills.

Results: A total of 117 patients met inclusion criteria (59 control patients and 58 experimental patients). Demographic characteristics, comorbidities, breast pathologic variables, surgery laterality, and immediate versus delayed reconstruction status were equivalent between groups. The control group had significantly higher average pain scores postoperatively (4.3 versus 3.6; P = 0.004). However, there were no significant differences in mean narcotic use (66.9 morphine milligram equivalents versus 60.2 morphine milligram equivalents; P = 0.47). Both length of stay and postoperative narcotic prescription refills were equivalent between groups (2.1 days versus 2.2 days, P = 0.55; 22% versus 17.2%, P = 0.52).

Conclusions: The addition of liposomal bupivacaine to the standard bupivacaine TAP block mixture in a standardized enhanced recovery after surgery protocol did not demonstrate a significant reduction in postoperative narcotic requirements after deep inferior epigastric perforator flap breast reconstruction compared with standard bupivacaine alone. Patient-reported pain scores, however, were lower among liposomal bupivacaine patients after the initial 24 hours postoperatively and consistent with a longer duration of analgesia.

Clinical question/level of evidence: Therapeutic, II.

Trial registration: ClinicalTrials.gov NCT04777591.

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References

    1. Tsai HC, Yoshida T, Chuang TY, et al. Transversus abdominis plane block: an updated review of anatomy and techniques. Biomed Res Int. 2017;2017:8284363.
    1. Hu D, Onel E, Singla N, Kramer WG, Hadzic A. Pharmacokinetic profile of liposome bupivacaine injection following a single administration at the surgical site. Clin Drug Investig. 2013;33:109–115.
    1. Malik O, Kaye AD, Kaye A, Belani K, Urman RD. Emerging roles of liposomal bupivacaine in anesthesia practice. J Anaesthesiol Clin Pharmacol. 2017;33:151–156.
    1. Gatherwright J, Knackstedt RW, Ghaznavi AM, et al. Prospective, randomized, controlled comparison of bupivacaine versus liposomal bupivacaine for pain management after unilateral delayed deep inferior epigastric perforator free flap reconstruction. Plast Reconstr Surg. 2018;141:1327–1330.
    1. Cohen SM. Extended pain relief trial utilizing infiltration of Exparel, a long-acting multivesicular liposome formulation of bupivacaine: a phase IV health economic trial in adult patients undergoing open colectomy. J Pain Res. 2012;5:567–572.

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