Exparel in postoperative pain managment after reconstructive breast and abdominal surgery

Taking Great Pains: EXPAREL® helps improve postop pain after breast reconstruction

Published on September 23, 2014, Plastic Surgery Practice

By Charles K. Lee, MD, FACS

The past decade has brought major treatment advances in breast reconstruction surgery. Most notably, autologous flap procedures have vastly improved the patient experience. But despite significant strides on the surgical front, one constant that continues to diminish the quality of life of patients undergoing breast surgery is postsurgical pain. Inadequate pain control after surgery has been correlated with long-term chronic pain,1 which affects between 27% and 48% of patients following breast surgery.2,3

While pain management is integral to an optimal recovery for all surgery patients, given the tremendous psychological and physical disease burden breast cancer patients endure prior to undergoing reconstruction, the need for exceptional postsurgical analgesia is especially critical for this population.

The current standard of care for postsurgical pain management following breast reconstruction consists of a combination of continuous nerve blocks, catheters (anywhere between two and four, in addition to two drains), opioids, and NSAIDs. While effective, the standard regimen has its share of downsides ranging from opioid-related adverse events, which prolong recovery and increase cost of care, to catheter-related issues such as infections at insertion sites, pump errors, and delayed ambulation due to continuous tethering to pain pumps. Despite the well-recognized drawbacks and due to a lack of comparably effective, yet more tolerable alternatives, blocks and pumps have become a fixture in the postsurgical pain-management toolbox.

Enter EXPAREL

A lot changed in 2011 with the US Food and Drug Administration approval of a novel formulation of bupivacaine, called EXPAREL® (bupivacaine liposome injectable suspension). EXPAREL can provide up to 72 hours of local analgesia and reduced opioid requirements via infiltration at the surgical site. Unlike standard bupivacaine, which produces a 6- to 8-hour analgesic effect, the bupivacaine in EXPAREL is encased in liposomes which break down over time to extend the release of the active drug over a 3-day period.

I was initially skeptical about the promise of a non-narcotic local anesthetic that produced prolonged pain relief without catheters, pumps, or IVs, and significantly reduced opioid burden. However, after a few initial cases, it was clear that EXPAREL could greatly enhance the recovery experience of all my patients, especially those undergoing breast cancer surgery and reconstruction.

Evidence Builds

As part of a broader effort to gain formulary acceptance, I conducted a small study with 25 patients to demonstrate the clinical value of EXPAREL in comparison to previous cases using a standard pain regimen (bupivacaine HCl block supplemented by opioid-based rescue, administered via patient-controlled analgesia [PCA]). Patients treated with EXPAREL, half of whom underwent breast reconstruction while the other half underwent aesthetic procedures, reported an average pain score of 3 (using a NRS scale of 1 to 10), compared to 7 for patients who received the standard pain regimen. In addition, patients who received EXPAREL reported being “highly satisfied” with their pain relief.

While the measurable reduction in pain was a key driver of pharmacy acceptance, the cost savings and reduced infection risk associated with the elimination of catheter-based pain control modalities also helped move the needle. Since we added EXPAREL to our pharmacy, I have almost entirely eliminated the use of PCAs, and patients report being more comfortable, able to ambulate sooner, and highly satisfied with their quality of care.

During the past 2 years, I have used EXPAREL in more than 300 cases, including hand and leg surgery, breast surgery, and facelifts, and observed consistent results in terms of pain reduction, opioid reduction, and satisfaction. By controlling pain during the critical few days after surgery without requiring invasive ports, and eliminating high opioid requirements, EXPAREL allows reconstructive surgery patients to focus on the vitally important psychological and practical aspects of healing from a life-changing procedure. Based on my experience, EXPAREL promises to redefine our approach to intraoperative and postoperative pain control.

Tips and Techniques

As a surgeon, I considered myself experienced in local infiltration techniques. However, EXPAREL ® behaves differently from traditional anesthetics, including bupivacaine HCl, in a few important ways. For starters, the liposomal composition makes EXPAREL more viscous than standard bupivacaine, so once placed, EXPAREL remains local and does not disperse.

Unlike Marcaine, which can be liberally applied around the site and massaged into the targeted region, EXPAREL needs precise placement into soft tissues in the region of the sensory nerves, as well as the muscle and fascia, to produce the desired effect. A 20-mL vial of EXPAREL (266 mg) can be expanded with up to 280 mL of preservative-free normal sterile saline for a total volume of 300 mL.

In most of my cases, I will expand the volume to approximately 60 to 100 mL, depending on the surface area to cover. For a DIEP flap, I expand the volume of EXPAREL up to 200 mL and infiltrate the tissues and muscle around the breast and abdomen, as well as the fascial planes (versus the subcutaneous area), and in the region where sensory fibers may be.

References

1. Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. Lancet. 2006;367(9522):1618-1625.

2. Carpenter JS, Sloan P, Andrykowski MA, et al. Risk factors for pain after mastectomy/lumpectomy. Cancer Pract. 1999;7(2):66-70.

3. Poleshuck EL, Katz J, Andrus CH, et al. Risk factors for chronic pain following breast cancer surgery: a prospective study. J Pain. 2006;7(9):626-634.

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Infected Mesh is an Infected Implant -- It must be removed.

      Prosthetic mesh is often used in hernia repair surgery, with over 20 million such procedures done annually around the world.   Mesh is used to augment tissue repair in hernias to reduce tension at the suture line where the "weakness" is strengthened or plugged to hold back internal structures (such as intestine or omentum) that want to bulge through these areas.    The mesh can be made of various materials, such as Polypropelene, Gortex, and other plastic materials which allows the body to grow scar tissue around it.  The thing remember about prosthetic mesh, is that it is NOT alive or biologically active.  Your body recognizes it as a foreign substance, and because of that, there are inherent risks.
     For the most part, prosthetic mesh works and does its job; however, when it becomes a problem, it usually becomes a BIG problem.   The worst problem of all is when the mesh becomes infected.  In that situation, with rare exception, the mesh must be removed--completely.   It must be completely removed because any portion that remains may harbor bacteria which the body cannot clear away (even with the most powerful antibiotics), leading to a chronic wound, deeper infection, absesses, or systemic infection.
     The treatment of infected mesh requires a step-wise approach with the first step in removing the mesh and debriding (cleaning) the wound.  This step may be repeated multiple times until the area is clean. Once deemed clean, the area that the mesh covered will need to be reconstructed, preferably with your own tissue (flaps), or in combination with a Biologic mesh that can grow with your tissues and that your body ultimately recognizes as "self" tissue.   It will take at least 6 weeks from the time of the final reconstruction to fully heal, and depending on the complexity of the wound, infection, and anatomy of the infected mesh, several months in total.
      Far too often, I have seen patients who have lived with this problem for too long.  A small, chronic wound, may be a sign of a much bigger problem deep down below.  Appropriate evaluation, diagnosis, and management is critical, but just as importantly, it is important to first recognize and know that you may have mesh in your body.  If it is close to an area that is draining or infected, the mesh must be ruled out as a potential source of problem.   Afterward, it may be necessary to find a team of surgeons, including a general surgeon and plastic surgeon, to work together to solve this difficult problem.

Where can the lymph nodes be taken for a lymph node transplant for Lymphedema surgery?

There are several accessible areas around the body where lymph nodes may be harvested with its blood vessels to be transplanted in an arm or leg for lymphedema treatment.   This includes the groin area (the area near the hip bone (Groin Flap)), the subaxillary region (arm pit region(Subaxillary Flap), and the neck/collar bone area (Transverse Cervical Flap)).   Each area contains a lymph node basin which can be harvested with the flap tissue.  Careful dissection and evaluation of the area needs to be done prior to using the tissues from each specific area.

Be sure to have a thorough discussion with your surgeon regarding your "donor site" options for lymph nodes when considering lymph node transplant to treat lymphedema.