Comparative Study of Liposomal Bupivacaine Versus Paravertebral Block for Pain Control Following Mastectomy with Immediate Tissue Expander Reconstruction.

BACKGROUND: Several approaches to minimize postoperative pain, nausea, and enhance recovery are available for patients undergoing mastectomy with immediate tissue expander (TE) reconstruction. We compared the effectiveness of intraoperative local infiltration of liposomal bupivacaine (LB) to preoperative paravertebral block (PVB). METHODS: We retrospectively reviewed patients who underwent mastectomy with immediate TE reconstruction between May 2012 and October 2014 and compared patients with preoperative ultrasound-guided PVB to those with intraoperative LB infiltration. RESULTS: Fifty-three patients (54.6 %) received LB and 44 received PVB. LB was associated with less opioid use in the recovery room (p < 0.001), fewer patients requiring antiemetics (p = 0.03), and lower day of surgery pain scores (p = 0.008). LB also was associated with longer time to first opioid use (p = 0.04). On multivariable analysis controlling for expander placement location, year of surgery, and axillary lymph node dissection (ALND), the only variable that remained statistically significant was lower opioid use in the recovery room for patients with LB (p = 0.03) and day of surgery pain scores approached significance (p = 0.05). There was no difference in the proportion of patients discharged within 36 h of surgery between the groups. Focusing on first cases of the day (where PVBs are performed in the OR) showed average time to skin incision was 15 min shorter in the LB group (p = 0.004). CONCLUSIONS: Local infiltration of LB in patients undergoing mastectomy with immediate TE reconstruction decreases narcotic requirements in the recovery room, shortens preoperative anesthesiology time, and provides similar, if not better, perioperative pain control compared with PVB.

Assessment of prophylactic antibiotic use in patients with surgical site infections.

BACKGROUND: Surgical site infections (SSIs) are the leading cause of hospital-acquired infections and are associated with substantial health care costs, with increased morbidity and death. The Surgical Care Improvement Project (SCIP) contains standards that are nationally reported with the aim of improving patient outcomes after surgery. Our institution's standards for antimicrobial prophylaxis in the perioperative period are more stringent than these measures and may be considered "beyond SCIP." The 4 elements of appropriate antimicrobial prophylaxis are timing, antibiotic selection, dosing, and intraoperative redosing. OBJECTIVE: To quantify antimicrobial SSI prophylaxis compliance in accordance with institutional standards and to identify potential opportunities for improvement. METHODS: Patients aged 18 years or older were included if they had an SSI between January 1, 2009, and June 30, 2010, according to the database maintained prospectively by the Infection Prevention and Control Unit. Adherence to our institution's practice standards was assessed through analysis of antibiotics administered-timing in relation to the incision, closure, and tourniquet inflation times for the procedure and antibiotic selection, dose, and redosing. RESULTS: Overall noncompliance with all 4 elements of antimicrobial prophylaxis was 75.4% among the 760 cases. Repeat dosing had the greatest noncompliance (45.1%); antibiotic selection had the lowest incidence of noncompliance (10.8%). CONCLUSIONS: Noncompliance existed in each element of antimicrobial SSI prophylaxis, with antibiotic redosing leading in noncompliance. With the implementation of tools to assist the surgical team in following institutional standards, noncompliance will likely decline and additional research opportunities will exist.

Modified aesthetic abdominoplasty approach in perforator free-flap breast reconstruction: Impact of drain free donor site on patient outcomes.

BACKGROUND: The use of progressive tension sutures alone has been shown to be comparable to using abdominal drains in aesthetic abdominoplasty. This study reviews outcomes with the use of barbed progressive tension suture technique without drains in DIEP donor site closure compared to standard closure with drains. METHODS: A two year retrospective review was conducted of DIEP flap reconstructions in the enhanced recovery program at Mayo Clinic, Rochester (USA). Donor site closure was divided into barbed progressive tension sutures (B-PTS) without drains, and standard abdominal closure with drains(S-AD). Demographics, perioperative data and donor site complications were documented. RESULTS: 93 patients were included in the study, 42 in the B-PTS no drain group and 51 in the S-AD with drains. 81% of all procedures were bilateral and 39% were immediate. Patients were discharged faster to the ward postoperatively and total hospital admission was reduced in the B-PTS group, 3.7 (SD = 1.4) days versus 4.7 (SD = 2.1) days in the standard group (P = 0 < 0.001 and 0.004 respectively). Less morphine was required postoperative day (POD) 1, 2 and 3 (P = 0.04, 0.03, 0.02 respectively), and time to mobilize was quicker but not statistically significant (P = 0.09) in the B-PTS group. Overall there were 18 patients in the S-AD group who had complications versus 9 in the B-PTS group (P = 0.14). The incidence of complications occurring within 30 days were lower in the B-PTS group (P = 0.05). The overall seroma rate was 5.4% and rates in the B-PTS group was 2.4% versus 7.8% in the S-AD group, P = 0.37. CONCLUSIONS: Use of barbed progressive tension sutures for abdominal closure after DIEP flap harvest can obviate the need for abdominal drains, reduce postoperative pain and encourage early discharge from the hospital without an increased risk in complications. LEVEL OF EVIDENCE: III.

Enhanced recovery after surgery in microvascular breast reconstruction.

BACKGROUND: Enhanced recovery after surgery (ERAS) pathways have been shown in multiple surgical specialties to decrease hospital length of stay (LOS) after surgery, but they have not been described for patients undergoing microvascular breast reconstruction. STUDY DESIGN: A standardized ERAS pathway was developed through multidisciplinary collaboration which addressed all phases of surgical care for patients undergoing free-flap breast reconstruction using an abdominal donor site. Two surgeons used the ERAS pathway, and results were compared with a historical cohort of the same 2 surgeons' patients treated by traditional care after surgery (TRAS). All patients underwent surgery between September 2010 and September 2013. The primary outcome measure was hospital LOS. RESULTS: A total of 100 patients were analyzed: 49 in the ERAS cohort, and 51 in the TRAS cohort, with a total of 181 flaps. Mean hospital LOS was shorter with ERAS than TRAS (3.9 vs 5.5 days; P<0.001). Total inpatient postoperative opioid usage for the first 3 days, in oral morphine equivalents, was less for ERAS than TRAS (167.3 vs 574.3 mg; P<0.001), a decrease of 71%, with similar pain scores for the 2 groups. Overall 30-day major complication rates were not significantly different between the groups (P=0.21). CONCLUSIONS: The initiation of an ERAS pathway significantly decreased hospital LOS in our study. The pathway also significantly decreased the amount of opioids used postoperatively by 71%, without a consequent increase in patient-reported pain.