Postoperative pain scores and opioid use after standard bupivacaine vs. liposomal bupivacaine regional blocks for abdominal cancer surgery: A propensity score matched study.

BACKGROUND: Fascial plane blocks (FPBs) are widely used for abdominal surgery with the assumption that liposomal bupivacaine (LB) is more effective than standard bupivacaine (SB). METHODS: This was a single-institution retrospective cohort study of patients administered FPBs with LB or SB â€‹+ â€‹admixtures (dexamethasone/dexmedetomidine) for open abdominal cancer surgery. Propensity score matching generated a 2:1 (LB:SB) matched cohort. Opioid use (mg oral morphine equivalents, OME) and severe pain (≥3 pain scores ≥7 in a 24-h period) were compared. RESULTS: Opioid use was >150 â€‹mg OME in 19.9 â€‹% (29/146) LB and 16.4 â€‹% (12/73) SB patients (p â€‹= â€‹0.586). Severe pain was experienced by 44 â€‹% (64/146) LB and 53 â€‹% (39/73) SB patients (p â€‹= â€‹0.198). On multivariable analysis, SB vs LB choice was not associated with high opioid volume >150 â€‹mg or severe pain. CONCLUSIONS: FPBs with standard bupivacaine were not associated with higher 72-h opioid use or more severe pain compared to liposomal bupivacaine.

Perioperative blood transfusions and survival in resected pancreatic adenocarcinoma patients given multimodality therapy.

BACKGROUND AND OBJECTIVES: The impact of perioperative blood transfusion (PBT) on outcomes for pancreatic ductal adenocarcinoma (PDAC) patients given multimodality therapy (MMT) remains undefined. We sought to evaluate the association of PBT with survival after PDAC resection. METHODS: Pancreatectomy patients (July 2011-December 2017) who received MMT were abstracted from a prospective database. Overall survival (OS) was compared by PBT within 30 days, 24 h (24HR-BT), or 24 h until 30 days (Postop-BT). RESULTS: Most (76.6%) of 312 MMT patients underwent neoadjuvant therapy (NT). Eighty-nine patients (28.5%) received PBT; 58 (18.6%) 24HR-BT, and 31 (9.9%) Postop-BT. Compared with surgery-first, NT patients received more 24HR-BTs (22.2% vs. 6.8%, p = 0.003) and PBTs overall (32.6% vs. 15.1%, p = 0.004). Overall median OS was 45 months. The association of PBT with shorter median OS appeared limited to first 24-h transfusions (34 months 24HR-BT vs. 48 months Postop-BT vs. 53 months no-PBT, p = 0.009) and was dose-dependent, with a median OS of 52 months for 0 units 24HR-BT, 35 months for 1 unit, and 25 months for ≥2 units (p = 0.004). Independent predictors of OS included node-positivity (hazard ratio [HR]: 1.93, p < 0.001), perineural invasion (HR: 1.64, p = 0.050), postoperative pancreatic fistula (HR: 1.94, p = 0.018), and 24HR-BT (HR: 1.75, p = 0.001). CONCLUSIONS: Transfusions given within 24 h are associated with dose-dependent decreases in survival after pancreatectomy for PDAC.

Impact of Intraoperative Dexamethasone on Surgical and Oncologic Outcomes for Patients with Resected Pancreatic Ductal Adenocarcinoma.

BACKGROUND: Administration of dexamethasone to mitigate postoperative nausea and vomiting has been suggested to improve short- and long-term outcomes after pancreatic ductal adenocarcinoma (PDAC) resection. This study aimed primarily to evaluate these hypotheses in a contemporary patient cohort treated with multimodality therapy. METHODS: The clinicopathologic and perioperative characteristics of consecutive resected PDAC patients (July 2011 to October 2018) were analyzed from a prospectively maintained database. Intraoperative administration of dexamethasone (4-10 mg) was retrospectively abstracted from the electronic medical record. RESULTS: The majority of 373 patients (59.8%) received intraoperative dexamethasone. Most of these patients underwent neoadjuvant therapy (75.3%), were potentially resectable at presentation (69.7%), and underwent pancreaticoduodenectomy (79.9%). Women were more likely to receive dexamethasone than men (69.9 vs 30.1%; p < 0.001). The cohorts were otherwise clinically similar. Intraoperative dexamethasone was not associated with differences in postoperative major complications (PMCs) (21.1 vs 19.3%; p = 0.68), postoperative pancreatic fistulas (6.3 vs 6.7%; p = 0.88), or composite infectious complications (28.7 vs 24.7%; p = 0.39). Dexamethasone was not associated with any improvement in median recurrence-free survival (RFS) (17 vs 17 months; p = 0.99) or overall survival (OS) (46 vs 43 months; p = 0.90). After adjustment for clinical factors including margin status, clinical classification, tumor size, and dexamethasone, the only factors independently associated with OS were pathologic node-positivity (hazard ratio [HR], 1.80, 95% confidence interval [CI], 1.32-2.47), perineural invasion (HR, 2.02; 95% CI, 1.23-3.31), multimodality therapy (HR, 0.30; 95% CI, 0.13-0.70), and PMCs (HR, 1.64; 95% CI, 1.17-2.29) (all p < 0.006). CONCLUSIONS: Dexamethasone failed to demonstrate any protective advantage in terms of mitigating short-term PMCs or infectious complications, or to confer any long-term survival benefit. Tumor biology, multimodality therapy, and PMCs remain the main prognostic factors after PDAC resection.

Inpatient Opioid Use After Pancreatectomy: Opportunities for Reducing Initial Opioid Exposure in Cancer Surgery Patients.

BACKGROUND: Despite advances in enhanced surgical recovery programs, strategies limiting postoperative inpatient opioid exposure have not been optimized for pancreatic surgery. The primary aims of this study were to analyze the magnitude and variations in post-pancreatectomy opioid administration and to characterize predictors of low and high inpatient use. METHODS: Clinical characteristics and inpatient oral morphine equivalents (OMEs) were downloaded from electronic records for consecutive pancreatectomy patients at a high-volume institution between March 2016 and August 2017. Regression analyses identified predictors of total OMEs as well as highest and lowest quartiles. RESULTS: Pancreatectomy was performed for 158 patients (73% pancreaticoduodenectomy). Transversus abdominus plane (TAP) block was performed for 80% (n = 127) of these patients, almost always paired with intravenous patient-controlled analgesia (IV-PCA), whereas 15% received epidural alone. All the patients received scheduled non-opioid analgesics (median, 2). The median total OME administered was 423 mg (range 0-4362 mg). Higher total OME was associated with preoperative opioid prescriptions (p < 0.001), longer hospital length of stay (LOS; p < 0.001), and no epidural (p = 0.006). The lowest and best quartile cutoff was 180 mg of OME or less, whereas the highest and worst quartile cutoff began at 892.5 mg. After adjustment for inpatient team, only epidural use [odds ratio (OR) 0.3; p = 0.04] predicted lowest-quartile OME. Preoperative opioid prescriptions (OR 8.1; p < 0.001), longer operative time (OR 3.4; p = 0.05), and longer LOS (OR 1.1; p = 0.007) predicted highest-quartile OME. CONCLUSIONS: Preoperative opioid prescriptions and longer LOS were associated with increased inpatient OME, whereas epidural use reduced inpatient OME. Understanding the predictors of inpatient opioid use and the variables predicting the lowest and highest quartiles can inform decision-making regarding preoperative counseling, regional anesthetic block choice, and novel inpatient opioid weaning strategies to reduce initial postoperative opioid exposure.

Subcostal Transverse Abdominis Plane Block for Acute Pain Management: A Review.

The subcostal transverse abdominis plane (SCTAP) block is the deposition of local anesthetic in the transverse abdominis plane inferior and parallel to the costal margin. There is a growing consensus that the SCTAP block provides better analgesia for upper abdominal incisions than the traditional transverse abdominis plane block. In addition, when used as part of a four-quadrant transverse abdominis plane block, the SCTAP block may provide adequate analgesia for major abdominal surgery. The purpose of this review is to discuss the SCTAP block, including its indications, technique, local anesthetic solutions, and outcomes.