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Pain management after laparoscopic appendectomy: Comparative effectiveness of innovative pre-emptive analgesia using liposomal bupivacaine

Published:September 23, 2021DOI:https://doi.org/10.1016/j.amjsurg.2021.09.019

      Highlights

      • Restricting post-operative opioid analgesia may lower the risk of opioid abuse.
      • Liposomal Bupivacaine (LB) may sustain pain control better than common local anesthetics.
      • Intraoperative LB use may reduce opioid consumption but maintain pain control.
      • This retrospective cohort study compared three LB regimens to a non-LB cohort.
      • LB cohorts had lower opioid use after laparoscopic appendectomy without increased pain.

      Abstract

      Background

      Laparoscopic appendectomy is standard of care for appendicitis in the US. Pain control that limits opioids is an important area of research given the opioid epidemic. This study examined post-appendectomy inpatient opioid use and pain scores following intraoperative use of liposomal bupivacaine (LB) versus non-liposomal bupivacaine.

      Methods

      This was a retrospective cohort study of 155 adults who underwent laparoscopic appendectomy for acute appendicitis. Patients were divided into four cohorts based on the analgesia administered: (i) bupivacaine hydrochloride (BH)± epinephrine; (ii) undiluted LB; (iii) LB diluted with normal saline; and (iv) LB diluted with BH.

      Results

      Baseline demographic/clinical attributes, intra-operative findings, and post-operative pain scores were equivalent across cohorts. Post-operative pre-discharge opioid use was higher in the BH vs. LB cohorts (mean 60.4 vs. 46.0, 35.5, and 30.4 morphine milligram equivalents, respectively; p < 0.001).

      Conclusions

      Pre-emptive analgesia with LB during laparoscopic appendectomy can reduce inpatient opioid use without significantly increasing post-operative pain scores.

      Keywords

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      References

        • McDermott K.W.
        • Freeman W.J.
        • Elixhauser A.
        Overview of Operating Room Procedures during Inpatient Stays in U.S. Hospitals, 2014.
        Agency for Healthcare Research and Quality: Center for Delivery, Organization, and Markets, Rockville, MD2017
        • Bennett J.
        • Boddy A.
        • Rhodes M.
        Choice of approach for appendicectomy: a meta-analysis of open versus laparoscopic appendicectomy.
        Surg Laparosc Endosc Percutaneous Tech. 2007; 17: 245-255https://doi.org/10.1097/SLE.0b013e318058a117
        • Sauerland S.
        • Jaschinski T.
        • Neugebauer E.A.
        Laparoscopic versus open surgery for suspected appendicitis.
        Cochrane Database Syst Rev. 2010; Cd001546https://doi.org/10.1002/14651858.CD001546.pub3
        • Wei B.
        • Qi C.L.
        • Chen T.F.
        • et al.
        Laparoscopic versus open appendectomy for acute appendicitis: a metaanalysis.
        Surg Endosc. 2011; 25: 1199-1208https://doi.org/10.1007/s00464-010-1344-z
        • Jaschinski T.
        • Mosch C.G.
        • Eikermann M.
        • Neugebauer E.A.
        • Sauerland S.
        Laparoscopic versus open surgery for suspected appendicitis.
        Cochrane Database Syst Rev. 2018; 11Cd001546https://doi.org/10.1002/14651858.CD001546.pub4
        • Tan-Tam C.
        • Yorke E.
        • Wasdell M.
        • Barcan C.
        • Konkin D.
        • Blair P.
        The benefits of laparoscopic appendectomies in obese patients.
        Am J Surg. 2012; 203: 609-612https://doi.org/10.1016/j.amjsurg.2012.01.007
        • Woodham B.L.
        • Cox M.R.
        • Eslick G.D.
        Evidence to support the use of laparoscopic over open appendicectomy for obese individuals: a meta-analysis.
        Surg Endosc. 2012; 26: 2566-2570https://doi.org/10.1007/s00464-012-2233-4
        • Wang D.
        • Dong T.
        • Shao Y.
        • Gu T.
        • Xu Y.
        • Jiang Y.
        Laparoscopy versus open appendectomy for elderly patients, a meta-analysis and systematic review.
        BMC Surg. 2019; 19https://doi.org/10.1186/s12893-019-0515-7
        • Ekstein P.
        • Szold A.
        • Sagie B.
        • Werbin N.
        • Klausner J.M.
        • Weinbroum A.A.
        Laparoscopic surgery may Be associated with severe pain and high analgesia requirements in the immediate post-operative period.
        Ann Surg. 2006; 243: 41-46https://doi.org/10.1097/01.sla.0000193806.81428.6f
        • Tomecka M.J.
        • Bortsov A.V.
        • Miller N.R.
        • et al.
        Substantial post-operative pain is common among children undergoing laparoscopic appendectomy.
        Paediatr Anaesth. 2012; 22: 130-135https://doi.org/10.1111/j.1460-9592.2011.03711.x
        • Chau D.L.
        • Walker V.
        • Pai L.
        • Cho L.M.
        Opiates and elderly: use and side effects.
        Clin Interv Aging. 2008; 3: 273-278https://doi.org/10.2147/cia.s1847
        • Calcaterra S.L.
        • Yamashita T.E.
        • Min S.J.
        • Keniston A.
        • Frank J.W.
        • Binswanger I.A.
        Opioid prescribing at hospital discharge contributes to chronic opioid use.
        J Gen Intern Med. 2016; 31: 478-485https://doi.org/10.1007/s11606-015-3539-4
        • Wilson N.
        • Kariisa M.
        • Seth P.
        • Smith I.V.H.
        • Davis N.L.
        Drug and opioid-involved overdose deaths — United States, 2017–2018.
        MMWR Morbidity and Mortality Weekly Report. 2020; 69: 290-297
        • Jiang X.
        • Orton M.
        • Feng R.
        • et al.
        Chronic opioid usage in surgical patients in a large academic center.
        Ann Surg. 2017; 265: 722-727https://doi.org/10.1097/sla.0000000000001780
        • Wright J.E.
        Controlled trial of wound infiltration with bupivacaine for post-operative pain relief after appendicectomy in children.
        Br J Surg. 1993; 80: 110-111https://doi.org/10.1002/bjs.1800800136
        • Cervini P.
        • Smith L.C.
        • Urbach D.R.
        The effect of intraoperative bupivacaine administration on parenteral narcotic use after laparoscopic appendectomy.
        Surg Endosc. 2002; 16: 1579-1582https://doi.org/10.1007/s00464-002-8803-0
        • Ko C.Y.
        • Thompson Jr., J.E.
        • Alcantara A.
        • Hiyama D.
        Preemptive analgesia in patients undergoing appendectomy.
        Arch Surg. 1997; 132 (discussion 877-878): 874-877https://doi.org/10.1001/archsurg.1997.01430320076012
        • Chahar P.
        • Cummings 3rd, K.C.
        Liposomal bupivacaine: a review of a new bupivacaine formulation.
        J Pain Res. 2012; 5: 257-264https://doi.org/10.2147/jpr.S27894
        • Prabhakar A.
        • Ward C.T.
        • Watson M.
        • et al.
        Liposomal bupivacaine and novel local anesthetic formulations.
        Best Pract Res Clin Anaesthesiol. 2019; 33: 425-432https://doi.org/10.1016/j.bpa.2019.07.012
        • Butz D.R.
        • Shenaq D.S.
        • Rundell V.L.
        • et al.
        Post-operative pain and length of stay lowered by use of Exparel in immediate, implant-based breast reconstruction.
        Plastic and Reconstrive Surgery Global Open. 2015; 3e391https://doi.org/10.1097/gox.0000000000000355
        • Cohen S.M.
        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: 567-572https://doi.org/10.2147/JPR.S38621
        • Gorfine S.R.
        • Onel E.
        • Patou G.
        • Krivokapic Z.V.
        Bupivacaine extended-release liposome injection for prolonged postsurgical analgesia in patients undergoing hemorrhoidectomy: a multicenter, randomized, double-blind, placebo-controlled trial.
        Dis Colon Rectum. 2011; 54: 1552-1559https://doi.org/10.1097/DCR.0b013e318232d4c1
        • Dasta J.
        • Ramamoorthy S.
        • Patou G.
        • Sinatra R.
        Bupivacaine liposome injectable suspension compared with bupivacaine HCl for the reduction of opioid burden in the postsurgical setting.
        Curr Med Res Opin. 2012; 28: 1609-1615https://doi.org/10.1185/03007995.2012.721760
        • Hutchins J.
        • Argenta P.
        • Berg A.
        • Habeck J.
        • Kaizer A.
        • Geller M.A.
        Ultrasound-guided subcostal transversus abdominis plane block with liposomal bupivacaine compared to bupivacaine infiltration for patients undergoing robotic-assisted and laparoscopic hysterectomy: a prospective randomized study.
        J Pain Res. 2019; 12: 2087-2094https://doi.org/10.2147/jpr.S193872
        • Ma P.
        • Lloyd A.
        • McGrath M.
        • et al.
        Reduction of opioid use after implementation of enhanced recovery after bariatric surgery (ERABS).
        Surg Endosc. 2020; 34: 2184-2190https://doi.org/10.1007/s00464-019-07006-3
        • Tominaga G.T.
        • Staudenmayer K.L.
        • Shafi S.
        • et al.
        The American association for the surgery of trauma grading scale for 16 emergency general surgery conditions: disease-specific criteria characterizing anatomic severity grading.
        Journal of Trauma and Acute Care Surgery. 2016; 81: 593-602https://doi.org/10.1097/ta.0000000000001127
        • Hernandez M.C.
        • Aho J.M.
        • Habermann E.B.
        • Choudhry A.J.
        • Morris D.S.
        • Zielinski M.D.
        Increased anatomic severity predicts outcomes: validation of the American association for the surgery of trauma's emergency general surgery score in appendicitis.
        Journal of Trauma and Acute Care Surgery. 2017; 82: 73-79https://doi.org/10.1097/ta.0000000000001274
        • Finnesgard E.J.
        • Hernandez M.C.
        • Aho J.M.
        • Zielinski M.D.
        The American association for the surgery of trauma emergency general surgery anatomic severity scoring system as a predictor of cost in appendicitis.
        Surg Endosc. 2018; 32: 4798-4804https://doi.org/10.1007/s00464-018-6230-0
        • Sandhu H.K.
        • Miller III, C.C.
        • Tanaka A.
        • Estrera A.L.
        • Charlton-Ouw K.M.
        Effectiveness of standard local anesthetic bupivacaine and liposomal bupivacaine for postoperative pain control in patients undergoing truncal incisions: a randomized clinical trial.
        JAMA Network Open. 2021; 4e210753https://doi.org/10.1001/jamanetworkopen.2021.0753
        • Kendall M.C.
        • Castro Alves L.J.
        • De Oliveira Jr., G.
        Liposome bupivacaine compared to plain local anesthetics to reduce postsurgical pain: an updated meta-analysis of randomized controlled trials.
        Pain Research and Treatment. 2018; 20185710169https://doi.org/10.1155/2018/5710169
        • Kang H.
        • Kim B.G.
        Intraperitoneal ropivacaine for effective pain relief after laparoscopic appendectomy: a prospective, randomized, double-blind, placebo-controlled study.
        J Int Med Res. 2010; 38: 821-832https://doi.org/10.1177/147323001003800309
        • Thanapal M.R.
        • Tata M.D.
        • Tan A.J.
        • et al.
        Pre-emptive intraperitoneal local anaesthesia: an effective method in immediate post-operative pain management and metabolic stress response in laparoscopic appendicectomy, A randomized, double-blinded, placebo-controlled study.
        ANZ J Surg. 2014; 84: 47-51https://doi.org/10.1111/j.1445-2197.2012.06210.x
        • Sevensma K.
        • Schleichert T.
        • Schwickerath C.
        • Shoemaker A.
        • Miller C.
        A randomized double blinded study to determine the effectiveness of utilizing intraperitoneal bupivacaine: does it reduce post-operative opioid use following laparoscopic appendectomy?.
        Am J Surg. 2019; 217: 479-482https://doi.org/10.1016/j.amjsurg.2018.10.045
        • Nedeljkovic S.S.
        • Kett A.
        • Vallejo M.C.
        • et al.
        Transversus abdominis plane block with liposomal bupivacaine for pain after cesarean delivery in a multicenter, randomized, double-blind, controlled trial.
        Anesth Analg. 2020; 131: 1830-1839https://doi.org/10.1213/ane.0000000000005075
        • Guerra L.
        • Philip S.
        • Lax E.A.
        • Smithson L.
        • Pearlman R.
        • Damadi A.
        Transversus abdominis plane blocks in laparoscopic colorectal surgery: better pain control and patient outcomes with liposomal bupivacaine than bupivacaine.
        Am Surg. 2019; 85: 1013-1016https://doi.org/10.1177/000313481908500945
        • Patzkowski M.S.
        • Stevens G.
        Multimodal analgesia in abdominal sepsis: a case report of liposome bupivacaine in ultrasound-guided rectus sheath blocks after unexpected open hemi-colectomy.
        Mil Med. 2015; 180: e728-e731https://doi.org/10.7205/milmed-d-14-00512
        • Hernandez M.C.
        • Finnesgard E.J.
        • Aho J.M.
        • Zielinski M.D.
        • Schiller H.J.
        Reduced opioid prescription practices and duration of stay after TAP block for laparoscopic appendectomy.
        J Gastrointest Surg. 2020; 24: 418-425https://doi.org/10.1007/s11605-018-04100-0
        • Colonna A.L.
        • Bellows B.K.
        • Enniss T.M.
        • et al.
        Reducing the pain: a cost-effectiveness analysis of transversus abdominis plane block using liposomal bupivacaine for outpatient laparoscopic ventral hernia repair.
        Surgery Open Science. 2020; 2: 75-80https://doi.org/10.1016/j.sopen.2019.12.003
        • Florence C.S.
        • Zhou C.
        • Luo F.
        • Xu L.
        The economic burden of prescription opioid overdose, abuse, and dependence in the United States, 2013.
        Med Care. 2016; 54: 901-906https://doi.org/10.1097/mlr.0000000000000625