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Postoperative analgesia and flap perfusion after pedicled TRAM flap reconstruction – continuous wound instillation with ropivacaine 0.2%. A pilot study
J Plast Reconstr Aesthet Surg 62:618-625, 2009
Ropivacaine plasma levels were within therapeutic range. Our data show a trend that continuous wound instillation of ropivacaine 0.2% increases pain relief after TRAM flap surgery with earlier bowel movement than intravenous opioid patient controlled analgesia (IV-PCA) alone. A dose of 960 mg of ropivacaine daily did not result in toxic plasma concentrations. Ropivacaine 0.2% did not show a vasoconstrictor effect.
Transverse rectus abdominis musculocutaneous (TRAM) flap surgery is a complex procedure characterised by an extensive wound site. We present a pilot study with 17 patients receiving continuous wound instillation with ropivacaine or isotonic saline. Patients undergoing TRAM flap surgery were included in the study and randomised to the ropi group or the control group. Two catheters were placed subcutaneously before wound site closure. At the end of surgery patients received a single shot dose of 20 ml ropivacaine 0.2% or isotonic saline. After surgery the continuous instillation of ropivacaine or isotonic saline was commenced at an infusion rate of 10 ml/h per catheter. The perfusion of the TRAM flap was measured intraoperatively and postoperatively over 48 h. Pain scores, patient satisfaction, and the quality of recovery score were also assessed postoperatively over 48 h. Ropivacaine plasma levels were quantified 24 and 48 h after start of infusion. Pain scores at rest and on coughing were lower for the ropi group and reached significance in the first 8 h at rest (P ¼ 0.007). Patient satisfaction, quality of recovery score, and adverse events were also comparable between the groups. Patients of the ropi group had bowel movement earlier than the control group (P ¼ 0.003). No differences were seen in the flap perfusion.
In this article, Dagtekin and colleagues performed a pilot study to assess the instillation of 0.2% ropivacaine for postoperative analgesia and flap perfusion in patients undergoing pedicled TRAM flap breast reconstruction. Patients were randomized to receive either continuous instillation of isotonic saline or 0.2% ropivacaine via 2 catheters: one placed on the abdominal fascia at the donor site and one beneath the pedicled TRAM flap in the chest. Surgeons were blinded to which study medication was given. The authors found a significant difference in the pain scores between the treatment groups within the first 8 hours after surgery, but no significant differences were seen between the treatment groups in the rescue medication consumed, patient satisfaction score, recovery score, and adverse events, including flap perfusion. The ropivacaine group experienced an earlier return of bowel function, with bowel function returning 1 day earlier than in the control group. Postoperative pain management is a crucial aspect of any surgical procedure and may directly affect patient satisfaction and outcomes. The instillation of local anesthetic agents via catheter infusion has been used for various surgical procedures with the hope of decreasing postoperative
Postoperative analgesia and flap perfusion after pedicled TRAM flap reconstruction – continuous wound instillation with ropivacaine 0.2%. A pilot study Dagtekin O, Hotz A, Kampe S, et al (Univ of Cologne, Germany)
pain, leading to less use of opioid analgesics, less nausea and vomiting, decreased hospital stays, and increased patient satisfaction. The use of pain-control infusion pumps in patients undergoing breast reconstruction with autologous tissue from the abdomen has been reported by others.1-3 These studies have shown significant decreases in the need for intravenous narcotic agents, less nausea and vomiting, and reduced hospital stays. Dagtekin and colleagues have added to the literature by demonstrating that patient-reported pain scores, as well as earlier return of bowel function, are also positively affected. The choice of the analgesic agent used (ie, bupivacaine vs ropivacaine) may need further investigation; however, I agree with the authors that ropivacaine may be a better choice because of the reports of less cardiac and central nervous system toxicity at concentrations equal to those used for bupivacaine. Regardless of the analgesic agent chosen, it is vital to place the catheters so that instillation of the agent reaches inside the rectus sheath for intercostal nerve blockade. Furthermore, it is necessary to place drainage tubes away from the catheters to prevent inadvertent removal of the agent. The vasoactive effects of topically administered anesthetic agents, such as lidocaine, which is used for microsurgical anastomosis and causes dilatation, are well known; however, as Dagtekin and colleagues discussed in this article, the evidence showing at what concentration ropivacaine has a vasoactive effect is conflicting. Until further evidence is published, using this agent topically to assist with flap perfusion, as demonstrated by this study, is not warranted. I commend Dagtekin and colleagues for continuing to explore ways to improve pain
Breast Diseases: A Year BookÒ Quarterly Vol 20 No 4 2010
469
management in patients undergoing breast reconstruction.
infusion and intravenous narcotic patient-controlled anesthesia pump for pain management after free TRAM flap breast reconstruction. Plast Reconstr Surg. 2008;122: 1010-1018.
M. A. Crosby, MD
References 1. Heller L, Kowalski AM, Wei C, Butler CE. Prospective, randomized, double-blind trial of local anesthetic
A Franco-British patients' and partners' satisfaction audit of breast reconstruction Guyomard V, Leinster S, Wilkinson M, et al (Univ of East Anglia, Norwich, United Kingdom) J Plast Reconstr Aesthet Surg 62:782-789, 2009
Aims.—To compare French and British patients’ and partners’ satisfaction with breast reconstruction after mastectomy and determine what factors affect it. Methodology.—The study analysed validated questionnaires from 182 pairs (the woman and her partner), split equally between France and the UK. The patients underwent breast surgery at the Norfolk and Norwich University Hospital (NNUH) and at the Hoˆpital Saint-Louis in Paris, France. All main surgical procedures were considered. Results.—Participants were satisfied with the outcome but satisfaction levels differed between France and the UK, British patients reporting higher satisfaction (P ¼ 0.029) because of a closer match between their expectation and the outcome. There were also statistically significant differences in: 1. The decision-making process and the factors influencing it: Consultants
470
2. Tan KJ, Farrow H. Improving postoperative analgesia for transverse rectus abdominis myocutaneous flap breast reconstruction; the use of
2. 3. 4. 5.
6.
and partners were more influential in France. Satisfaction with information: French participants felt less well informed. Pain control management: higher satisfaction was reported in France. The confidence level shown after breast reconstruction: British patients felt more confident. The importance of the determinants of aesthetic satisfaction: higher expectation levels were reported by the French for all determinants. Satisfaction with determinants: symmetry and shape scored lowest in both countries; French patients expressed highest satisfaction for implants and British patients for latissimus dorsi (LD) and deep inferior epigastric perforator (DIEP) flaps.
There was no difference in satisfaction levels between patients and partners who accurately reported on patients’ views and whose own views matched patients’. Satisfaction was correlated to the level of information, pain management, recovery time, technique used, cosmetic results, intervention timing, but not to the independent assessment of the outcome. This study by Guyomard and colleagues compared French and British patients’ and partners’ satisfaction with breast reconstruction after mastectomy. The authors found
Breast Diseases: A Year BookÒ Quarterly Vol 20 No 4 2010
a local anaesthetic infusion catheter. J Plast Reconstr Aesthet Surg. 2009; 62:206-210. 3. Losken A, Parris JJ, Douglas TD, Codner MA. Use of the infusion pain pump following transverse rectus abdominis muscle flap breast reconstruction. Ann Plast Surg. 2005; 54:479-482.
that patient and partner satisfaction with the end results of the reconstruction differed between France and the UK; patients and partners from both countries reported being satisfied, but British patients reported a higher level of satisfaction. This is an interesting study, but the results are difficult to interpret. The 2 groups of patients that the authors compared are very different. First, there was a cultural difference between the French and British patients, as French patients appeared to have higher expectations in terms of body image when compared with UK patients. Second, the French and the UK health care delivery systems are very different; in France, a single team performed both mastectomy and reconstruction, whereas ablation and reconstruction were performed by 2 different teams of surgeons in the UK. Third, the timing of breast reconstruction was different: most of the patients in France underwent delayed reconstruction, whereas most of the patients in the UK received immediate breast reconstruction. Finally, the reconstructive methods were very different: most of the French patients underwent reconstruction with implants, whereas many of the UK patients underwent reconstruction with autologous tissue.
Ropivacaine plasma levels were within therapeutic range. Our data show a trend that continuous wound instillation of ropivacaine 0.2% increases pain relief after TRAM flap surgery with earlier bowel movement than intravenous opioid patient controlled analgesia (IV-PCA) alone. A dose of 960 mg of ropivacaine daily did not result in toxic plasma concentrations. Ropivacaine 0.2% did not show a vasoconstrictor effect.
Transverse rectus abdominis musculocutaneous (TRAM) flap surgery is a complex procedure characterised by an extensive wound site. We present a pilot study with 17 patients receiving continuous wound instillation with ropivacaine or isotonic saline. Patients undergoing TRAM flap surgery were included in the study and randomised to the ropi group or the control group. Two catheters were placed subcutaneously before wound site closure. At the end of surgery patients received a single shot dose of 20 ml ropivacaine 0.2% or isotonic saline. After surgery the continuous instillation of ropivacaine or isotonic saline was commenced at an infusion rate of 10 ml/h per catheter. The perfusion of the TRAM flap was measured intraoperatively and postoperatively over 48 h. Pain scores, patient satisfaction, and the quality of recovery score were also assessed postoperatively over 48 h. Ropivacaine plasma levels were quantified 24 and 48 h after start of infusion. Pain scores at rest and on coughing were lower for the ropi group and reached significance in the first 8 h at rest (P ¼ 0.007). Patient satisfaction, quality of recovery score, and adverse events were also comparable between the groups. Patients of the ropi group had bowel movement earlier than the control group (P ¼ 0.003). No differences were seen in the flap perfusion.
In this article, Dagtekin and colleagues performed a pilot study to assess the instillation of 0.2% ropivacaine for postoperative analgesia and flap perfusion in patients undergoing pedicled TRAM flap breast reconstruction. Patients were randomized to receive either continuous instillation of isotonic saline or 0.2% ropivacaine via 2 catheters: one placed on the abdominal fascia at the donor site and one beneath the pedicled TRAM flap in the chest. Surgeons were blinded to which study medication was given. The authors found a significant difference in the pain scores between the treatment groups within the first 8 hours after surgery, but no significant differences were seen between the treatment groups in the rescue medication consumed, patient satisfaction score, recovery score, and adverse events, including flap perfusion. The ropivacaine group experienced an earlier return of bowel function, with bowel function returning 1 day earlier than in the control group. Postoperative pain management is a crucial aspect of any surgical procedure and may directly affect patient satisfaction and outcomes. The instillation of local anesthetic agents via catheter infusion has been used for various surgical procedures with the hope of decreasing postoperative
Postoperative analgesia and flap perfusion after pedicled TRAM flap reconstruction – continuous wound instillation with ropivacaine 0.2%. A pilot study Dagtekin O, Hotz A, Kampe S, et al (Univ of Cologne, Germany)
pain, leading to less use of opioid analgesics, less nausea and vomiting, decreased hospital stays, and increased patient satisfaction. The use of pain-control infusion pumps in patients undergoing breast reconstruction with autologous tissue from the abdomen has been reported by others.1-3 These studies have shown significant decreases in the need for intravenous narcotic agents, less nausea and vomiting, and reduced hospital stays. Dagtekin and colleagues have added to the literature by demonstrating that patient-reported pain scores, as well as earlier return of bowel function, are also positively affected. The choice of the analgesic agent used (ie, bupivacaine vs ropivacaine) may need further investigation; however, I agree with the authors that ropivacaine may be a better choice because of the reports of less cardiac and central nervous system toxicity at concentrations equal to those used for bupivacaine. Regardless of the analgesic agent chosen, it is vital to place the catheters so that instillation of the agent reaches inside the rectus sheath for intercostal nerve blockade. Furthermore, it is necessary to place drainage tubes away from the catheters to prevent inadvertent removal of the agent. The vasoactive effects of topically administered anesthetic agents, such as lidocaine, which is used for microsurgical anastomosis and causes dilatation, are well known; however, as Dagtekin and colleagues discussed in this article, the evidence showing at what concentration ropivacaine has a vasoactive effect is conflicting. Until further evidence is published, using this agent topically to assist with flap perfusion, as demonstrated by this study, is not warranted. I commend Dagtekin and colleagues for continuing to explore ways to improve pain
Breast Diseases: A Year BookÒ Quarterly Vol 20 No 4 2010
469
management in patients undergoing breast reconstruction.
infusion and intravenous narcotic patient-controlled anesthesia pump for pain management after free TRAM flap breast reconstruction. Plast Reconstr Surg. 2008;122: 1010-1018.
M. A. Crosby, MD
References 1. Heller L, Kowalski AM, Wei C, Butler CE. Prospective, randomized, double-blind trial of local anesthetic
A Franco-British patients' and partners' satisfaction audit of breast reconstruction Guyomard V, Leinster S, Wilkinson M, et al (Univ of East Anglia, Norwich, United Kingdom) J Plast Reconstr Aesthet Surg 62:782-789, 2009
Aims.—To compare French and British patients’ and partners’ satisfaction with breast reconstruction after mastectomy and determine what factors affect it. Methodology.—The study analysed validated questionnaires from 182 pairs (the woman and her partner), split equally between France and the UK. The patients underwent breast surgery at the Norfolk and Norwich University Hospital (NNUH) and at the Hoˆpital Saint-Louis in Paris, France. All main surgical procedures were considered. Results.—Participants were satisfied with the outcome but satisfaction levels differed between France and the UK, British patients reporting higher satisfaction (P ¼ 0.029) because of a closer match between their expectation and the outcome. There were also statistically significant differences in: 1. The decision-making process and the factors influencing it: Consultants
470
2. Tan KJ, Farrow H. Improving postoperative analgesia for transverse rectus abdominis myocutaneous flap breast reconstruction; the use of
2. 3. 4. 5.
6.
and partners were more influential in France. Satisfaction with information: French participants felt less well informed. Pain control management: higher satisfaction was reported in France. The confidence level shown after breast reconstruction: British patients felt more confident. The importance of the determinants of aesthetic satisfaction: higher expectation levels were reported by the French for all determinants. Satisfaction with determinants: symmetry and shape scored lowest in both countries; French patients expressed highest satisfaction for implants and British patients for latissimus dorsi (LD) and deep inferior epigastric perforator (DIEP) flaps.
There was no difference in satisfaction levels between patients and partners who accurately reported on patients’ views and whose own views matched patients’. Satisfaction was correlated to the level of information, pain management, recovery time, technique used, cosmetic results, intervention timing, but not to the independent assessment of the outcome. This study by Guyomard and colleagues compared French and British patients’ and partners’ satisfaction with breast reconstruction after mastectomy. The authors found
Breast Diseases: A Year BookÒ Quarterly Vol 20 No 4 2010
a local anaesthetic infusion catheter. J Plast Reconstr Aesthet Surg. 2009; 62:206-210. 3. Losken A, Parris JJ, Douglas TD, Codner MA. Use of the infusion pain pump following transverse rectus abdominis muscle flap breast reconstruction. Ann Plast Surg. 2005; 54:479-482.
that patient and partner satisfaction with the end results of the reconstruction differed between France and the UK; patients and partners from both countries reported being satisfied, but British patients reported a higher level of satisfaction. This is an interesting study, but the results are difficult to interpret. The 2 groups of patients that the authors compared are very different. First, there was a cultural difference between the French and British patients, as French patients appeared to have higher expectations in terms of body image when compared with UK patients. Second, the French and the UK health care delivery systems are very different; in France, a single team performed both mastectomy and reconstruction, whereas ablation and reconstruction were performed by 2 different teams of surgeons in the UK. Third, the timing of breast reconstruction was different: most of the patients in France underwent delayed reconstruction, whereas most of the patients in the UK received immediate breast reconstruction. Finally, the reconstructive methods were very different: most of the French patients underwent reconstruction with implants, whereas many of the UK patients underwent reconstruction with autologous tissue.