A new pain-control protocol involving long-acting medication has been found to be effective enough for mastectomy patients to be discharged the same day of surgery, according to research presented at the American College of Surgeons Clinical Congress 2018. 

Surgeons at the University Medical Center – New Orleans (UMC-NO) have come up with the practice-changing method, found to be a safe and effective way to alleviate pain for mastectomy patients, allowing them to be discharged to home the same day of surgery, while also reducing the need for stronger opioids during their recovery. 

"Our aim was to apply a better pain control regimen to this group of mastectomy patients in order to reduce hospital stays without increasing their risk for postoperative complications," said lead study author Radbeh Torabi, MD, an integrated plastic surgery resident at Louisiana State University Health Science Center (LSUHSC) in New Orleans.

In recent years, study coauthor and principal investigator for this research, Adam I. Riker, MD, FACS, a surgical oncologist at the University Medical Center–New Orleans developed a multimodal method of pain control using a new, long-acting pain medication called liposomal bupivacaine (Exparel®), which functions as a nerve block when injected adjacent along the intercostal rib spaces in the area near the armpit. Liposomal bupivacaine is a local anesthetic that lasts about three to five days, thus, providing an effective method of pain control for much longer than previously possible.

"This nerve block first became available to me about eight years ago. Before that, the longest acting local anesthetics we had lasted only about six to eight hours, which required us to often admit these patients overnight to obtain adequate pain control prior to discharge," he said.

"I was an early adopter of using liposomal bupivacaine for many of my operative cases, many with large incisions and the expected post-operative incisional pain, and I started applying its use to my mastectomy patients, specifically to find out whether this could be done safely and effectively while trying to obtain a longer amount of time for adequate pain control and not requiring that overnight stay."

Researchers looked at patient records of 100 women who underwent mastectomies performed by Dr. Riker between November 2015 and July 2017. The average age was 57 years old, with an average body-mass index (BMI) of 30. All patients were treated with this novel multimodal pain regimen, which consists of the injection of liposomal bupivacaine into the neurovascular bundle of the rib space (intercostal space) at four to five different levels, combined with an intraoperative dose of IV ketorolac and a single dose of IV acetaminophen.

"If the nerve block is performed properly, the vast majority of patients wake up in the recovery room with little, or often, no pain whatsoever," Dr. Riker said. "After the operation, our patients go home with a prescription for a few days of acetaminophen/codeine rather than acetaminophen/oxycodone, which is a much stronger opioid that has a very high potential for opioid abuse. With the current opioid abuse epidemic in the US, we were trying to come up with an effective regimen for pain control that minimized the need for post-operative oral narcotics at home."

"Once patients recover from anesthesia, they can be discharged home," Dr. Torabi said. Typically, mastectomy patients spend one to two nights in the hospital. However, "patients who underwent mastectomy with the nerve block were out of the hospital, on average, in less than five hours from their operation and with little associated pain, which shows that this pain control method may enable patients to leave the hospital the same day as their procedure and recover at home, avoiding both the cost of an overnight hospital stay and reducing the risk of potential hospital-aquired complications," he explained.

The researchers found that out of 100 mastectomy cases, only five patients returned to the emergency room within 30 days, with only three patients returning due to inadequate pain control. Two patients were readmitted: one for a suspected stroke and the other for a wound infection. The average follow-up period was about five months.

Although researchers did not perform a detailed cost analysis of potential cost savings, they estimate that the potential cost savings is significant, based solely on the cost savings associated with outpatient surgery and no overnight hospital stays. "That in itself would most likely result in tremendous dollars saved per patient, not even considering other cost savings, such as lower opioid use, less time spent in the recovery room and a more rapid discharge to home," Dr. Torabi said. "Another reason our study is important is because multiple states are beginning to pass laws with hard limits on how much opioids can be prescribed."

Better pain control is critical to a successful outpatient outcome. Moving forward, Dr. Riker plans to perfect this pain control protocol by further investigating some potential pre-operative options that may further add to the current pain management regimen.

"I hope our study will get a lot of surgeons to at least start addressing the issue of how to maximize pain control postoperatively in order to provide effective pain control and patient satisfaction on a purely outpatient basis. Some surgeons are locked into the dogma that you have to keep a mastectomy patient in the hospital overnight, but I really think that utilization of this multimodal approach allows for a safe and effective alternative," Dr. Riker said.