Allison M Barrett, MD, FACS1, John A Afthinos, MD, FACS1, Christopher Funfgeld, PAC, MPAS1, Vaughn E Nossaman, MD2, Kevin K Kresofsky, MD2. 1Long Island Jewish Forest Hills Hospital, 2Nassau University Medical Center
Introduction: The overuse of postoperative narcotics has gained attention due to the epidemic of opiate abuse in the United States. Multimodal postoperative pain management strategies can address this through the addition of non-opiate analgesia and are incorporated within enhanced recovery after surgery (ERAS) pathways. We hypothesize that the use of an intraoperative transversus abdominis plane (TAP) block with liposomal bupivacaine will decrease the use of narcotic pain medications in patients undergoing bariatric surgery.
Methods: This is a retrospective review of in-hospital pain medication use for patients who underwent bariatric surgery from 2016-2018 at a single institution. From 2016 – 2017 patients received injection of bupivacaine locally at incision sites. From 2017 – 2018, patients received a laparoscopic-guided TAP block with a mixture of 20 mL of liposomal bupivacaine, 30 mL of 0.5% bupivacaine, and 100 mL of normal saline at the beginning of the procedure. This was injected by the surgeon bilaterally at the level of the anterior axillary line, with extension into the subcostal space. Injections were performed with a 20G or 22G spinal needle and were placed with laparoscopic visualization. Postoperatively, all patients received standing intravenous ketorolac and acetaminophen, unless contraindicated. Patients were excluded from the study if they required a concomitant procedure, returned to the OR, had alterations in surgical technique, or were on narcotics or benzodiazepines preoperatively. In-hospital narcotic use was converted to morphine equivalent units, according to previously published equianalgesic tables.
Results: A total of 80 patients underwent bariatric surgery during the time period and 15 patients were excluded. TAP block was performed in 39 patients, compared to 24 who did not have a TAP block. Mean age was 41, and pre-operative BMI was not different between the groups. Intraoperative dosing of morphine equivalent units, acetaminophen, and ketorolac were also not statistically different between the groups. Use of narcotics on postoperative day 0 was significantly less for the TAP-block group (5.97 vs 10.14 mg morphine, p=0.016). Pain scores in the PACU and up to 24 hours postoperatively were not different, nor was the use of acetaminophen and ketorolac postoperatively or length of stay. There were no medication-related adverse events.
Conclusion: Performance of an intraoperative TAP block decreases the use of postoperative narcotic medication use, but does not affect length of stay. As a part of an ERAS protocol, a TAP block is a useful approach for minimizing postoperative opiate use.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 94388
Program Number: P056
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster