Crystal Dustin T, Ibrahim Ahmed M S, Blankensteijn Louise L, Cuccolo Nicholas G, Kazei Darya, Zitkovsky Helen S, Lee Bernard T, Lin Samuel J
Division of Plastic Surgery, Hospital of the University of Pennsylvania, Perlman School of Medicine, Philadelphia, Pa.
Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
Plast Reconstr Surg Glob Open. 2021 Nov 16;9(11):e3932. doi: 10.1097/GOX.0000000000003932. eCollection 2021 Nov.
Pain and discomfort are frequently experienced following mastectomy with concomitant breast implant- or tissue expander-based alloplastic breast reconstruction (AlBR). Unfortunately, postoperative opioids have decreased efficacy in AlBR, short-term complication profiles, and are fraught by long-term dependence. This systematic review aims to identify opioid-sparing pain management strategies in AlBR.
A systematic literature search of MEDLINE, Embase, Web of Science, and Cochrane Central Register was performed in September 2018. PRISMA guidelines were followed, and the review was prospectively registered in PROSPERO (CRD42018107911). The search identified 1184 articles. Inclusion criteria were defined as patients 18 years or older undergoing AlBR.
Fourteen articles were identified assessing opioid-sparing strategies in AlBR. This literature included articles evaluating enhanced recovery protocols (two), intercostal blocks (two), paravertebral blocks (four), liposomal bupivacaine (three), diclofenac (one), and local anesthesia infusion pumps (two). The literature included five randomized trials and nine cohort studies. Study characteristics, bias (low to high risk), and reporting outcomes were extensively heterogeneous between articles. Qualitative analysis suggests reduced opioid utilization in enhanced recovery after surgery (ERAS) pathways, paravertebral blocks, and use of liposomal bupivacaine.
A variety of opioid-sparing strategies are described for pain management in AlBR. Multimodal analgesia should be provided via ERAS pathways as they appear to reduce pain and spare opioid use. Targeted paravertebral blocks and liposomal bupivacaine field blocks appear to be beneficial in sparing opioids and should be considered as essential components of ERAS protocols. Additional prospective, randomized trials are necessary to delineate the efficacy of other studied modalities.
在乳房切除术后同时进行基于乳房植入物或组织扩张器的异体乳房重建（AlBR）时，患者经常会经历疼痛和不适。不幸的是，术后使用阿片类药物在AlBR中的疗效降低，短期并发症较多，且存在长期依赖的问题。本系统评价旨在确定AlBR中减少阿片类药物使用的疼痛管理策略。
2018年9月对MEDLINE、Embase、科学网和Cochrane中心注册库进行了系统的文献检索。遵循PRISMA指南，并在PROSPERO（CRD42018107911）中对该评价进行了前瞻性注册。检索共识别出1184篇文章。纳入标准定义为年龄在18岁及以上接受AlBR的患者。
共识别出14篇评估AlBR中减少阿片类药物使用策略的文章。这些文献包括评估加速康复方案（2篇）、肋间阻滞（2篇）、椎旁阻滞（4篇）、脂质体布比卡因（3篇）、双氯芬酸（1篇）和局部麻醉输注泵（2篇）的文章。文献包括5项随机试验和9项队列研究。各文章之间的研究特征、偏倚（低到高风险）和报告结果差异很大。定性分析表明，在术后加速康复（ERAS）途径、椎旁阻滞和使用脂质体布比卡因时，阿片类药物的使用减少。
描述了多种用于AlBR疼痛管理的减少阿片类药物使用的策略。应通过ERAS途径提供多模式镇痛，因为它们似乎可以减轻疼痛并减少阿片类药物的使用。针对性的椎旁阻滞和脂质体布比卡因区域阻滞似乎有利于减少阿片类药物的使用，应被视为ERAS方案的重要组成部分。需要更多的前瞻性随机试验来明确其他研究方法的疗效。
