Systematic Review of Liposomal Bupivacaine (Exparel) for Postoperative Analgesia.
BACKGROUND
Management of postoperative pain often requires multimodal approaches. Suboptimal dosages of current therapies can leave patients experiencing periods of insufficient analgesia, often requiring rescue therapy. With absence of a validated and standardized approach to pain management, further refinement of treatment protocols and targeted therapeutics is needed. Liposomal bupivacaine (Exparel) is a longer acting form of traditional bupivacaine that delivers the drug by means of a multivesicular liposomal system. The effectiveness of liposomal bupivacaine has not been systematically analyzed relative to conventional treatments in plastic surgery.


METHODS
A comprehensive literature search of the MEDLINE, PubMed, and Google Scholar databases was conducted for studies published through October of 2015 with search terms related to liposomal bupivacaine and filtered for relevance to postoperative pain control in plastic surgery. Data on techniques, outcomes, complications, and patient satisfaction were collected.


RESULTS
A total of eight articles were selected and reviewed from 160 identified. Articles covered a variety of techniques using liposomal bupivacaine for postoperative pain management. Four hundred five patients underwent procedures (including breast reconstruction, augmentation mammaplasty, abdominal wall reconstruction, mastectomy, and abdominoplasty) where pain was managed with liposomal bupivacaine and compared with those receiving traditional pain management. Liposomal bupivacaine use showed adequate safety and tolerability and, compared to traditional protocols, was equivalent or more effective in postoperative pain management.


CONCLUSIONS
Liposomal bupivacaine is a safe method for postoperative pain control in the setting of plastic surgery and may represent an alternative to more invasive pain management systems such as patient-controlled analgesia, epidurals, peripheral nerve catheters, or intravenous narcotics.
Lexington, Ky.; Seattle, Wash.; Palo Alto, Calif.; Rochester, Minn.; and Washington, D.C.|From the Division of Plastic Surgery, Department of Surgery, University of Kentucky College of Medicine; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington Medical Center; Stanford University School of Medicine; the Division of Plastic Surgery, Department of Surgery, Mayo Clinic; and the Department of Plastic Surgery, Georgetown University Hospital.
Krishna S
KS
Vyas
Lexington, Ky.; Seattle, Wash.; Palo Alto, Calif.; Rochester, Minn.; and Washington, D.C.|From the Division of Plastic Surgery, Department of Surgery, University of Kentucky College of Medicine; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington Medical Center; Stanford University School of Medicine; the Division of Plastic Surgery, Department of Surgery, Mayo Clinic; and the Department of Plastic Surgery, Georgetown University Hospital.
Sibi
S
Rajendran
Lexington, Ky.; Seattle, Wash.; Palo Alto, Calif.; Rochester, Minn.; and Washington, D.C.|From the Division of Plastic Surgery, Department of Surgery, University of Kentucky College of Medicine; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington Medical Center; Stanford University School of Medicine; the Division of Plastic Surgery, Department of Surgery, Mayo Clinic; and the Department of Plastic Surgery, Georgetown University Hospital.
Shane D
SD
Morrison
Lexington, Ky.; Seattle, Wash.; Palo Alto, Calif.; Rochester, Minn.; and Washington, D.C.|From the Division of Plastic Surgery, Department of Surgery, University of Kentucky College of Medicine; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington Medical Center; Stanford University School of Medicine; the Division of Plastic Surgery, Department of Surgery, Mayo Clinic; and the Department of Plastic Surgery, Georgetown University Hospital.
Afaaf
A
Shakir
Lexington, Ky.; Seattle, Wash.; Palo Alto, Calif.; Rochester, Minn.; and Washington, D.C.|From the Division of Plastic Surgery, Department of Surgery, University of Kentucky College of Medicine; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington Medical Center; Stanford University School of Medicine; the Division of Plastic Surgery, Department of Surgery, Mayo Clinic; and the Department of Plastic Surgery, Georgetown University Hospital.
Samir
S
Mardini
Lexington, Ky.; Seattle, Wash.; Palo Alto, Calif.; Rochester, Minn.; and Washington, D.C.|From the Division of Plastic Surgery, Department of Surgery, University of Kentucky College of Medicine; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington Medical Center; Stanford University School of Medicine; the Division of Plastic Surgery, Department of Surgery, Mayo Clinic; and the Department of Plastic Surgery, Georgetown University Hospital.
Valerie
V
Lemaine
Lexington, Ky.; Seattle, Wash.; Palo Alto, Calif.; Rochester, Minn.; and Washington, D.C.|From the Division of Plastic Surgery, Department of Surgery, University of Kentucky College of Medicine; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington Medical Center; Stanford University School of Medicine; the Division of Plastic Surgery, Department of Surgery, Mayo Clinic; and the Department of Plastic Surgery, Georgetown University Hospital.
Maurice Y
MY
Nahabedian
Lexington, Ky.; Seattle, Wash.; Palo Alto, Calif.; Rochester, Minn.; and Washington, D.C.|From the Division of Plastic Surgery, Department of Surgery, University of Kentucky College of Medicine; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington Medical Center; Stanford University School of Medicine; the Division of Plastic Surgery, Department of Surgery, Mayo Clinic; and the Department of Plastic Surgery, Georgetown University Hospital.
Stephen B
SB
Baker
Lexington, Ky.; Seattle, Wash.; Palo Alto, Calif.; Rochester, Minn.; and Washington, D.C.|From the Division of Plastic Surgery, Department of Surgery, University of Kentucky College of Medicine; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington Medical Center; Stanford University School of Medicine; the Division of Plastic Surgery, Department of Surgery, Mayo Clinic; and the Department of Plastic Surgery, Georgetown University Hospital.
Brian D
BD
Rinker
Lexington, Ky.; Seattle, Wash.; Palo Alto, Calif.; Rochester, Minn.; and Washington, D.C.|From the Division of Plastic Surgery, Department of Surgery, University of Kentucky College of Medicine; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington Medical Center; Stanford University School of Medicine; the Division of Plastic Surgery, Department of Surgery, Mayo Clinic; and the Department of Plastic Surgery, Georgetown University Hospital.
Henry C
HC
Vasconez
D000700:Analgesics / Q000008:administration & dosage* / Q000627:therapeutic use; D002045:Bupivacaine / Q000008:administration & dosage* / Q000627:therapeutic use; D003692:Delayed-Action Preparations; D006801:Humans; D008081:Liposomes; D010149:Postoperative Pain / Q000188:drug therapy*; D019651:Plastic Surgery Procedures
D000700:Analgesics; D003692:Delayed-Action Preparations; D008081:Liposomes; D002045:Bupivacaine
Dzau VJ, Pizzo PA. Relieving pain in America: Insights from an Institute of Medicine committee. JAMA 2014;312:15071508.
Katz J, Weinrib A, Fashler SR, et al. The Toronto General Hospital Transitional Pain Service: Development and implementation of a multidisciplinary program to prevent chronic postsurgical pain. J Pain Res. 2015;8:695702.
Meissner W, Coluzzi F, Fletcher D, et al. Improving the management of post-operative acute pain: Priorities for change. Curr Med Res Opin. 2015;31:21312143.
Sanguineti VA, Wild JR, Fain MJ. Management of postoperative complications: General approach. Clin Geriatr Med. 2014;30:261270.
Tighe P, Buckenmaier CC III, Boezaart AP, et al. Acute pain medicine in the United States: A status report. Pain Med. 2015;16:18061826.
Koh JC, Lee J, Kim SY, Choi S, Han DW. Postoperative pain and intravenous patient-controlled analgesia-related adverse effects in young and elderly patients: A retrospective analysis of 10,575 patients. Medicine (Baltimore) 2015;94:e2008.
Golembiewski J, Dasta J. Evolving role of local anesthetics in managing postsurgical analgesia. Clin Ther. 2015;37:13541371.
Kress HG, Aldington D, Alon E, et al. A holistic approach to chronic pain management that involves all stakeholders: Change is needed. Curr Med Res Opin. 2015;31:17431754.
Lovich-Sapola J, Smith CE, Brandt CP. Postoperative pain control. Surg Clin North Am. 2015;95:301318.
Chandran GJ, Lalonde DH. A review of pain pumps in plastic surgery. Can J Plast Surg. 2010;18:1518.
Andreae MH, Andreae DA. Local anaesthetics and regional anaesthesia for preventing chronic pain after surgery. Cochrane Database Syst Rev. 2012;10:CD007105.
Kelley BP, Shauver MJ, Chung KC. Management of acute postoperative pain in hand surgery: A systematic review. J Hand Surg Am. 2015;40:16101619, 1619.e1.
Fiala T. Transversus abdominis plane block during abdominoplasty to improve postoperative patient comfort. Aesthet Surg J. 2015;35:7280.
Ilfeld BM, Viscusi ER, Hadzic A, et al. Safety and side effect profile of liposome bupivacaine (Exparel) in peripheral nerve blocks. Reg Anesth Pain Med. 2015;40:572582.
Abdelsattar JM, Boughey JC, Fahy AS, et al. Comparative study of liposomal bupivacaine versus paravertebral block for pain control following mastectomy with immediate tissue expander reconstruction. Ann Surg Oncol. 2016;23:465470.
Abdelsattar JM, Degnim AC, Hieken TJ, Saint-Cyr M, Boughey JC. Local infiltration of liposomal bupivacaine for pain control in patients undergoing mastectomy with immediate tissue expander reconstruction. Ann Surg Oncol. 2015;22:34023403.
Butz DR, Shenaq DS, Rundell VL, et al. Postoperative pain and length of stay lowered by use of Exparel in immediate, implant-based breast reconstruction. Plast Reconstr Surg Glob Open 2015;3:e391.
Eberle N, Newman M. Patient perception of postoperative pain after administration of liposomal bupivacaine in plastic surgery. Ann Plast Surg. 2015;74(Suppl 4):S198S200.
Fayezizadeh M, Petro CC, Rosen MJ, Novitsky YW. Enhanced recovery after surgery pathway for abdominal wall reconstruction: Pilot study and preliminary outcomes. Plast Reconstr Surg. 2014;134(Suppl 2):151S159S.
Feierman DE, Kronenfeld M, Gupta PM, Younger N, Logvinskiy E. Liposomal bupivacaine infiltration into the transversus abdominis plane for postsurgical analgesia in open abdominal umbilical hernia repair: Results from a cohort of 13 patients. J Pain Res. 2014;7:477482.
Leiman D, Barlow M, Carpin K, Piña EM, Casso D. Medial and lateral pectoral nerve block with liposomal bupivacaine for the management of postsurgical pain after submuscular breast augmentation. Plast Reconstr Surg Glob Open 2014;2:e282.
Minkowitz HS, Onel E, Patronella CK, Smoot JD. A two-year observational study assessing the safety of DepoFoam bupivacaine after augmentation mammaplasty. Aesthet Surg J. 2012;32:186193.
Morales R Jr, Mentz H III, Newall G, Patronella C, Masters O III. Use of abdominal field block injections with liposomal bupivacaine to control postoperative pain after abdominoplasty. Aesthet Surg J. 2013;33:11481153.
Smoot JD, Bergese SD, Onel E, Williams HT, Hedden W. The efficacy and safety of DepoFoam bupivacaine in patients undergoing bilateral, cosmetic, submuscular augmentation mammaplasty: A randomized, double-blind, active-control study. Aesthet Surg J. 2012;32:6976.
Baxter R, Bramlett K, Onel E, Daniels S. Impact of local administration of liposome bupivacaine for postsurgical analgesia on wound healing: A review of data from ten prospective, controlled clinical studies. Clin Ther. 2013;35:312320.e5.
Cohen SM. 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;5:567572.
Hutchins J, Delaney D, Vogel RI, et al. Ultrasound guided subcostal transversus abdominis plane (TAP) infiltration with liposomal bupivacaine for patients undergoing robotic assisted hysterectomy: A prospective randomized controlled study. Gynecol Oncol. 2015;138:609613.
Surdam JW, Licini DJ, Baynes NT, Arce BR. The use of Exparel (liposomal bupivacaine) to manage postoperative pain in unilateral total knee arthroplasty patients. J Arthroplasty 2015;30:325329.
Melnyk M, Casey RG, Black P, Koupparis AJ. Enhanced recovery after surgery (ERAS) protocols: Time to change practice? Can Urol Assoc J. 2011;5:342348.
Mentz HA, Ruiz-Razura A, Newall G, Patronella CK. Use of a regional infusion pump to control postoperative pain after an abdominoplasty. Aesthetic Plast Surg. 2005;29:415421; discussion 422.
Viscusi ER, Sinatra R, Onel E, Ramamoorthy SL. The safety of liposome bupivacaine, a novel local analgesic formulation. Clin J Pain 2014;30:102110.
Richards BG, Schleicher WF, Zins JE. Putting it all together: Recommendations for improving pain management in plastic surgical procedures-surgical facial rejuvenation. Plast Reconstr Surg. 2014;134(Suppl 2):108S112S.