Opioid Use Decreases in Gynecologic Cancer Surgery with Liposomal Bupivacaine

Charles Bankhead

June 2016, Vol 7, No 5 - Gynecologic Cancer

The use of liposomal bupivacaine during major surgery for gynecologic malignancies achieved similar pain control with significantly less use of opioids and patient-controlled analgesia (PCA) as conventional bupivacaine. The 30-day costs did not differ significantly between the groups of patients undergoing complex cytoreductive procedures, as reported at the 2016 ­Society of Gynecologic Oncology annual meeting. “Use of liposomal bupivacaine in complex cytoreductive surgery decreased systemic opioid requirements, the need for IV [intravenous] rescue opioids, and the need for PCA, but resulted in comparable pain scores and was cost neutral,” said Eleftheria Kalogera, MD, Instructor and Resident Phy­sician in Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN. “Similar but less dramatic improvements were observed in the staging laparotomy cohort.” After the introduction of an enhanced recovery pathway in 2011, the average length of stay for complex cytoreduction procedures in ovarian cancer decreased by 50% to 5 days. The use of PCA decreased from 99% of all patients to 30%, and narcotic use during the first 48 hours decreased by 80%, resulting in a savings of more than $800,000. Patient satisfaction exceeded 90%, said Dr Kalogera. In 2013, liposomal bupivacaine was added to the enhanced recovery pathway. The rationale for the switch came from the prolonged half-life (and associated analgesia) of liposomal bupivacaine compared with conventional bupivacaine hydrochloride (72 hours vs 8 hours, respectively). Dr Kalogera and colleagues reviewed the records of 193 patients who underwent complex cytoreductive surgery (N = 121) or staging laparotomy (N = 72) after the switch. For comparison, they used the medical records of 165 patients who underwent the same procedures after the implementation of the enhanced recovery pathway, but before the addition of liposomal bupivacaine. Complex cytoreductive surgery was defined as staging plus 1 or more procedures that added to the overall surgical complexity, such as bowel resection, diaphragm resection, or splenectomy. The primary end point was cumulative pain score. The secondary end points included opioid use, which was defined by opioid morphine equivalents, and the 30-day costs. The cumulative pain scores at 24 hours and at 48 hours did not differ significantly by bupivacaine formulation used for complex cytoreduction or staging laparotomy. All end points related to opioid use and PCA favored liposomal bupivacaine for patients undergoing complex cytoreduction. In the liposomal bupivacaine group, the median opioid morphine equivalents were significantly lower than in the conventional bupivacaine group through 24 hours, 48 hours, and the remaining length of stay. Significantly fewer patients in the liposomal bupivacaine group required IV rescue medication for pain relief than in the conventional bupivacaine cohort. Moreover, the time to first dose of IV rescue medication was significantly prolonged with liposomal bupivacaine, with most of the difference occurring within the first 24 hours after administration. In the staging laparotomy comparison, pain scores and most outcomes related to opioid use were similar between the groups of patients who received liposomal or conventional ­bupivacaine. The only significant differences (all favoring liposomal bupivacaine) were a need for IV rescue opioids, time to first dose of IV opioid, patients requiring PCA, opioid-free postoperative day 2, and continuing opioid-free for the remaining length of stay. The patients undergoing cytoreductive procedures had significantly less nausea with liposomal bupivacaine at 24 hours and at 48 hours, as well as a lower rate of ileus. The staging laparotomy group also had less nausea at 24 hours and at 48 hours. The median 30-day costs associated with complex cytoreduction were similar with liposomal ($31,562) and conventional bupivacaine ($33,498), as were the pharmacy costs. In the laparotomy comparison, the procedures performed with liposomal bupivacaine cost more than those with conventional bupivacaine ($26,234 vs $22,920, respectively), but most of the difference was attributable to procedural cost ($9741 vs $7296, respectively), because the pharmacy costs were similar ($1901 vs $1686, respectively).