Cory WuFollow

Date of Award

January 2025

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Jinlei Li

Abstract

Breast cancer patients who undergo mastectomy for treatment have the option to proceed with cosmetic breast reconstruction, of which microsurgical flap techniques have become more and more predominant. Optimized recovery from these large-scale surgeries can impact both hospital resources and long-term patient health. The abdominal donor site is the prime suspect for the postoperative pain and delay in return of baseline functional status. Previous literature and clinical practice support the surgically placed transverses abdominal regional block as part of the multimodal analgesia regimen to aid recovery due to incisional pain control, but the technique lacks the ability to impact visceral pain. The anterior quadratus lumborum block, an emerging advanced fascial plane block is a promising alternative, because of its ability to block stimuli in the anterior abdominal region from both somatic and visceral stimuli.

This study follows a quality improvement initiative completed as part of a larger movement to implement new Early Recovery After Surgery (ERAS)-informed guidelines to improve recovery of patients who undergo the Deep Inferior Epigastric Artery Perforator (DIEP) microsurgical breast reconstruction procedure. 413 patients in total were retrospectively analyzed in this study. The control group (N=254) underwent the procedure before implementation of the pilot and received the standard clinical practice of an intraoperative surgically placed, landmark-based intraoperative transversus abdominus plane block using bupivacaine and liposomal bupivacaine. The experimental group (N=159) underwent the procedure after implementation of this new clinical pathway and received preoperative ultra-sound guided bilateral anterior quadratus lumborum block (aQLB) by a regional anesthesia team using bupivacaine plus dexamethasone sodium phosphate (DXP) and methylprednisolone acetate (MPA). Our working hypothesis was implementation of preoperative anesthesiologist-placed aQLB would improve postoperative outcomes after DIEP breast reconstruction. The primary outcome measured was average daily opioid consumption, and secondary outcomes included average daily pain scores, time to first ambulation, and hospital length of stay.

Final analysis of the data revealed a statistically significant decrease in the time to first ambulation in the experimental group by 17% or 7.7 hours (p = <0.005). Other secondary outcome metrics such as average daily opioid usage and hospital length of stay trended towards improvement in the experimental group, but did not reach statistical significance. Average daily pain was statistically significantly higher for the experimental group, but as stated above, did not result in increased opioid consumption for the experimental group. Subgroup analysis showed that the patients who received a quadratus lumborum block alongside a regional chest block were the ones who saw the greatest improvement in time to first ambulation, compared to those who only received a quadratus lumborum block.

The data demonstrates that the anterior quadratus lumborum block may have utility in improving the return to functional status in the immediate postoperative period following DIEP breast reconstruction. We also see that chest regional blockade may have a synergistic effect alongside the quadratus lumborum block in amplifying the improvements seen in mobility. The quadratus lumborum block was also shown to be non-inferior in terms of opioid consumption or hospital length of stay compared to the status quo surgically placed landmark-based transversus abdominus block with liposomal bupivacaine.

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