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Reply: Transversus Abdominis Plane Block Reduces Morphine Consumption in the Early Postoperative Period following Microsurgical Abdominal Tissue Breast Reconstruction A Double-Blind, Placebo-Controlled, Randomized Trial

Zhong, Toni M.D., M.H.S.; Novak, Christine B. P.T., Ph.D.; Hofer, Stefan O. P. M.D., Ph.D.

Plastic and Reconstructive Surgery: May 2015 - Volume 135 - Issue 5 - p 920e–921e
doi: 10.1097/PRS.0000000000001182
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University Health Network Breast Restoration Program, Division of Plastic and Reconstructive Surgery, University Health Network, Toronto, Ontario, Canada

Department of Surgery, Division of Plastic Reconstructive Surgery, Toronto Western Hospital Hand Program, Toronto, Ontario, Canada

Division of Plastic Surgery, Department of Surgery and Department of Surgical Oncology, University Health Network, Toronto, Ontario, Canada

Correspondence to Dr. Zhong, University Health Network Breast Restoration Program, Division of Plastic and Reconstructive Surgery, TGH, 8NU-871, 200 Elizabeth Street, University Health Network, Toronto, Ontario M5G 2C4, Canada, toni.zhong@uhn.ca

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Sir:

We thank Dr. Wheble and colleagues for their interest in our study regarding the use of transversus abdominis plane blocks with bupivacaine following microsurgical abdominal tissue breast reconstruction. Dr. Wheble and colleagues present their results from a retrospective, nonrandomized, observational study that evaluated the use of a single ultrasound-guided transversus abdominis plane block (n = 12) compared with a historic cohort (n = 15).1 They found using this technique that there was a significantly lower morphine requirement in the transversus abdominis plane block group, a significant reduction in hospital stay, and fewer episodes of postoperative nausea and vomiting. As a result, they suggested that, for pain control, the use of a single dose of ultrasound-guided transversus abdominis plane block may be as effective and more cost-effective and have fewer potential complications.

To address the issue of safety, inserting a soft-tipped epidural catheter into the triangle of Petit under direct vision was a completely safe procedure and we did not have any transversus abdominis plane block–related complications in our study.2 In many ways, for a surgeon, directly visualizing the layers of the abdominal wall is a safer technique than using an ultrasound-guided technique. As in the study design by Dr. Wheble and colleagues,1 we previously performed a study to compare a group of patients who received transversus abdominis plane block with a historic control group who did not, and found an impressively significant reduction in morphine consumption in the transversus abdominis plane block group by approximately 75 percent.3 However, it is important to note that effects of the intervention tend to be more pronounced in observational studies compared with randomized controlled trials when both known and unknown confounders are balanced between the two groups through randomization. Therefore, to definitively determine whether a single dose of ultrasound-guided transversus abdominis plane block is more effective, a double-blind, randomized, controlled trial study design should be used to test this hypothesis. The issue of the cost effectiveness of a single dose versus multiple intermittent boluses of bupivacaine for pain control is an important and pertinent issue that has not been investigated and requires further investigation.

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DISCLOSURE

The authors have no financial interest to declare in relation to the content of this communication.

Toni Zhong, M.D., M.H.S.

University Health Network Breast Restoration Program

Division of Plastic and Reconstructive Surgery

University Health Network

Christine B. Novak, P.T., Ph.D.

Department of Surgery

Division of Plastic Reconstructive Surgery

Toronto Western Hospital Hand Program

Stefan O. P. Hofer, M.D., Ph.D.

Division of Plastic Surgery

Department of Surgery and

Department of Surgical Oncology

University Health Network

Toronto, Ontario, Canada

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REFERENCES

1. Wheble GA, Tan EK, Turner M, Durrant CA, Heppell S.. Surgeon-administered, intra-operative transversus abdominis plane block in autologous breast reconstruction: A UK hospital experience. J Plast Reconstr Aesthet Surg. 2013;66:1665–1670
2. Zhong T, Ojha M, Bagher S, et al. Transversus abdominis plane block reduces morphine consumption in the early postoperative period following microsurgical abdominal tissue breast reconstruction: A double-blind, placebo-controlled, randomized trial. Plast Reconstr Surg. 2014;134:870–878
3. Zhong T, Wong KW, Cheng H, et al. Transversus abdominis plane (TAP) catheters inserted under direct vision in the donor site following free DIEP and MS-TRAM breast reconstruction: A prospective cohort study of 45 patients. J Plast Reconstr Aesthet Surg. 2013;66:329–336
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