Multimodal Analgesia in Head and Neck Free Flap Reconstruction: A Systematic Review

Objective Postoperative pain after head and neck cancer surgery is commonly treated with opioids, which are associated with considerable side effects. The objective of this study is to analyze the safety and efficacy of using multimodal analgesia (MMA) for patients undergoing head and neck cancer surgery with free flap reconstruction. Data Sources A systematic search was conducted in PubMed, Cochrane, Embase, Scopus, and clinicaltrials.gov. Review Methods All studies comparing patients receiving MMA (gabapentin, corticosteroids, local anesthetic, acetaminophen, nonsteroidal anti-inflammatory drugs [NSAIDs]) vs patients receiving opioids for head and neck cancer surgery with free flap reconstruction were screened. The primary outcome was postoperative opioid usage. Secondary outcomes included length of stay, subjective pain scores, surgical/medical complications, adverse effects, and 30-day outcomes. Results A total of 10 studies representing 1253 patients (MMA, n = 594; non-MMA, n = 659) met inclusion criteria. Gabapentinoids were the most commonly used intervention (72.9%) followed by NSAIDs (44.6%), acetaminophen (44.3%), corticosteroids (25.1%), ketamine (7.2%), and nerve block (3.4%). Eight studies reported a significant decrease in postoperative opioid usage in the MMA groups. Subjective pain had wider variation, with most studies citing significant pain improvement. There were no differences in surgical outcomes, medical complications, adverse effects, or 30-day mortality and readmission rates. Conclusion With the rise of the opioid epidemic, MMA may play an important role in the treatment of postoperative pain after head and neck cancer surgery. A growing body of literature demonstrates a variety of effective perioperative regimens.

[1]  R. Middleton,et al.  Rationalizing post‐operative prophylactic anticoagulation in reconstructive head and neck cancer patients: a review , 2021, ANZ journal of surgery.

[2]  Michael Lawrence Barnett,et al.  Nonopioid, Multimodal Analgesia as First-line Therapy After Otolaryngology Operations: Primer on Nonsteroidal Anti-inflammatory Drugs (NSAIDs) , 2020, Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery.

[3]  O. Militsakh,et al.  Association of multimodal analgesia with perioperative safety and opioid use following head and neck microvascular reconstruction , 2020, Head & neck.

[4]  Juan S. Uribe,et al.  Implementation of a Standardized Multimodal Postoperative Analgesia Protocol Improves Pain Control, Reduces Opioid Consumption, and Shortens Length of Hospital Stay After Posterior Lumbar Spinal Fusion. , 2020, Neurosurgery.

[5]  N. Bailard,et al.  Association Between Multimodal Analgesia Administration and Perioperative Opioid Requirements in Patients Undergoing Head and Neck Surgery With Free Flap Reconstruction. , 2020, JAMA otolaryngology-- head & neck surgery.

[6]  Thomas S Lee,et al.  Opioid sparing multimodal analgesia treats pain after head and neck microvascular reconstruction , 2019, The Laryngoscope.

[7]  K. Stenson,et al.  Association of Perioperative Opioid-Sparing Multimodal Analgesia With Narcotic Use and Pain Control After Head and Neck Free Flap Reconstruction. , 2019, JAMA facial plastic surgery.

[8]  Natalie S Blencowe,et al.  RoB 2: a revised tool for assessing risk of bias in randomised trials , 2019, BMJ.

[9]  K. Hamunen,et al.  Systematic review on analgesics and dexamethasone for post-tonsillectomy pain in adults. , 2019, British journal of anaesthesia.

[10]  Eric A. Monteiro,et al.  Opioid prescribing practices following elective surgery in Otolaryngology-Head & Neck Surgery , 2019, Journal of Otolaryngology - Head & Neck Surgery.

[11]  Jesus Monico,et al.  The role of intravenous acetaminophen in post‐operative pain control in head and neck cancer patients , 2019, Laryngoscope investigative otolaryngology.

[12]  I. Binswanger,et al.  The United States opioid epidemic. , 2019, Seminars in perinatology.

[13]  A. Amini,et al.  Short- and Long-term Opioid Use in Patients with Oral and Oropharynx Cancer , 2018, Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery.

[14]  Qian Zhang,et al.  Efficacy and safety of lower extremity nerve blocks for postoperative analgesia at free fibular flap donor sites , 2018, Head & neck.

[15]  D. Kallogjeri,et al.  Effect of Perioperative Gabapentin Use on Postsurgical Pain in Patients Undergoing Head and Neck Mucosal Surgery: A Randomized Clinical Trial , 2018, JAMA otolaryngology-- head & neck surgery.

[16]  O. Militsakh,et al.  Development of Multimodal Analgesia Pathways in Outpatient Thyroid and Parathyroid Surgery and Association With Postoperative Opioid Prescription Patterns , 2018, JAMA otolaryngology-- head & neck surgery.

[17]  L. Buchmann,et al.  Association of Celecoxib Use With Decreased Opioid Requirements After Head and Neck Cancer Surgery With Free Tissue Reconstruction , 2018, JAMA otolaryngology-- head & neck surgery.

[18]  Deborah S. Lowery,et al.  Preoperative Multimodal Analgesia Decreases Postanesthesia Care Unit Narcotic Use and Pain Scores in Outpatient Breast Surgery , 2018, Plastic and reconstructive surgery.

[19]  J. Eloy,et al.  Opioid prescribing patterns among otolaryngologists: Crucial insights among the medicare population , 2018, The Laryngoscope.

[20]  A. Whittemore,et al.  Persistent Postoperative Opioid Use in Older Head and Neck Cancer Patients , 2018, Otolaryngology Head & Neck Surgery.

[21]  F. Jamali,et al.  Clinical Outcomes of Aspirin Interaction with Other Non-Steroidal Anti-Inflammatory Drugs: A Systematic Review. , 2018, Journal of pharmacy & pharmaceutical sciences : a publication of the Canadian Society for Pharmaceutical Sciences, Societe canadienne des sciences pharmaceutiques.

[22]  N. Hagemeier Introduction to the opioid epidemic: the economic burden on the healthcare system and impact on quality of life. , 2018, The American journal of managed care.

[23]  C. Kuo,et al.  Opioid Prescribing Patterns among Otolaryngologists , 2018, Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery.

[24]  Yi-fan Chen,et al.  Postoperative Hematoma in Microvascular Reconstruction of the Head and Neck , 2018, Annals of plastic surgery.

[25]  O. Militsakh,et al.  Multimodal Analgesia in Outpatient Head and Neck Surgery: A Feasibility and Safety Study , 2017, JAMA otolaryngology-- head & neck surgery.

[26]  Jessica M. Kohring,et al.  Multimodal Analgesia in Foot and Ankle Surgery. , 2017, The Orthopedic clinics of North America.

[27]  T. Grosser Cardiovascular Safety of Celecoxib, Naproxen, or Ibuprofen for Arthritis. , 2017, The New England journal of medicine.

[28]  O. Ljungqvist,et al.  Optimal Perioperative Care in Major Head and Neck Cancer Surgery With Free Flap Reconstruction: A Consensus Review and Recommendations From the Enhanced Recovery After Surgery Society , 2017, JAMA otolaryngology-- head & neck surgery.

[29]  M. Wax,et al.  The role of postoperative hematoma on free flap compromise , 2015, The Laryngoscope.

[30]  Tiejun Tong,et al.  Optimally estimating the sample mean from the sample size, median, mid-range, and/or mid-quartile range , 2015, Statistical methods in medical research.

[31]  Nitin A. Pagedar,et al.  Ketorolac After Free Tissue Transfer , 2014, The Annals of otology, rhinology, and laryngology.

[32]  M. Wax,et al.  Effect of Postoperative Aspirin on Outcomes in Microvascular Free Tissue Transfer Surgery , 2013, Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery.

[33]  C. Leung,et al.  Analgesic effects of preoperative gabapentin after tongue reconstruction with the anterolateral thigh flap. , 2012, Hong Kong medical journal = Xianggang yi xue za zhi.

[34]  L. Favard,et al.  The Early and Delayed Analgesic Effects of Ketamine After Total Hip Arthroplasty: A Prospective, Randomized, Controlled, Double-Blind Study , 2009, Anesthesia and analgesia.

[35]  R. Shayan,et al.  PREVENTING POSTOPERATIVE HAEMATOMAS IN MICROVASCULAR RECONSTRUCTION OF THE HEAD AND NECK: LESSONS LEARNT FROM 126 CONSECUTIVE CASES , 2008, ANZ journal of surgery.

[36]  Constance M. Chen,et al.  The Effect of Postoperative Anticoagulation on Microvascular Thrombosis , 2007, Annals of plastic surgery.

[37]  Concomitant Use of Ibuprofen and Aspirin , 2007 .

[38]  T. Hadlock,et al.  Effects of Aspirin and Low‐Dose Heparin in Head and Neck Reconstruction using Microvascular Free Flaps , 2005, The Laryngoscope.

[39]  K. Slim,et al.  Methodological index for non‐randomized studies (MINORS): development and validation of a new instrument , 2003, ANZ journal of surgery.

[40]  P. White Multimodal analgesia: its role in preventing postoperative pain. , 2008, Current opinion in investigational drugs.