EXPAREL® (Bupivacaine Liposome Injectable Suspension) in a Multimodal Pain Management Approach for Bariatric Surgery

Approximately 200,000 bariatric surgeries are performed annually in the United States.¹ More than half of these surgeries are sleeve gastrectomy procedures, in which the stomach is divided and vertically stapled to reduce capacity by more than 85%.^1,2 Overall, bariatric surgery is considered the most effective and enduring treatment for severe obesity and can positively affect related comorbidities such as type 2 diabetes, hypertension, heart disease, and sleep apnea.²

HCPLive recently hosted an interview with Brian Binetti, MD, FACS, director of metabolic and bariatric surgery at North Dutchess Hospital in Rhinebeck, New York, who has performed over 1000 surgical procedures, predominantly bariatric surgeries, since 2009. He was drawn to specialize in this type of surgery because of the satisfaction that patients receive from this life-changing event. In this interview, Dr. Binetti discussed challenges involved with bariatric surgery, his team’s multimodal approach, and his use of EXPAREL for effective perioperative pain management.

Challenges associated with recovery after bariatric surgery

Postoperative recovery for bariatric patients typically involves an overnight hospital stay. Goals for patients the first night include demonstrating the ability to keep down fluids and to walk. This process can be challenging. “[Bariatric patients] tend to be higher-risk patients in general,” said Dr. Binetti. “We face a lot of challenges in terms of helping them get through the process of surgery and through the hospital stay.” Preexisting medical conditions need to be managed for optimal outcomes. In addition, bowel function is compromised by abdominal surgery, and the pace of recovery is limited by how quickly bowel function returns.

Bowel function is also slowed if opioids are used for pain management. “Opioids are fairly dangerous,” said Dr. Binetti. “If we can eliminate using opioids, that’s a very important step to help combat the addiction crisis.” Given that just one opioid dose can lead to an addiction, Dr. Binetti shared, reducing use of opioids has been a focus for him and his team. “During the induction of anesthesia, during the anesthesia itself, and postoperatively, we’ve really tried to eliminate opioid use, so that the patient’s bowel function returns very quickly and they can be comfortable leaving the hospital the next day.”

Clinical impact of EXPAREL for bariatric surgery

EXPAREL has allowed Dr. Binetti’s practice to go from using opioids quite routinely—intraoperatively and postoperatively, and in the outpatient setting—to rarely using them at all. “We have tracked our opioid usage very rigorously in our practice,” said Dr. Binetti. “Last year we did more than 250 bariatric procedures, and we only had 2 patients use 1 pain pill [each] the whole year. We’ve seen a significant reduction in opioid use.”

Dr. Binetti began to use EXPAREL in 2011, excited for the opportunity to extend pain management for his patients. Now, he has completed more than 1000 procedures using EXPAREL. “[EXPAREL is] just a part of what we do in our process… [we] use it effectively to give our patients the best pain control we can,” said Dr. Binetti. His patients “have a very short length of stay. Most leave the first day after surgery.” The effect on patients has been tremendous, he said. “All those things have led to improved patient outcomes and patient satisfaction scores…patients are happier, patients are comfortable. I’m very glad that I’m able to use EXPAREL in the operating room for my patients.”

Use of EXPAREL in the operating room

Dr. Binetti shared how he uses EXPAREL extensively in the operating room. His team combines EXPAREL with bupivacaine hydrochloride 0.5%, which is a shorter-acting anesthetic. This combination “gives a very fast ‘on’ and a relatively fast ‘off’ while our EXPAREL starts to work,” said Dr. Binetti. “… EXPAREL [takes] a little bit longer to start working because the bupivacaine is encased in liposomes, so the bupivacaine hydrochloride 0.5% allows us to get a quicker, shorter-acting nerve block.” The team expands the volume of this combination with saline, which allows them to perform a large regional pain block, essentially blocking the whole abdominal wall rather than just incision sites.

Typically, Dr. Binetti makes approximately 5 incisions for the surgery and administers EXPAREL for each incision site. Then he performs a transversus abdominis plane block, which helps numb the abdominis wall. He even uses EXPAREL for a rectus sheath block to help block the nerves further. “We really try to expand the way we use EXPAREL in the operating room,” Dr. Binetti said.

For a gastric sleeve procedure, Dr. Binetti uses EXPAREL in an expanded format: 20 mL EXPAREL combined with 30 mL bupivacaine hydrochloride 0.5% and 150 mL normal saline, which results in 200 mL of local anesthetic. He uses 10 mL of this injection for each incision site. With this process, “not only do we numb the skin, but we numb down to the peritoneum for each of our port sites,” shared Dr. Binetti. Then he uses 50 mL on each side for a transversus abdominis plane block, which “goes from the ribs all the way down to the hips,” said Dr. Binetti. The final 50 mL are divided equally on each side of the rectus sheath.

EXPAREL as part of a multimodal approach

In Dr. Binetti’s practice, EXPAREL is used as part of a preoperative, intraoperative, and postoperative multimodal approach, with the goal of eliminating opioid use as much as possible while effectively managing pain and giving patients a smooth, comfortable hospital experience.

Patient education

A 1-hour patient education class is offered to patients prior to surgery on what to expect with the bariatric surgical process. Patients are told that EXPAREL will work over the course of days, and that a large percent of their abdominal wall will be numb, which patients typically find interesting.

Multimodal pain management

Preoperatively, Dr. Binetti’s team uses nonopioid pain relievers, such as intravenous acetaminophen. Intraoperatively, as mentioned earlier, EXPAREL is combined with bupivacaine hydrochloride 0.5% and saline. Postoperatively, the team uses multiple forms of intravenous nonopioid medications, such as nonsteroidal anti-inflammatory drugs, antispasmodic medications, and muscle relaxants, to keep patients comfortable.

Multidisciplinary and holistic approach

In addition to educating patients before surgery and effectively controlling their pain perioperatively, Dr. Binetti’s practice seeks to positively influence other holistic variables. These include “[patient] level of comfort in bed, how the nurses interact with them, how the doctors interact with them, and how the rest of the team interacts with them as they go through the hospital system,” said Dr. Binetti.

Looking ahead

Dr. Binetti noted the importance of increasing awareness of EXPAREL’s benefits and teaching a variety of specialists how to use the therapy correctly to expand its use across different surgeries for optimized pain management and to reduce reliance on opioids. “With the opioid crisis being what it is in our country, we have a responsibility to look at different options [in the postsurgical environment] to try to limit opioid usage,” said Dr. Binetti. “EXPAREL is a powerful tool we have to do that…I see [it as] an important part of reducing or eliminating opioid use throughout the hospital system.” He reiterated how his own practice has successfully reduced the use of postoperative narcotics substantially and stated that his patients benefit greatly from nonopioid options. “[EXPAREL administration is] fairly easy to do and it’s fairly easy to learn. [It] benefits my patients and improves their satisfaction, which improves my results and my benefit to the hospital and the community.”

Brian Binetti, MD, FACS, has a consulting relationship with Pacira BioSciences, Inc.

Important Notice

This site is intended to provide medical and product information to health care professionals in the United States.

To report an adverse event, email drugsafety@pacira.com or call 1-855-793-9727.

For medical inquiries related to EXPAREL, submit a request to Medical Information or call 1-855-793-9727.

These are not all of the potential important safety considerations for EXPAREL; please see the full Prescribing Information.

Indication

EXPAREL^® (bupivacaine liposome injectable suspension) is indicated for single-dose infiltration in patients aged 6 years and older to produce postsurgical local analgesia and in adults as an interscalene brachial plexus nerve block to produce postsurgical regional analgesia. Safety and efficacy have not been established in other nerve blocks.

Important Safety Information

EXPAREL is contraindicated in obstetrical paracervical block anesthesia.

Adverse reactions reported in adults with an incidence greater than or equal to 10% following EXPAREL administration via infiltration were nausea, constipation, and vomiting; adverse reactions reported in adults with an incidence greater than or equal to 10% following EXPAREL administration via interscalene brachial plexus nerve block were nausea, pyrexia, and constipation.

Adverse reactions with an incidence greater than or equal to 10% following EXPAREL administration via infiltration in pediatric patients six to less than 17 years of age were nausea, vomiting, constipation, hypotension, anemia, muscle twitching, vision blurred, pruritus, and tachycardia.

If EXPAREL and other non-bupivacaine local anesthetics, including lidocaine, are administered at the same site, there may be an immediate release of bupivacaine from EXPAREL. Therefore, EXPAREL may be administered to the same site 20 minutes after injecting lidocaine.

EXPAREL is not recommended to be used in the following patient populations: patients <6 years old for infiltration, patients younger than 18 years old for interscalene brachial plexus nerve block, and/or pregnant patients.

Because amide-type local anesthetics, such as bupivacaine, are metabolized by the liver, EXPAREL should be used cautiously in patients with hepatic disease.

Warnings and Precautions Specific to EXPAREL

Avoid additional use of local anesthetics within 96 hours following administration of EXPAREL.

EXPAREL is not recommended for the following types or routes of administration: epidural, intrathecal, regional nerve blocks other than interscalene brachial plexus nerve block, or intravascular or intra-articular use.

The potential sensory and/or motor loss with EXPAREL is temporary and varies in degree and duration depending on the site of injection and dosage administered and may last for up to 5 days, as seen in clinical trials.

Warnings and Precautions for Bupivacaine-Containing Products

Central Nervous System (CNS) Reactions: There have been reports of adverse neurologic reactions with the use of local anesthetics. These include persistent anesthesia and paresthesia. CNS reactions are characterized by excitation and/or depression.

Cardiovascular System Reactions: Toxic blood concentrations depress cardiac conductivity and excitability, which may lead to dysrhythmias, sometimes leading to death.

Allergic Reactions: Allergic-type reactions (eg, anaphylaxis and angioedema) are rare and may occur as a result of hypersensitivity to the local anesthetic or to other formulation ingredients.

Chondrolysis: There have been reports of chondrolysis (mostly in the shoulder joint) following intra-articular infusion of local anesthetics, which is an unapproved use.

Methemoglobinemia: Cases of methemoglobinemia have been reported with local anesthetic use.

Please refer to full Prescribing Information.

References

1. Estimate of bariatric surgery numbers, 2011-2020. American Society for Metabolic and Bariatric Surgery. June 2022. Accessed October 12, 2022. https://asmbs.org/resources/estimate-of-bariatric-surgery-numbers

2. Metabolic and bariatric surgery. American Society for Metabolic and Bariatric Surgery. July 2021. Accessed October 12, 2022. https://asmbs.org/resources/metabolic-and-bariatric-surgery