Demonstrating the benefits of transversus abdominis plane blocks on patient outcomes in laparoscopic colorectal surgery: review of 200 consecutive cases

Efficacy of transversus abdominis plane block for gastric surgery: a meta-analysis

BACKGROUND

Multimodal analgesia is an important component of Enhanced Recovery After Surgery (ERAS). Transversus abdominis plane (TAP) block helps achieve this pain management in various types of surgeries. To evaluate the efficacy of TAP block versus non-TAP approaches for postoperative pain management and recovery after gastric surgery.

METHODS

A systematic literature search across four databases (Cochrane, Embase, Web of Science, PubMed) until February 2024 identified relevant randomized controlled trials (RCTs) evaluating TAP block in gastric surgery. Two independent reviewers screened studies, extracted data, and assessed analyses.

PRIMARY OUTCOME

postoperative pain scores.

SECONDARY OUTCOMES

postoperative opioid consumption, hospital stay, time to ambulation, and time to flatus.

RESULTS

Twelve RCTs involving 841 participants were included. Compared to non-TAP, the TAP group demonstrated significantly lower visual analog scale (VAS) pain scores at 1, 3, 6, 12, 24, and 48 h postoperatively (WMD range: -0.62 to -0.97). Time to first ambulation (SMD - 0.46; 95% CI: -0.92, 0.00) and first flatus (WMD - 5.17; 95% CI: -8.58, -1.77) were shorter in the TAP group. Postoperative opioid consumption was reduced with TAP (WMD - 1.89; 95% CI: -2.41, -1.37), with no difference in hospital stay between groups.

CONCLUSION

TAP block effectively relieves pain after gastric surgery, decreases postoperative morphine requirements, and modestly shortens bed rest duration while promoting intestinal function recovery. However, it does not significantly affect the overall hospital length of stay.

Impact of Fascial Plane Block on Postoperative Length of Stay and Opioid Use Among Colectomy Patients Within an Established Enhanced Recovery After Surgery Program: A Retrospective Cohort Study

Background

Use of fascial plane blocks is increasing yet their impact on hospital length of stay (LOS) and opioid use within the context of an enhanced recovery after surgery (ERAS) pathway has been inconclusive. We address this gap by examining the impact of fascial plane blocks on postoperative LOS and opioid use for colorectal surgical procedures in a hospital setting with a robust ERAS program.

Methods

This is a retrospective cohort study using electronic health record data from a large, integrated health care delivery system with an established ERAS program in Northern California. Patients include adults who underwent non-emergent laparoscopic (n=5496) or non-laparoscopic (n=708) colectomy surgery from January 1, 2015 to May 20, 2021. The main exposure was type of anesthesia: general with long-acting fascial plane block, general with short-acting fascial plane block, or general only. Outcomes included postoperative LOS and average daily morphine milligram equivalents (MME) up to three days post-surgery.

Results

Most patients were older than age 50 (86% laparoscopic; 83% non-laparoscopic), female (52% laparoscopic; 58% non-laparoscopic), and non-Hispanic White (64% laparoscopic; 62% non-laparoscopic). In LOS adjusted models for laparoscopic and non-laparoscopic surgery, there was no significant difference for LOS with general with long-acting fascial plane block or with general with short-acting fascial plane block, compared to general only. In MME adjusted models for laparoscopic surgery, general with short-acting fascial plane block was associated with higher MME compared with general only (RE: 1.14,[95% CI: 1.03-1.25], p-value=0.01). However, in non-laparoscopic surgery, general with long-acting fascial plane block was associated with lower MME (RE: 0.63, [95% CI: 0.42-0.93], p-value=0.02), compared with general only.

Conclusion

Fascial plane blocks did not impact postoperative LOS in either surgical group but long acting resulted in lower overall postoperative opioid use for non-laparoscopic surgery.

Anterior Transversus Abdominis Plane Block for Lower Extremity Revascularization

INTRODUCTION

Regional anesthesia remains underutilized in vascular surgery; therefore, we retrospectively reviewed and compared the usage of perioperative opioids in patients undergoing lower extremity revascularization surgery, who received the anterior transversus abdominis plane (TAP) block along with local anesthesia at the incision site versus who did not receive any regional anesthesia.

METHODS

We conducted a retrospective review of 107 patients undergoing open or hybrid lower extremity revascularization under general anesthesia at a single institution between 2017 and 2022. Patients were divided into two groups. Regional block group (n = 41 [38%]) (femoral endarterectomy 27%; femoral endarterectomy + endovascular intervention 51%; infrainguinal bypass 22%) received both an intraoperative anterior TAP block and local anesthesia at the incision site; No regional block group (n = 66 [62%]) (femoral endarterectomy 29%; femoral endarterectomy + endovascular intervention 13%; infrainguinal bypass 58%) did not receive either regional or local anesthesia.

RESULTS

There were no significant differences in either the procedural metrics or intraprocedural complications between the two groups. The in-hospital stay was shorter in the Regional group, 1 (1, 3) versus the No regional group, 3 (2, 7), P < 0.001. The median intraoperative morphine milliequivalents use was 20 (15, 25) in the Regional block group and 25 (20, 35) in the No regional block group, P = 0.008. The median postoperative opioids use at 24h was 75 (60, 98) in the Regional block group and 113 (83, 151) in the No regional block group, P < 0.001; at 48h was 103 (70, 118) in the Regional block group and 148 (90, 210) in the No regional block group, P = 0.027; at 72h was 105 (70, 138) in the Regional block group and 196 (113, 263) in the No regional block group, P = 0.010.

CONCLUSIONS

Anterior TAP block combined with local anesthesia at the incision site seems to be a safe postoperative analgesia option for patients undergoing lower extremity revascularization surgery that could potentially help reducing both intra and postoperative opioids requirement.

Opioid free analgesia after return home in ambulatory colonic surgery patients: a single-center observational study

BACKGROUND

Because of the adverse effects of morphine and its derivatives, non-opioid analgesia procedures are proposed after outpatient surgery. Without opioids, the ability to provide quality analgesia after the patient returns home may be questioned. We examined whether an opioid-free strategy could ensure satisfactory analgesia after ambulatory laparoscopic colectomy.

METHODS

We performed a retrospective observational single-center study (of prospective collected database) including all patients eligible for scheduled outpatient colectomy. Postoperative analgesia was provided by paracetamol and nefopam. Postoperative follow-up included pain at mobilization (assessed by a numerical rating scale, NRS), hemodynamic variables, temperature, resumption of transit and biological markers of postoperative inflammation. The primary outcome was the proportion of patients with moderate to severe pain (NRS > 4) the day after surgery.

RESULTS

Data from 144 patients were analyzed. The majority were men aged 59 ± 12 years with a mean BMI of 27 [25-30] kg/m2. ASA scores were 1 for 14%, 2 for 59% and 3 for 27% of patients. Forty-seven patients (33%) underwent surgery for cancer, 94 for sigmoiditis (65%) and 3 (2%) for another colonic pathology. Postoperative pain was affected by time since surgery (Q3 = 52.4,p < 0.001) and decreased significantly from day to day. The incidence of moderate to severe pain at mobilization (NRS > 4) on the first day after surgery was (0.19; 95% CI, 0.13-0.27).

CONCLUSION

Non-opioid analgesia after ambulatory laparoscopic colectomy seems efficient to ensure adequate analgesia. This therapeutic strategy makes it possible to avoid the adverse effects of opioids.

TRIAL REGISTRATION

The study was retrospectively registered and approved by the relevant institutional review board (CERAR) reference IRB 00010254-2018 - 188). All patients gave written informed consent for analysis of their data. The anonymous database was declared to the French Data Protection Authority (CNIL) (reference 221 2976 v0 of April 12, 2019).

Postoperative NSAIDs use and the risk of anastomotic leakage after restorative resection for colorectal cancer

BACKGROUND

Although non-steroidal anti-inflammatory drugs (NSAIDs) are useful options for multimodal opioid-sparing analgesia, their effect on anastomotic leakage (AL) after colorectal surgery remains unclear. We aimed to investigate the association between early postoperative NSAID use and AL occurrence in patients who underwent colorectal cancer surgery at a high-volume tertiary care center.

METHODS

This retrospective observational study included all adult patients who underwent elective colorectal cancer resection surgery during 2011-2021 at a tertiary teaching hospital. Based on NSAID use within five postoperative days, patients were classified into either NSAID or no NSAID groups. We performed multivariable logistic regression analysis for the primary outcome, AL, within the first 30 postoperative days, before and after propensity score analysis using stabilized inverse probability of treatment weighting (sIPTW).

RESULTS

Among the 7928 patients analyzed, 0.6% experienced AL after surgery. The occurrence rates of AL were 1.7% (12/714) and 0.5% (37/7214) in the NSAID and no NSAID groups, respectively. Multivariable logistic regression analysis revealed that early postoperative NSAID use was significantly associated with AL [odds ratio (OR), 3.41; 95% confidence interval (CI), 1.76-6.60; P < 0.001]. Significance was maintained after sIPTW (OR, 3.65; 95% CI, 1.86-6.72; P < 0.001).

CONCLUSION

Early postoperative NSAID use was significantly associated with AL in patients undergoing colorectal cancer surgery at a high-volume tertiary care center. Further prospective studies are required to investigate NSAIDs' clinically meaningful unfavorable effects following colorectal cancer surgery.

Effects of Novel Multimodal Transversus Abdominis Plane Block on Postoperative Opioid Usage and Hospital Length of Stay Following Elective Ventral Hernia Repair

Background and objective Traditional transversus abdominis plane (TAP) blocks consisting of a local anesthetic, typically bupivacaine, have previously been shown to reduce postoperative pain following gastrointestinal surgery, including hernia repair. However, elective abdominal wall reconstructions for the repair of large ventral hernias continue to cause patients significant postoperative pain, resulting in prolonged hospital stays and need for opioid pain medication. This study aimed to analyze the postoperative opioid pain medication usage and hospital length of stay (LOS) in patients who received a nontraditional multimodal TAP block of ropivacaine (local anesthetic), ketorolac (non-steroidal anti-inflammatory), and epinephrine following elective ventral hernia repair. Methods A retrospective review of medical records for patients who underwent elective robotic ventral hernia repair by a single surgeon was conducted. Postoperative hospital LOS and opioid usage for patients with the multimodal TAP block were compared to those without. Results A total of 334 patients met the inclusion criteria for LOS analysis: 235 received the TAP block and 109 did not. Patients who received the TAP block had a statistically significant shorter LOS compared to patients who had no TAP block (1.09 ± 1.22 days vs. 2.53 ± 1.57 days; P<0.001). Medical records for 281 patients, 214 with the TAP block and 67 without the TAP block, contained information and were analyzed for postoperative opioid usage. A statistically significantly fewer number of patients who had the TAP block required hydromorphone patient-controlled analgesia pump (3.3% vs. 36%; P<0.001) and oral opioids (29% vs. 78%; P<0.001) postoperatively. Those with TAP block required intravenous opioids more frequently (50% vs 10%; P<0.001) although at much less dosages than those without TAP block (4.86 ± 2.62 mg vs. 10.29 ±3.90 mg; P<0.001). Conclusion In conclusion, this multimodal TAP block of ropivacaine, ketorolac, and epinephrine may represents an effective method to improve hospital LOS and postoperative opioid usage in patients undergoing robotic abdominal wall reconstruction for ventral hernia repair.

ERAS programme in a Portuguese tertiary hospital: An audit of the first six months of implementation in elective colorectal surgery

INTRODUCTION AND OBJECTIVES

Enhanced Recovery After Surgery (ERAS) is a multimodal strategy designed to optimize postoperative recovery and reduce morbidity, length of hospital stay, and care costs. The aim of this study was to evaluate compliance and clinical outcomes 6 months of implementation of the program in scheduled colorectal surgery in a tertiary hospital.

MATERIAL AND METHODS

Data from 209 patients who underwent elective colorectal surgery were analysed. The first 102 patients (pre-ERAS group) who underwent surgery between January and May 2018, before the implementation of the program, were compared with the 107 patients treated between May and October 2019, after ERAS implementation. The main outcomes were patient education and counselling, use of intravenous fluids, early mobilization, incidence of postoperative nausea and vomiting, return of bowel function, length of stay, complications, mortality, and overall compliance.

RESULTS

The ERAS program was associated with a significant increase in patient education and counselling (p<0.001) and with a significant reduction in intra- and postoperative IV fluid administration (p=0.007 and p<0.001, respectively) and postoperative nausea or vomiting (17.6% vs 5.0%, p=0.007). Time to recovery of activities of daily living (5.29 vs 2.85 days; p<0.001), time to solid oral intake (6.21 vs 4.35 days; p<0.001), time to first flatus (2.41 vs 1.51 days; p<0.001) and defecation (3.35 vs 1.66 days; p<0.001) decreased with ERAS. There were no statistically significant differences in length of stay, complications, and mortality.

CONCLUSION

This study showed that the ERAS program improved perioperative outcomes and postoperative recovery in patients undergoing colorectal surgery in our hospital.

Transversus Abdominis Plane Block Versus Local Wound Infiltration for Postoperative Pain After Laparoscopic Colorectal Cancer Resection: a Randomized, Double-Blinded Study

BACKGROUND

Despite the extensive administration of the enhanced recovery after surgery (ERAS) program, postoperative pain remains a major concern for patients. Transversus abdominis plane (TAP) block and local wound infiltration (LWI) are two techniques that have been widely applied in abdominal surgery. However, these two techniques have rarely been compared in terms of their analgesic effects on patients that undergo laparoscopic colorectal surgery with the ERAS program.

METHODS

A randomized, double-blinded study was conducted in this study. Briefly, 174 patients that underwent colorectal surgery with the ERAS program were randomly allocated to TAP block treatment (TAP group) or local wound infiltration (LWI group). All patients were assessed for their pain scores at rest and in motion at 6, 24, 48, and 72 h after surgery. The administration frequency of bolus for PCIA and the use amount of rescue analgesics (parecoxib) were recorded. Finally, the patients were monitored with follow-up surveys on their postoperative function recovery, complications, lengths of stay, treatment cost, and satisfaction.

RESULTS

In terms of the pain scores at rest and in motion, the two groups revealed no significant difference throughout the study sessions, and no difference was found in the administration frequency of bolus and the use amount of parecoxib. Moreover, the two groups demonstrated similar results in their postoperative recovery, and no significant differences were found in terms of postoperative complications.

CONCLUSIONS

Compared with local wound infiltration, transversus abdominis plane block is not significantly advantageous for postoperative pain control and recovery in patients undergoing laparoscopic colorectal surgery with the ERAS program. However, local wound infiltration might be preferred since it is available with less technical difficulties.

Efficacy of laparoscopic transversus abdominis plane block on postoperative pain management and surgery side effects in laparoscopic bariatric surgeries

PURPOSE

Transversus abdominis plane (TAP) block is a new option for reducing postoperative pain. This study investigated the effects of laparoscopic TAP block on postoperative adverse events and analgesia and antiemetics requirements after bariatric surgery.

METHODS

In this randomized clinical trial study, patients were randomly divided into control (N = 20) or TAP block (N = 20) groups. In the TAP block group, the block was performed under direct laparoscopic guidance after surgery and before the removal of trocars.

RESULTS

Fifteen patients (75%) versus four patients (20%) received opioids within the first 6 h in the control and TAP groups, respectively (p-value < 0.001). The cumulative amount of opioids consumed in the 24 and 48 h after surgery was lower in the TAP group (p-value < 0.001). The visual analog scale (VAS) regarding general and wound-specific pain was significantly lower in the TAP group compared to the control group at 6 and 24 h both at rest and in movement. However, there was no significant difference at 48 h postoperatively. The percentages of patients having postoperative nausea and vomiting (PONV), pruritus, and resumption of bowel movement were not significantly different between the two groups at any time (6, 24, and 48 h) postoperatively.

CONCLUSION

Laparoscopic-guided TAP block is a pragmatic, applicable, and minimally invasive regional technique and can be part of effective postoperative pain management in morbidly obese patients undergoing bariatric surgery. Applying it laparoscopically without the need for ultrasound is also useful and effective.

Perioperative analgesia with ultrasound-guided quadratus lumborum block for transurethral resection of prostate

BACKGROUND

Prostatic hyperplasia is a physiological aging process in men. After transurethral resection of prostate (TURP), visceral pain is the main cause. The effective postoperative analgesia can reduce the occurrence of postoperative complications. This study mainly studied the analgesic effect of quadratus lumborum block (QLB) on TURP.

METHODS

We divided 62 patients undergoing TURP into 2 groups using a random number table method (QLB 2 group and non-QLB [control] group). Patients in the QLB group underwent ultrasound-guided posterior QLB with 20 mL of 0.25% ropivacaine on each side, and those in the control group received only general anesthesia. The primary outcome for this study was the consumption analgesic pump during 0 to 24 hours. The secondary outcomes included the first pressing time of analgesic pump during 0 to 24 hours, the pain at rest and when coughing at 1, 4, 8, 12, and 24 hours post-operation as measured with a visual analogue scale for pain, length of the hospital stay, and complications (nausea and vomiting, dizziness, and abdominal distension).

RESULTS

Patients in the QLB group presented less consumption, later first pressing time of analgesic pump during 0 to 24 hours after surgery lower visual analogue scale scores at 1, 4, 8, 12, and 24 hours postsurgery than those in the control group. Moreover, their mean length of hospital stay was shorter (P = .023), and they experienced less postoperative complications than the patients in the control group.

CONCLUSIONS

Ultrasound-guided QLB in TURP provided a significant analgesic effect in our patients the first day after surgery. This analgesic model may improve the postoperative recovery after TURP.

Efficacy of transversus abdominis plane (TAP) block in colorectal surgery: a systematic review and meta-analysis

BACKGROUND

Multimodal opioid-sparing analgesia is a key component of the enhanced recovery after surgery (ERAS) protocol for postoperative pain management. Transversus abdominis plane (TAP) block has contributed to the implementation of this approach in different kinds of surgical procedures. The aim of this study was to evaluate the efficacy of TAP block and its impact on recovery in colorectal surgery.

METHODS

A comprehensive literature search of the PubMed, Embase, and Scopus databases was conducted. Studies that compared TAP block to a control group (no TAP block or placebo) after colorectal resections were included. The effects of TAP block in patients undergoing colorectal surgery were assessed, including the technical aspects of the procedure. Two measures were used to evaluate the effectiveness of postoperative pain control: a numeric pain rating score at rest and on coughing or movement at 24 h following surgery and the opioid requirement at 24 h. Clinical aspects of recovery were postoperative ileus, surgical site infection, postoperative nausea and vomiting, and length of hospital stay.

RESULTS

Sixteen studies were included in the analysis. Data showed that TAP block is a safe procedure associated with a significant reduction in the pain score at rest [WMD - 0.91 (95% CI - 1.56; - 0.27); p < 0.05] and on coughing or movement [WMD - 0.36 (95% CI - 0.72; - 0.01); p < 0.05] at 24 h after surgery and a significant decrease in morphine consumption in the TAP block group the day after surgery [WMD - 2.07 (95% CI - 2.63; - 1.51); p < 0.001].

CONCLUSIONS

TAP block appears to provide both an effective analgesia and a significant reduction in opioid use on the first postoperative day after colorectal surgery. Its use does not seem to lead to increased postoperative complications.

Implementation of liposomal bupivacaine transversus abdominis plane blocks into the colorectal enhanced recovery after surgery protocol: a natural experiment

BACKGROUND

Enhanced recovery after surgery (ERAS) programs are now standard of care for colorectal surgery. Efforts have been aimed at decreasing postoperative opioid consumption. The goal of this study is to evaluate the effect of liposomal bupivacaine transversus abdominis plane (TAP) blocks on opioid use and its downstream effect on rates of ileus and hospital length of stay (LOS).

METHODS

We performed a retrospective pre- and postintervention time-trend analysis (2016-2018) of ERAS patients undergoing laparoscopic colorectal surgery at two academic medical centers within the same hospital system. The intervention was liposomal bupivacaine TAP blocks versus standard local infiltration with bupivacaine with a primary outcome of total morphine milligram equivalents (MME) administered within 72 h of surgery. Secondary outcomes included hospital LOS and rate of postoperative ileus.

RESULTS

There were 556 patients included at the control hospital, and 384 patients were included at the treatment hospital. Patients at both hospitals were similar with regard to age, body mass index, comorbidities, and surgical indication. In an adjusted time-trend analysis, the treatment hospital was associated with a significant decrease in MME administered (- 15.9 mg, p = 0.04) and hospital LOS (- 0.8 days, p < 0.001). There was no significant decrease in the rate of ileus at the treatment hospital (- 6.9%, p = 0.08).

CONCLUSIONS

In a time-trend analysis, the addition of liposomal bupivacaine TAP blocks into the ERAS protocol resulted in significantly reduced opioid use and shorter hospital LOS for patients undergoing surgery at the treatment hospital. Liposomal bupivacaine TAP blocks should be considered for inclusion in the standard ERAS protocol.

Surgeon-delivered laparoscopic transversus abdominis plane blocks are non-inferior to anesthesia-delivered ultrasound-guided transversus abdominis plane blocks: a blinded, randomized non-inferiority trial

BACKGROUND

The transversus abdominis plane (TAP) block is an important non-narcotic adjunct for post-operative pain control in abdominal surgery. Surgeons can use laparoscopic guidance for TAP block placement (LTAP), however, direct comparisons to conventional ultrasound-guided TAP (UTAPs) have been lacking. The aim of this study is to determine if surgeon placed LTAPs were non-inferior to anesthesia placed UTAPs for post-operative pain control in laparoscopic colorectal surgery.

METHODS

This was a prospective, randomized, patient and observer blinded parallel-arm non-inferiority trial conducted at a single tertiary academic center between 2016 and 2018 on adult patients undergoing laparoscopic colorectal surgery. Narcotic consumption and pain scores were compared for LTAP vs. UTAP for 48 h post-operatively.

RESULTS

60 patients completed the trial (31 UTAP, 29 LTAP) of which 25 patients were female (15 UTAP, 10 LTAP) and the mean ages (SD) were 60.0 (13.6) and 61.5 (14.3) in the UTAP and LTAP groups, respectively. There was no significant difference in post-operative narcotic consumption between UTAP and LTAP at the time of PACU discharge (median [IQR] milligrams of morphine, 1.8 [0-4.5] UTAP vs. 0 [0-8.7] LTAP P = .32), 6 h post-operatively (5.4 [1.8-17.1] UTAP vs. 3.6 [0-12.6] LTAP P = .28), at 12 h post-operatively (9.0 [3.6-29.4] UTAP vs. 7.2 [0.9-22.5] LTAP P = .51), at 24 h post-operatively (9.0 [3.6-29.4] UTAP vs. 7.2 [0.9-22.5] LTAP P = .63), and 48 h post-operatively (39.9 [7.5-70.2] UTAP vs. 22.2 [7.5-63.8] LTAP P = .41). Patient-reported pain scores as well as pre-, intra-, and post-operative course were similar between groups. Non-inferiority criteria were met at all post-op time points up to and including 24 h but not at 48 h.

CONCLUSIONS

Surgeon-delivered LTAPs are safe, effective, and non-inferior to anesthesia-administered UTAPs in the immediate post-operative period.

TRIAL REGISTRY

The trial was registered at clinicaltrials.gov Identifier NCT03577912.

Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations: 2018

BACKGROUND

This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol.

METHODS

A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

RESULTS

All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly.

CONCLUSIONS

The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.

Implementation of an ERAS Pathway in Colorectal Surgery

Enhanced Recovery after Surgery (ERAS) protocols have been demonstrated to improve hospital length of stay and outcomes in patients undergoing colorectal surgery. This article presents the specific components of an ERAS protocol implemented at the authors' institution. In particular, details of both surgical and anesthetic ERAS pathways are provided with explanation of all aspects of preoperative, perioperative, and postoperative care. Evidence supporting inclusion of various aspects within the ERAS protocol is briefly reviewed. The ERAS protocol described has significantly benefitted postoperative outcomes in colorectal patients and can be employed at other institutions wishing to develop an ERAS pathway for colorectal patients. A checklist is provided for clinicians to easily reference and facilitate implementation of a standardized protocol.

Evaluation of Ultrasound-Guided Transversus Abdominis Plane Block for Postoperative Analgesia in Patients Undergoing Intraperitoneal Onlay Mesh Repair

Introduction:

Ventral hernia is a commonly performed surgical procedure in adults. Laparoscopic intraperitoneal onlay mesh repair (IPOM) of ventral hernia is procedure of choice. IPOM of ventral hernia is associated with significant pain. Hence, our aim was to study the efficacy of instilling preemptive local analgesia for reducing postoperative pain in patients undergoing laparoscopic ventral hernia repairs.

Objective:

To study the role of local infiltration of 10 ml of 0.5% ropivacaine in the anterior abdominal wall preoperatively to improve pain scores compared to conventional intravenous systemic analgesia.

Materials and Methods:

The study pool consists of two groups of patients (25 in each group) admitted for laparoscopic uncomplicated ventral hernia repair. Analysis was performed by the SPSS program (Company – International Business Machines Corporation, headquartered at Armonk, New York, USA) for Windows, version 17.0. Normally distributed continuous variables were compared using ANOVA. Categorical variables were analyzed using the Chi-square test.

Results:

Both groups were matching in terms of demographic features. Postoperatively, pain assessment was performed every 30 min for the first 2 h and was followed up for a period of 24 h at intervals (4, 6, 12, and 24 h). Postoperatively, patients were also assessed for time of ambulation, time of return of bowel sounds at 6, 12, and 24 h, and length of hospital stay. Side effects and complication were noted.

Conclusion:

Our study demonstrated that supplementing US-guided transversus abdominis plane (TAP) block to conventional systemic analgesics resulted in decreased VAS scores and decreased requirement of rescue analgesics. The patients ambulated early had earlier appearance of bowel sounds and decreased length of hospital stay. There was also decreased incidence of nausea and vomiting. TAP block for laparoscopic IPOM surgery significantly decreases postoperative pain and opioid requirement in patients.

A pragmatic approach to evaluating new techniques in regional anesthesia and acute pain medicine

Anesthesiologists set up regional anesthesia and acute pain medicine programs in order to improve the patient outcomes and experience. Given the increasing frequency and volume of newly described techniques, applying a pragmatic framework can guide clinicians on how to critically review and consider implementing the new techniques into clinical practice. A proposed framework should consider how a technique: increases access; enhances efficiency; decreases disparities and improves outcomes. Quantifying the relative contribution of these four factors using a point system, which will be specific to each practice, can generate an overall scorecard to help clinicians make decisions on whether or not to incorporate a new technique into clinical practice or replace an incumbent technique within a clinical pathway.

Laparoscopic-guided transversus abdominis plane block versus trocar site local anesthetic infiltration in gynecologic laparoscopy

Background

Relieving postoperative pain and prompt resumption of physical activity are of the utmost importance for the patients and surgeons. Infiltration of local anesthetic is frequently used methods of pain control postoperatively. Laparoscopically delivered transversus abdominis plane block is a new modification of ultrasound-guided transversus abdominis plane block.

This study was conducted to compare the efficacy of laparoscopic-guided transversus abdominis plane block with trocar site local anesthetic infiltration for pain control after gynecologic laparoscopy.

Results

No statistically significant difference between the two groups in mean visual analogue scale at 1, 18, and 24 h (P = 0.34, P = 0.41, and P = 0.61, respectively), while the mean visual analogue scale was significantly lower in the laparoscopic-guided transversus abdominis plane block group than in the trocar site local anesthetic infiltration group at 3, 6, and 12 h (P = 0.049, P = 0.011, and P = 0.042, respectively). No statistically significant difference was observed in the cumulative narcotics consumed at 3 h (P = 0.52); however, women with transversus abdominis plane block have consumed significantly less amount of narcotics than women with trocar site infiltration at 6, 12, and 24 h (P = 0.04, P = 0.038, and P = 0.031 respectively). Patient satisfaction was significantly higher in the laparoscopic-guided transversus abdominis plane block group (P = 0.035).

Conclusion

Laparoscopic-guided transversus abdominis plane block is more effective in reduction of both pain scores in the early postoperative period and the cumulative narcotics consumption than trocar site local anesthetic infiltration in gynecologic laparoscopy.

Trial registration

Clinical Trials.gov NCT02973451

Optimizing an Enhanced Recovery Pathway Program: Development of a Postimplementation Audit Strategy

BACKGROUND

Enhanced recovery pathways (ERPs) are bundled best-practice process measures associated with reduction of preventable harm, decreased length of stay (LOS), and increased overall value of care. An auditing procedure was developed to assess compliance with 18 ERP process measures and establish a system for identifying and addressing defects in measure implementation.

METHODS

For a one-year period, the electronic health records of 413 consecutive patients treated on a multidisciplinary ERP for colorectal surgery at an academic medical center were evaluated with the audit procedure. Patients were stratified who both met the expected LOS, as defined by LOS less than the historical (pre-ERP) average LOS for the same procedure ("successes"), and exceeded the historical LOS ("outliers"). On the basis of the results of the audit process, a number of system-level interventions were developed. The results were then assessed for a three-month follow-up period to determine the impact on process measure compliance and LOS.

RESULTS

Detailed review of outliers identified several defects that improved following implementation of system-level changes, such as early mobility after surgery (44.4% vs. 59.5; p = 0.02). Although increased compliance through selective process measure optimization did not lead to a significant reduction in overall LOS (days; 5.2 ± 5.0 vs. 4.9 ± 3.0; p = 0.37), the audit procedure was associated with a significant reduction in outliers' LOS (days; 12.2 ± 6.8 vs. 9.0 ± 2.1; p = 0.03).

CONCLUSION

Concentrating audits in patients who fail to meet expectations on an ERP is an effective strategy to maximize identification of defects in and improve on pathway implementation.

Enhanced recovery after surgery: Pain management

Effective pain management is fundamental to enhanced recovery after surgery. Selection of strategies should be tailored to patient and operation. As well as improving the quality of recovery, effective analgesia reduces the host stress response, facilitates mobilization and allows resumption of oral intake. Multi-modal regimens combining paracetamol, non-steroidal anti-inflammatory agents where indicated, a potent opioid and a local anaesthetic technique achieve effective analgesia while limiting the dose and thereby side effects of any one agent.

The Role of Transversus Abdominis Plane Blocks in Enhanced Recovery After Surgery Pathways for Open and Laparoscopic Colorectal Surgery

INTRODUCTION

The concepts of Enhanced Recovery After Surgery (ERAS^®) have steadily increased in usage, with benefits in patient outcomes and hospital length of stay. One important component of successful implementation of ERAS protocol is optimized pain control, via the multimodal approach, which includes neuraxial or regional anesthesia techniques and reduction of opioid use as the primary analgesic. Transversus abdominis plane (TAP) block is one such regional anesthesia technique, and it has been widely studied in abdominal surgery.

MATERIALS AND METHODS

We performed an extensive literature search in MEDLINE and PubMed. We review the benefits of TAP blocks for colorectal surgery, both laparoscopic and open. We organize the data by surgery type, by method of TAP block performance, and by a comparison of TAP block to alternative analgesic techniques or to placebo. We examine different endpoints, such as postoperative pain, analgesic use, return of bowel function, and length of stay.

RESULTS

The majority of studies examined TAP blocks in the context of laparoscopic colorectal surgery, with many, but not all, demonstrating significantly less use of postoperative opioids in comparison to placebo, wound infiltration, and standard postoperative patient-controlled analgesia with intravenous opioid administration. There is evidence that use of liposomal bupivacaine may be more effective than conventional long-acting local anesthetics. Noninferiority of TAP infusions has been demonstrated, compared with continuous thoracic epidural infusions.

CONCLUSION

TAP blocks are easily performed, cost-effective, and an opioid-sparing adjunct for laparoscopic colorectal surgery, with minimal procedure-related morbidity. The evidence is in concordance with several of the goals of ERAS pathways.

Use of Regional Anesthesia Techniques: Analysis of Institutional Enhanced Recovery After Surgery Protocols for Colorectal Surgery

INTRODUCTION

Principles of Enhanced Recovery After Surgery (ERAS^®) protocols are well established, with the primary goal of optimizing perioperative care and recovery. The use of multimodal analgesia is a key component of these protocols, including regional analgesia techniques such as thoracic epidural analgesia (TEA), transversus abdominis plane (TAP), rectus sheath blocks or continuous wound infiltration (CWI)/catheters, and spinal anesthesia. We compare and contrast regional anesthesia approaches in different institutional colorectal surgery ERAS protocols.

MATERIALS AND METHODS

ERAS protocols for open and laparoscopic colorectal surgery were obtained from 15 different healthcare facilities mostly located in North American and one in New Zealand. A comparison was then made with respect to regional anesthesia recommendations.

RESULTS

The most commonly used regional technique among protocols was TEA. TAP blocks were the next most common, with rectus sheath blocks and continuous wound catheters only mentioned in one protocol each.

CONCLUSION

There are both similarities and differences in regional anesthesia techniques, which may be due to institution- and provider-level factors. Most protocols advocate for TEA use, which has been associated with a lower incidence of paralytic ileus, attenuation of the surgical stress response, improved intestinal blood flow, improved analgesia, and reduction of opioid use. Use of spinal anesthesia may lead to earlier mobilization compared to TEA, and lower doses of intrathecal morphine are recommended to reduce respiratory depression. TAP blocks were indicated for laparoscopic procedures. Rectus sheath blocks, which are listed in some protocols, may provide analgesia equivalent to epidural anesthesia, while avoiding complications of TEA. CWI has been effective in reducing postoperative pain, hastening recovery, and improving pulmonary function.

Transversus abdominis plane (TAP) block versus thoracic epidural analgesia (TEA) in laparoscopic colon surgery in the ERAS program

AIM

The enhanced recovery after surgery (ERAS) pathway and laparoscopic approach had been proven beneficial for patients and should now be considered as a standard of care in colorectal surgery. Multimodal analgesia is the gold standard in the ERAS program with the use of thoracic epidural analgesia (TEA). Few data are available on Transversus abdominis plane (TAP) blocks in laparoscopic colorectal surgery and ERAS pathway. The aim of this study is to evaluate the efficacy of TAP block compared to TEA in the management of postoperative pain and the impact on the recurrence of postoperative nausea, vomiting and ileus in laparoscopic colorectal surgery in the ERAS program.

METHOD

From October 2014 to October 2016, 182 patients underwent elective colon surgical interventions in enhanced recovery after surgery pathway. The patients were divided into two groups: Group 1 (n = 92) and Group 2 (n = 91) who received TEA and TAP block, respectively, with a standardized postoperative analgesic regimen consisting of regular 1 g of paracetamol every 8 h and a rescue dose with intravenous non-steroidal anti-inflammatory drugs infusion for both groups.

RESULTS

No differences were observed in baseline patient characteristics, clinical variables and surgical procedures between the two groups, as well as in the postoperative complications rate (p = 0.515) in accordance with Clavien-Dindo classification, 90-day mortality (p = 0.319), hospital stay (p = 0.469) and 30-day readmission rate (p = 0.711). Patients in the TAP block group showed lower postoperative nausea and vomiting rates (p = 0.025), as well as lower ileus (p = 0.031) and paraesthesia rates (p = 0.024). No differences were found in urinary retention (p = 0.157). Despite the "opioid-free" analgesia protocol in the TAP block group, pain intensity was comparable between the two groups (p = 0.651).

CONCLUSION

TAP block combined with an opioid-sparing analgesia in the setting of the laparoscopic colorectal surgery and ERAS program is feasible and effective in postoperative pain control.

Liposomal Bupivacaine Use in Transversus Abdominis Plane Blocks Reduces Pain and Postoperative Intravenous Opioid Requirement After Colorectal Surgery

BACKGROUND

Enhanced recovery protocols frequently use multimodal postoperative analgesia to improve postoperative outcomes in patients undergoing colorectal surgery.

OBJECTIVE

The purpose of this study was to evaluate liposomal bupivacaine use in transversus abdominis plane blocks on postoperative pain scores and opioid use after colorectal surgery.

DESIGN

This was a retrospective cohort study comparing outcomes between patients receiving nonliposomal anesthetic (n = 104) and liposomal bupivacaine (n = 303) blocks.

SETTINGS

The study was conducted at a single tertiary care center.

PATIENTS

Patients included those identified within an institutional database as inpatients undergoing colorectal procedures between 2013 and 2015 who underwent transversus abdominis plane block for perioperative analgesia.

MAIN OUTCOME MEASURES

The study measured postoperative pain scores and opioid requirements.

RESULTS

Patients receiving liposomal bupivacaine had significantly lower pain scores for the first 24 to 36 postoperative hours. Pain scores were similar after 36 hours. The use of intravenous opioids among the liposomal bupivacaine group decreased by more than one third during the hospitalization (99.1 vs 64.5 mg; p = 0.040). The use of ketorolac was also decreased (49.0 vs 18.3 mg; p < 0.001). In subgroup analysis, the decrease in opioid use was observed between laparoscopic and robotic procedures but not with laparotomies. No significant differences were noted in the use of oral opioids, acetaminophen, or ibuprofen. Postoperative length of stay and total cost were decreased in the liposomal bupivacaine group but did not achieve statistical significance.

LIMITATIONS

The study was limited by its retrospective, single-center design and heterogeneity of block administration.

CONCLUSIONS

Attenuated pain scores observed with liposomal bupivacaine use were associated with significantly lower intravenous opioid and ketorolac use, suggesting that liposomal bupivacaine-containing transversus abdominis plane blocks are well aligned with the opioid-reducing goals of many enhanced recovery protocols.

Protocol for a multicentre, prospective, observational cohort study of variation in practice in perioperative analgesic strategies in elective laparoscopic colorectal surgery: the LapCoGesic Study

INTRODUCTION

Laparoscopic surgery combined with enhanced recovery programmes has become the gold standard in the elective management of colorectal disease. However, there is no consensus with regard to the optimal perioperative analgesic regime in this cohort of patients, with a number of options available, including thoracic epidural spinal analgesia, patient-controlled analgesia, subcutaneous and/or intraperitoneal local anaesthetics, local anaesthetic wound infiltration catheters and transversus abdominis plane blocks. This study aims to explore any differences in analgesic strategies employed across the North East of England and to assess whether any variation in practice has an impact on clinical outcomes.

METHODS AND ANALYSIS

All North East Colorectal units will be recruited for participation by the Northern Surgical Trainees Research Association (NoSTRA). Data will be collected over a consecutive 2-month period. Outcome measures will include postoperative pain score, postoperative opioid analgesic use and side effects, length of stay, 30-day complication rates, 30-day reoperative rates and 30-day readmission rates.

ETHICS AND DISSEMINATION

Ethical approval for this study has been granted by the National Research Ethics Service. The protocol will be disseminated through NoSTRA. Individual unit data will be presented at local meetings. Overall collective data will be published in peer-reviewed journals and presented at relevant surgical meetings.

Efficacy of transversus abdominis plane block with liposomal bupivacaine during open abdominal wall reconstruction

BACKGROUND

Transversus abdominis plane block (TAPb) is an analgesic adjunct used for abdominal surgical procedures. Liposomal bupivacaine (LB) demonstrates prolonged analgesic effects, up to 72 hours. We evaluated the analgesic efficacy of TAPb using LB for patients undergoing open abdominal wall reconstruction (AWR).

METHODS

Fifty patients undergoing AWR with TAPb using LB (TAP-group) were compared with a matched historical cohort undergoing AWR without TAPb (control group). Outcome measures included postoperative utilization of morphine equivalents, numerical rating scale pain scores, time to oral narcotics, and length of stay (LOS).

RESULTS

Cohorts were matched demographically. No complications were associated with TAPb or LB. TAP-group evidenced significantly reduced narcotic requirements on operative day (9.5 mg vs 16.5 mg, P = .004), postoperative day (POD) 1 (26.7 mg vs 39.5 mg, P = .01) and POD2 (29.6 mg vs 40.7 mg, P = .047) and pain scores on operative day (5.1 vs 7.0, P <.001), POD1 (4.2 vs 5.5, P = .002), and POD2 (3.9 vs 4.8, P = .04). In addition, TAP-group demonstrated significantly shorter time to oral narcotics (2.7 days vs 4.0 days, P <.001) and median LOS (5.2 days vs 6.8 days, P = .004).

CONCLUSIONS

TAPb with LB demonstrated significant reductions in narcotic consumption and improved pain control. TAPb allowed for earlier discontinuation of intravenous narcotics and shorter LOS. Intraoperative TAPb with LB appears to be an effective adjunct for perioperative analgesia in patients undergoing open AWR.

Local wound infiltration plus transversus abdominis plane (TAP) block versus local wound infiltration in laparoscopic colorectal surgery and ERAS program

BACKGROUND

Few data are available on TAP block in laparoscopic colorectal surgery and ERAS program. The aim of this prospective study was to evaluate local wound infiltration plus TAP block compared to local wound infiltration in the management of postoperative pain, nausea and vomiting, ileus and use of opioids in the context of laparoscopic colorectal surgery and ERAS program.

METHODS

From March 2014 to March 2015, 48 patients were treated by laparoscopic resection and ERAS program for colorectal cancer and diverticular disease at the Division of General and Hepatobiliary Surgery, University of Verona Hospital Trust. Among these, 24 patients received local wound infiltration plus TAP block (TAP block group) and 24 patients received local wound infiltration (control group).

RESULTS

No differences were observed in baseline patient characteristics, clinical variables and surgical procedures between the two groups. Local wound infiltration plus TAP block allowed to achieve pain control despite a reduced use of opioid analgesics (P = 0.009). The adoption of TAP block resulted beneficial on the prevention of postoperative nausea (P = 0.002) and improvement of essential outcomes of ERAS program as recovery of bowel function (P = 0.005), urinary catheter removal (P = 0.003) and capability to tolerate oral diet (P = 0.027).

CONCLUSIONS

TAP block plus local wound infiltration in the setting of laparoscopic colorectal surgery and ERAS program guarantees a reduced use of opioid analgesics and good pain control allowing the improvement of essential items of enhanced recovery pathways.

Efficacy of laparoscopic transversus abdominis plane block for elective laparoscopic cholecystectomy in elderly patients

Transversus abdominis plane (TAP) block technique seems to offer one of the most efficient methods for a local pain control. Our aim is to demonstrate the effectiveness and safety of TAP block for post-operative pain control under laparoscopic vision in elderly patients during laparoscopic cholecystectomy. The patients aged more than 65 years old, who had cholecystectomy due to symptomatic cholelithiasis, were retrospectively evaluated. The patients that were operated under general anesthesia + laparoscopic TAP block and those who were operated only under only general anesthesia were compared according to their' age and gender, comorbidities, American Society of Anesthesiologists scores, visual analog scale (VAS) for pain and length of stay in the hospital. Median (±interquartile range) values of post-operative 24th-hour-VAS for pain was found consecutively 2 (±1-3) in TAP block + group and 3 (±2-5) in TAP block - group. The median post-operative 24th-hour-VAS value in overall patients was three. Patients' VAS values were higher in the TAP block - group with a statistically significant difference (p = 0.001). Furthermore, no statistically significant difference was found for other parameters in two groups. The laparoscopic-guided TAP block can easily be performed and has potential for lower visceral injury risk and shorter operational time. Efficacy, safety and other advantages (analgesic requirements, etc.) make it an ideal abdominal field block in elderly patients.

Transversus abdominal plane (TAP) block for postoperative pain management: a review

Transversus abdominal plane (TAP) block has a long history and there is currently extensive clinical experience around TAP blocks. The aim of this review is to provide a summary of the present evidence on the effects of TAP block and to provide suggestions for further studies. There are several approaches to performing abdominal wall blocks, with the rapid implementation of ultrasound-guided technique facilitating a major difference in TAP block performance. During surgery, an abdominal wall block may also be applied by the surgeon from inside the abdominal cavity. Today, there are more than 11 meta-analyses providing a compiled evidence base around the effects of TAP block. These analyses include different procedures, different techniques of TAP block administration and, importantly, they compare the TAP block with a variety of alternative analgesic regimes. The effects of TAP block during laparoscopic cholecystectomy seem to be equivalent to local infiltration analgesia and also seem to be beneficial during laparoscopic colon resection. The effects of TAP are more pronounced when it is provided prior to surgery and these effects are local anaesthesia dose-dependent. TAP block seems an interesting alternative in patients with, for example, severe obesity where epidural or spinal anaesthesia/analgesia is technically difficult and/or poses a risk. There is an obvious need for further high-quality studies comparing TAP block prior to surgery with local infiltration analgesia, single-shot spinal analgesia, and epidural analgesia. These studies should be procedure-specific and the effects should be evaluated, both regarding short-term pain and analgesic requirement and also including the effects on postoperative nausea and vomiting, recovery of bowel function, ambulation, discharge, and protracted recovery outcomes (assessed by e.g., postoperative quality of recovery scale).

Pilot study of a novel pain management strategy: evaluating the impact on patient outcomes

BACKGROUND

Our objective was to evaluate the impact of a novel multimodal pain management strategy on intraoperative opioid requirements, postoperative pain, narcotic use, and length of stay.

METHODS

Consecutive patients undergoing elective laparoscopic colorectal resection were managed with an experimental protocol. The protocol uses a post-induction, pre-incision bilateral TAP block and local peritoneal infiltration at port sites with long-acting liposomal bupivacaine (20 mL long-acting liposomal bupivacaine, 30 mL 0.25 % bupivacaine, 30 mL saline). Experimental patients were matched on age, body mass index, gender, comorbidity, diagnosis, and procedure to a control group that received no block or local wound infiltration. Both groups followed a standardized enhanced recovery pathway. Demographics, perioperative, and postoperative outcomes were evaluated. The main outcome measures were intraoperative opioids, postoperative pain, opioid use, and length of stay.

RESULTS

Fifty patients were analyzed-25 experimental and 25 controls. Patients were well matched on all demographics. In both cohorts, the main diagnosis was colorectal cancer and primary procedure performed a segmental resection. Operative times were similar (p = 0.41). Experimental patients received significantly less intraoperative fentanyl (mean 158 mcg experimental vs. 299 mcg control; p < 0.01). The experimental group had significantly lower initial (p < 0.01) and final PACU pain scores (p = 0.04) and shorter LOS (3.0 vs. 4.1 days, p = 0.04) compared to controls. Experimental patients trended toward shorter PACU times and lower opioid use and daily pain scores throughout the hospital stay. Postoperative complication and readmission rates were similar across groups. There were no reoperations or mortality.

CONCLUSIONS

Our multimodal pain management strategy reduced intraoperative opioid administration. Postoperatively, improvements in PACU time, postoperative pain and narcotic use, and lengths of stay were seen in the experimental cohort. With the favorable finding from the pilot study, further investigation is warranted to fully evaluate the impact of this pain management protocol on patient satisfaction, clinical and financial outcomes.