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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

  • Daniel J. Wong
  • Thomas Curran
  • Vitaliy Y. Poylin
  • Thomas E. CataldoEmail author
Article
  • 104 Downloads

Abstract

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.

Keywords

Transversus abdominis plane (TAP) block Laparoscopy Post-operative pain control Enhanced recovery after surgery 

Notes

Acknowledgements

The authors thank Shaelah Huntington and Dr. Marc Shnider for their contributions. This work was conducted with support from Harvard Catalyst|The Harvard Clinical and Translational Science Center (National Center for Advancing Translational Sciences, National Institutes of Health Award UL1 TR001102) and financial contributions from Harvard University and its affiliated academic healthcare centers. The content is solely the responsibility of the authors and does not necessarily represent the official views of Harvard Catalyst, Harvard University and its affiliated academic healthcare centers, or the National Institutes of Health.

Compliance with ethical standards

Disclosures

Dr. Curran reports personal fees from KCI Inc, outside the scope of the submitted work. Dr. Wong, Dr. Poylin, and Dr. Cataldo have no conflicts of interest or financial ties to disclose.

References

  1. 1.
    Spanjerberg W, Reurings J, Keus F, Cjhm VL (2011) Fast track surgery versus conventional recovery strategies for colorectal surgery. Cochrane Database Syst Rev.  https://doi.org/10.1002/14651858.CD007635.pub2 CrossRefGoogle Scholar
  2. 2.
    Zhuang C-L, Ye X-Z, Zhang X-D et al (2013) Enhanced recovery after surgery programs versus traditional care for colorectal surgery. Dis Colon Rectum 56:667–678.  https://doi.org/10.1097/DCR.0b013e3182812842 CrossRefGoogle Scholar
  3. 3.
    Lee L, Mata J, Ghitulescu GA et al (2015) Cost-effectiveness of enhanced recovery versus conventional perioperative management for colorectal surgery. Ann Surg 262:1026–1033.  https://doi.org/10.1097/SLA.0000000000001019 CrossRefPubMedGoogle Scholar
  4. 4.
    Carmichael JC, Keller DS, Baldini G et al (2017) Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon Rectum 60:761–784.  https://doi.org/10.1097/DCR.0000000000000883 CrossRefGoogle Scholar
  5. 5.
    Wick EC, Grant MC, Wu CL (2017) Postoperative multimodal analgesia pain management with nonopioid analgesics and techniques a review. JAMA Surg 152:691–697.  https://doi.org/10.1001/jamasurg.2017.0898 CrossRefPubMedGoogle Scholar
  6. 6.
    Hain E, Maggiori L, Prost à la Denise J, Panis Y (2018) Transversus abdominis plane (TAP) block in laparoscopic colorectal surgery improves postoperative pain management: a meta-analysis. Color Dis 20:279–287.  https://doi.org/10.1111/codi.14037 CrossRefGoogle Scholar
  7. 7.
    Johns N, O’Neill S, Ventham NT et al (2012) Clinical effectiveness of transversus abdominis plane (TAP) block in abdominal surgery: a systematic review and meta-analysis. Color Dis 14:635–642.  https://doi.org/10.1111/j.1463-1318.2012.03104.x CrossRefGoogle Scholar
  8. 8.
    Favuzza J, Brady K, Delaney CP (2013) Transversus abdominis plane blocks and enhanced recovery pathways: making the 23-h hospital stay a realistic goal after laparoscopic colorectal surgery. Surg Endosc Other Interv Tech 27:2481–2486.  https://doi.org/10.1007/s00464-012-2761-y CrossRefGoogle Scholar
  9. 9.
    Pirrera B, Alagna V, Lucchi A et al (2017) Transversus abdominis plane (TAP) block versus thoracic epidural analgesia (TEA) in laparoscopic colon surgery in the ERAS program. Surg Endosc Other Interv Tech.  https://doi.org/10.1007/s00464-017-5686-7 CrossRefGoogle Scholar
  10. 10.
    Elkassabany N, Ahmed M, Malkowicz SB et al (2013) Comparison between the analgesic efficacy of transversus abdominis plane (TAP) block and placebo in open retropubic radical prostatectomy: a prospective, randomized, double-blinded study. J Clin Anesth 25:459–465.  https://doi.org/10.1016/j.jclinane.2013.04.009 CrossRefPubMedGoogle Scholar
  11. 11.
    Jadon A, Jain P, Chakraborty S et al (2018) Role of ultrasound guided transversus abdominis plane block as a component of multimodal analgesic regimen for lower segment caesarean section: a randomized double blind clinical study. BMC Anesthesiol 18:1–7.  https://doi.org/10.1186/s12871-018-0512-x CrossRefGoogle Scholar
  12. 12.
    Gao T, Zhang JJ, Xi FC et al (2017) Evaluation of transversus abdominis plane (TAP) block in hernia surgery. Clin J Pain 33:369–375.  https://doi.org/10.1097/AJP.0000000000000412 CrossRefPubMedGoogle Scholar
  13. 13.
    McDermott G, Korba E, Mata U et al (2012) Should we stop doing blind transversus abdominis plane blocks? Br J Anaesth 108:499–502.  https://doi.org/10.1093/bja/aer422 CrossRefPubMedGoogle Scholar
  14. 14.
    Favuzza J, Delaney CP (2013) Laparoscopic-guided transversus abdominis plane block for colorectal surgery. Dis Colon Rectum 56:389–391.  https://doi.org/10.1097/DCR.0b013e318280549b CrossRefPubMedGoogle Scholar
  15. 15.
    Park SY, Park JS, Choi GS et al (2017) Comparison of analgesic efficacy of laparoscope-assisted and ultrasound-guided transversus abdominis plane block after laparoscopic colorectal operation: a randomized, single-blind, non-inferiority trial. J Am Coll Surg 225:403–410.  https://doi.org/10.1016/j.jamcollsurg.2017.05.017 CrossRefPubMedGoogle Scholar
  16. 16.
    Fields AC, Gonzalez DO, Chin EH et al (2015) Laparoscopic-assisted transversus abdominis plane block for postoperative pain control in laparoscopic ventral hernia repair: a randomized controlled trial. J Am Coll Surg 221:462–469.  https://doi.org/10.1016/j.jamcollsurg.2015.04.007 CrossRefPubMedGoogle Scholar
  17. 17.
    Elamin G, Waters PS, Hamid H et al (2015) Efficacy of a laparoscopically delivered transversus abdominis plane block technique during elective laparoscopic cholecystectomy: a prospective, double-blind randomized trial. J Am Coll Surg 221:335–344.  https://doi.org/10.1016/j.jamcollsurg.2015.03.030 CrossRefPubMedGoogle Scholar
  18. 18.
    Zaghiyan KN, Mendelson BJ, Eng MR et al (2019) Randomized clinical trial comparing laparoscopic versus ultrasound-guided transversus abdominis plane block in minimally invasive colorectal surgery. Dis Colon Rectum 62:203–210.  https://doi.org/10.1097/DCR.0000000000001292 CrossRefPubMedGoogle Scholar
  19. 19.
    Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213.  https://doi.org/10.1097/01.sla.0000133083.54934.ae CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Schumi J, Wittes JT (2011) Through the looking glass: understanding non-inferiority. Trials 12:106.  https://doi.org/10.1186/1745-6215-12-106 CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    McDonnell JG, O’Donnell B, Curley G et al (2007) The analgesic efficacy of transversus abdominis plane block after abdominal surgery: a prospective randomized controlled trial. Anesth Analg 104:193–197.  https://doi.org/10.1213/01.ane.0000250223.49963.0f CrossRefPubMedGoogle Scholar
  22. 22.
    Siddiqui MRS, Sajid MS, Uncles DR et al (2011) A meta-analysis on the clinical effectiveness of transversus abdominis plane block. J Clin Anesth 23:7–14.  https://doi.org/10.1016/j.jclinane.2010.05.008 CrossRefPubMedGoogle Scholar
  23. 23.
    Ma N, Duncan JK, Scarfe AJ et al (2017) Clinical safety and effectiveness of transversus abdominis plane (TAP) block in post-operative analgesia: a systematic review and meta-analysis. J Anesth 31:432–452.  https://doi.org/10.1007/s00540-017-2323-5 CrossRefPubMedGoogle Scholar
  24. 24.
    Keller DS, Ermlich BO, Delaney CP (2014) Demonstrating the benefits of transversus abdominis plane blocks on patient outcomes in laparoscopic colorectal surgery: review of 200 consecutive cases. J Am Coll Surg 219:1143–1148.  https://doi.org/10.1016/j.jamcollsurg.2014.08.011 CrossRefPubMedGoogle Scholar
  25. 25.
    Stokes AL, Adhikary SD, Quintili A et al (2017) Liposomal bupivacaine use in transversus abdominis plane blocks reduces pain and postoperative intravenous opioid requirement after colorectal surgery. Dis Colon Rectum 60:170–177.  https://doi.org/10.1097/DCR.0000000000000747 CrossRefPubMedGoogle Scholar
  26. 26.
    Torgeson M, Kileny J, Pfeifer C et al (2018) Conventional epidural vs transversus abdominis plane block with liposomal bupivacaine: a randomized trial in colorectal surgery. J Am Coll Surg.  https://doi.org/10.1016/j.jamcollsurg.2018.04.021 CrossRefPubMedGoogle Scholar
  27. 27.
    Barrington MJ, Ivanusic JJ, Rozen WM, Hebbard P (2009) Spread of injectate after ultrasound-guided subcostal transversus abdominis plane block: a cadaveric study. Anaesthesia 64:745–750.  https://doi.org/10.1111/j.1365-2044.2009.05933.x CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Division of Colon & Rectum SurgeryBeth Israel Lahey Health Medical Center, Harvard Medical SchoolBostonUSA
  2. 2.Beth Israel Lahey Health Medical CenterBostonUSA

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