Optimal approach for ultrasound-guided transversus abdominis plane (TAP) blocks for abdominal surgeries: a protocol for systematic review and meta-analysis.

INTRODUCTION: Transversus abdominis plane (TAP) blocks are commonly used for postoperative analgesia after various abdominal surgeries. There are several different approaches for performing TAP blocks, mainly including posterior, lateral and subcostal approaches. An increasing number of randomised controlled trials (RCTs) have compared the analgesic effects of different TAP block approaches, but the results have not been consistent. This protocol aims to determine the optimal approach of ultrasound-guided TAP blocks for postoperative analgesia after abdominal surgery. METHODS AND ANALYSIS: Four databases, including Web of Science, PubMed, EMBASE and the Cochrane Library will be systematically searched to identify RCTs that compared the analgesic effects of different ultrasound-guided TAP block approaches. The search interval will range from the inception of the databases to 30 July 2024. The postoperative opioid consumption over 24 hours will be defined as the primary outcome. The secondary outcomes will include the analgesia duration, postoperative pain scores at rest and during movement at different timepoints and the incidence of adverse effects. All the statistical analyses will be conducted using RevMan V.5.4. The quality of evidence will be evaluated by the Grading of Recommendations Assessment, Development and Evaluation approach. ETHICS AND DISSEMINATION: Ethical approval will not be needed. The results will be submitted to one peer-reviewed journal when completed. PROSPERO REGISTRATION NUMBER: CRD42024510141.

FEASIBILITY AND EFFECTIVENESS OF GENERAL ANESTHESIA WITH OPIOIDS VERSUS OPIOID-FREE ANESTHESIA PLUS TRANSVERSUS ABDOMINIS PLANE BLOCK ON POSTOPERATIVE OUTCOMES AFTER MINI GASTRIC BYPASS SURGERY.

Opioid-free anesthesia (OFA) is increasingly used at present in surgical practice by many hospitals as a new and very promising anesthesiologic regimen. This study aimed to compare the efficacy of standard general anesthesia with opioids with so-called opioid-free anesthesia on postoperative outcomes of patients who underwent gastric bypass surgery. This randomized, single-blind clinical study enrolled 103 patients scheduled for elective gastric bypass surgery. They were assigned randomly to receive either general anesthesia without opioids plus transversus abdominis plane (TAP) block (Group 1: 53 patients) or general anesthesia with opioids (Group 2: 50 patients). 21.4% (22/103) males and 78.6% (81/103) females were operated. The average age of patients was 40.9 and the average BMI - 48.4. Patients from both groups (patients who received general anesthesia + TAP and patients who received general anesthesia with opioids) were assessed for postoperative pain at rest using a 0-to-10 visual analog pain scale (0 = no pain, 5 = moderate pain, and 10 = the most severe pain possible). In group 1 - 34% (18/53) of patients did not receive any medication against pain and 66% (35/53) received Dexalgin Inject 25mg/ml 2 ml. There was no need in opioids. In group 2 - 10% (5/50) of patients did not receive any medication against pain, 38% (19/50) received Dexalgin Inject 25mg/ml 2 ml and 52% (26/50) received Dexalgin Inject 25mg/ml 2 ml + Promedol 20mg/ml 1ml. Type of anesthesia is a significant predictor of postoperative outcomes, such as pain intensity, extubation time, intensive care stay, and hospital length of stay in patients undergoing gastric bypass surgery. Patients, who received (OFA) plus (TAP) block had better pain control than those who received general anesthesia with opioids. No opioids were used in group 1. In addition, the duration of hospital stay in group 1 was shorter, and the average cost for postoperative hospital stay was 2.39 times lower than in group 2. OFA can be used as a reliable and effective anesthesiologic technique in patients scheduled for bariatric surgery.

Effect of postoperative intermittent boluses of subcostal quadratus lumborum block on pulmonary function recovery and analgesia after gastrectomy: a randomized controlled clinical trial.

BACKGROUND: Following the gastrectomy, the reduction in pulmonary function is partly attributed to postoperative pain. Subcostal quadratus lumborum block (QLB) has recently emerged as a promising component in multimodal analgesia. We aimed to assess the impact of intermittent boluses of subcostal QLB on pulmonary function recovery and analgesic efficacy after gastrectomy. METHODS: Sixty patients scheduled for gastrectomy were randomly assigned to either control group (multimodal analgesia) or intervention group (intermittent boluses of subcostal QLB plus multimodal analgesia). Two primary outcomes included the preservation of forced expiratory volume in the first second (FEV1) and the pain scores (0-10 cm visual analog score) on coughing 24 h postoperatively. We assessed the pulmonary function parameters, pain score, morphine consumption and number of rescue analgesia at a 24-h interval up to 72 h (Day1, Day2, Day3 respectively) as secondary outcomes. RESULTS: 59 patients were analyzed in a modified intention-to-treat set. The preservation of FEV1 (median difference: 4.0%, 97.5% CI: -5.7 to 14.9, P = 0.332) and pain scores on coughing (mean difference: 0.0 cm, 97.5% CI: -1.1 to 1.2, P = 0.924) did not differ significantly between two groups. In the intervention group, the recovery of forced vital capacity (FVC) was faster 72 h after surgery (interaction effect of group*(Day3-Day0): estimated effect (ß) =0.30 L, standard error (SE) =0.13, P = 0.025), pain scores at rest were lower in the first 3 days (interaction effect of group*(Day1-Day0): ß = - 0.8 cm, SE = 0.4, P = 0.035; interaction effect of group*(Day2-Day0): ß = - 1.0 cm, SE = 0.4, P = 0.014; and interaction effect of group*(Day3-Day0): ß = - 1.0 cm, SE = 0.4, P values = 0.009 respectively), intravenous morphine consumption was lower during 0-24 h (median difference: -3 mg, 95% CI -6 to -1, P = 0.014) and in total 72 h (median difference: -5 mg, 95% CI -10 to -1, P = 0.019), and the numbers of rescue analgesia was fewer during 24-48 h (median difference: 0, 95% CI 0 to 0, P = 0.043). Other outcomes didn't show statistical differences. CONCLUSION: Postoperative intermittent boluses of subcostal QLB did not confer advantages in terms of the preservation of FEV1 or pain scores on coughing 24 h after gastrectomy. However, notable effects were observed in analgesia at rest and FVC recovery.

Quadratus lumborum block vs. transversus abdominis plane block for postoperative pain control in patients with nephrectomy: A systematic review and network meta-analysis.

STUDY OBJECTIVE: This systematic review and network meta-analysis aimed to compare the analgesic efficacy of transversus abdominis plane block (TAPB) and quadratus lumborum block (QLB) on nephrectomy. DESIGN: Systematic review and network meta-analysis. PATIENTS: Patients undergoing nephrectomy. INTERVENTIONS: TAPB and QLB for postoperative analgesia. MEASUREMENTS: The primary outcome was 24 h morphine-equivalent consumptions after surgery. Secondary outcomes included postoperative pain scores, postoperative opioid consumption, postoperative rescue analgesia, postoperative nausea and vomiting (PONV), length of hospital stay after surgery, and patient satisfaction. MAIN RESULTS: Fourteen studies involving 883 patients were included. Seven studies compared TAPB to control, six studies compared QLB to control, and one study compared TAPB to QLB. For direct meta-analysis of the post-surgical 24 h morphine-equivalent consumption, QLB was lower than control (mean difference [95%CI]: -18.16 [-28.96, -7.37]; I2 = 88%; p = 0.001), while there was no difference between TAPB and control (mean difference [95%CI]: -8.34 [-17.84, 1.17]; I2 = 88%; p = 0.09). Network meta-analysis showed similar findings that QLB was ranked as the best anesthetic technique for reducing postoperative 24 h opioid consumption (p-score = 0.854). Moreover, in direct meta-analysis, as compared to control, the time of first postoperative rescue analgesia was prolonged after QLB (mean difference [95%CI]: 165.00 [128.99, 201.01]; p < 0.00001), but not TAPB (mean difference [95%CI]: 296.82 [-91.92, 685.55]; p = 0.13). Meanwhile, QLB can effectively reduce opioid usages at intraoperative period, as well as at postoperative 6 h and 48 h, while TAPB can only reduce opioid consumption at 6 h after surgery. As compared to control, both TAPB and QLB exhibited the reduction in PONV and pain scores at post-surgical some timepoints. Also, QLB (mean difference [95%CI]: -0.29 [-0.49, -0.08]; p = 0.006) but not TAPB (mean difference [95%CI]: 0.60 [-0.25, 1.45]; p = 0.17) exhibited the shorter postoperative length of hospital stay than control. CONCLUSIONS: QLB is more likely to be effective in reducing postoperative opioid use than TAPB, whereas both of them are superior to control with regard to the reduction in postoperative pain intensity and PONV. TRIAL REGISTRATION: PROSPERO identifier: CRD42022358464.

Application of an OFA strategy to ERAS in a 102-year-old patient undergoing colon cancer surgery: A case report.

RATIONALE: Colorectal cancer is the third most common cancer and the second leading cause of cancer-related deaths worldwide. Opioid-free anesthesia (OFA) is an opioid-sparing technique that focuses on multimodal or balanced analgesia, relying on non-opioid adjuncts and regional anesthesia. Enhanced recovery after surgery (ERAS) protocols, often under the auspices of a perioperative pain service, can help guide and promote opioid reduced and OFA, without negatively impacting perioperative pain management or recovery. Ultrasound-guided regional nerve block is currently a good option for OFA due to anesthesiologists' mastery of ultrasound techniques. The safety of the OFA strategy for quadratus lumborum block (QLB) + transversus abdominis plane block (TAP) in the super-elderly patients has not been reported and remains unclear. We report a case of OFA anesthesia in a super-elderly patient with colon cancer. PATIENT CONCERNS: A 102-year-old female was admitted to the hospital due to "abdominal pain for a week" and received conservative treatment for more than 20 days, with poor results. DIAGNOSES: The patient was diagnosed with colorectal cancer associated with bronchiectasis and infection, multiple nodules in the right lower lung, and sinus arrhythmia. INTERVENTIONS: As the patient was a super-elderly patient with multiple diseases, we used an OFA strategy with general anesthesia combined with QLB and TAP. OUTCOMES: The patient awakened quickly and completely after surgery, and extubation was successful 2 min after surgery without anesthesia complications, which is in line with the concept of ERAS. LESSONS: The OFA strategies of ultrasound guidance quadratus lumborum block (Ul-QLB) and ultrasound guidance transversus abdominis plane block (Ul-TAP) may be safe and effective for ERAS in super-elderly patients with colorectal cancer surgery.

Randomized single blind trial to compare the short term post-operative outcome and cost analysis of laparoscopic versus ultrasound guided transversus abdominis plane block in patients undergoing bariatric surgery.

INTRODUCTION: Laparoscopic Bariatric surgery despite being minimally invasive can cause moderate to severe pain in the immediate postoperative period. Adequate pain management remains a major challenge. Transversus Abdominis Plane (TAP) block is a regional anesthesia technique which blocks the sensory nerve supply of anterior-lateral abdominal wall. AIMS AND OBJECTIVES: Primary: evaluate Laparoscopic versus ultrasound (USG)-guided TAP block on immediate post-operative analgesia after undergoing laparoscopic bariatric surgery. Secondary: compare cost effectiveness of Laparoscopic versus ultrasound-guided TAP block after undergoing bariatric surgery. MATERIALS AND METHODS: Randomized Single blind study undertaken after sample size was calculated by (N) = 2(Zα + Z1-ß)2σ2/δ2 which proposed 60 patients in each group. Block randomization was done after excluding redo/revision surgeries and patients were alloted Group I: Laparoscopic-guided TAP block & Group II: USG-guided TAP block. In both groups, Bilaterally, 20 ml (0.25%) bupivacaine was injected immediately after completion of bariatric surgery. SPSS v23 (IBM Corp.) was used for analysis. RESULTS: Group I (N = 61 53F/8 M) & Group II (N = 60 42F/18 M) were demographically comparable. Group I (3.58 ± 0.67) had significantly lower procedure time compared to Group II (12.47 ± 1.61) (p-Value < 0.001). First rescue analgesia was administered at 7.07 ± 2.61 h in Group I vs 7.21 ± 2.39 h in Group II (p-Value 0.659). In first 24 h rescue analgesic dose requirement in Group I was 1.29 ± 0.53 vs 1.39 ± 0.50 in Group II (p-Value 0.487). VAS scores during rest and movement till 24 h post-operative were statistically similar. Procedural cost was more in group II. CONCLUSION: Laparoscopic-guided TAP block is a safe and cost-effective approach for postoperative pain management after bariatric surgery and provides similar comparable analgesic effect as the USG-TAP block. Laparoscopic TAP is a surgeon delivered, easy to administer and significantly less time-consuming procedure which is feasible even when an ultrasound machine is not available.

Comparing ultrasound-guided modified thoracoabdominal nerves block through perichondrial approach with oblique subcostal transversus abdominis plane block for patients undergoing laparoscopic cholecystectomy: a randomized, controlled trial.

BACKGROUND: Laparoscopic cholecystectomy(LC) causes significant postoperative pain. Oblique subcostal transversus abdominis plane(OSTAP) block was described for postoperative analgesia, especially for upper abdominal surgeries. Modified thoracoabdominal nerves block through perichondrial approach(M-TAPA) block is a new technique defined by the modification of the thoracoabdominal nerves through perichondrial approach (TAPA) block, in which local anesthetics are delivered only to the underside of the perichondral surface. The primary aim of this study was to evaluate the effect of M-TAPA and OSTAP blocks as part of multimodal analgesia on postoperative opioid consumption in patients undergoing LC. METHOD: The present study was designed as a randomized, controlled, prospective study. Seventy-six adult patients undergoing LC were randomly assigned to receive either bilaterally M-TAPA or OSTAP block after the induction of anesthesia and before surgery using bupivacaine 0.25%, 25 ml. The primary outcome was assessed as postoperative 24 h opioid consumption, between groups were compared. Secondary outcomes were Numerical Rational scale(NRS) scores, time to first opioid analgesia, patient recovery, using the Quality of Recovery-15 (QoR-15) scale, nausea and vomiting, sedation score, metoclopramide consumption, and evaluating the analgesic range of dermatome. RESULTS: The mean tramadol consumption at the postoperative 24th hour was higher in the group OSTAP than in group M-TAPA (P = 0.047). NRS movement score at 12th hour was statistically significantly lower in group M-TAPA than in group OSTAP (P = 0.044). Dermatomes showed intense sensory analgesia between T7-11 in both groups, and it was determined that there was proportionally more involvement in the group M-TAPA. There were no differences between the groups in terms of other results. CONCLUSIONS: After the LC surgery, ultrasound-guided M-TAPA block effectively reduced opioid consumption, postoperative pain, and QoR-15 scores similar to OSTAP block. CLINICAL TRIAL REGISTRATION: The study was registered prospectively at clinicaltrials.gov (trial ID: NCT05108129 on 4/11/2021).

Pulsed radiofrequency in a paediatric patient with disabling ACNES.

Chronic abdominal pain is a highly prevalent entity in the paediatric population and represents a diagnostic challenge for professionals. It is frequently underdiagnosed, and must be treated by a multidisciplinary team after a detailed clinical evaluation has been performed to rule out other pathologies. Anterior cutaneous nerve entrapment syndrome (ACNES) occurs when the anterior cutaneous abdominal nerves become pinched or trapped, causing intense, unilateral, circumscribed abdominal pain. Patients often present a positive Pinch test or Carnett's sign. A stepwise therapeutic approach should be used, reserving the most invasive techniques for patients with refractory ACNES. Among the many different treatments available, local anaesthesia infiltration has shown a high success rate, and surgery should only be performed in the most refractory cases. We report the case of an 11-year old girl with a 6-month history of ACNES that severely affected her quality of life, who responded well to pulsed radiofrequency ablation.

Effects of different anesthesia methods on postoperative immune function in patients undergoing gastrointestinal tumor resection.

To investigate the effects of different anesthetic methods on postoperative immune function in patients undergoing gastrointestinal tumor resection. Ninety patients undergoing laparoscopic gastrointestinal tumor resection were divided into 3 groups. Patients in the GA group were anesthetized by total intravenous anesthesia. The GE group was anesthetized by general anesthesia combined with epidural anesthesia. The GN group was anesthetized by general anesthesia combined with bilateral Transversus Abdominis Plane block (TAP) and rectus sheath nerve blocks. General anesthesia is total intravenous anesthesia in all three groups. Blood samples were taken to test the changes of peripheral lymphocyte subtype analysis, and levels of plasma cortisol, epinephrine, norepinephrine. Also, the dosage of anesthetic drugs, recovery time, and visual analog scale (VAS) scores were recorded. Postoperative immune indexes, including CD4 count, CD8 count, B, and NK cells, in the GE group were significantly higher than those in NA and GA groups (P < 0.01). Perioperative stress indices, including epinephrine levels, norepinephrine level and aldosterone level, in the GE group were significantly lower than in the GA group and GN group (P < 0.01). The intraoperative/total sufentanil dosage and remifentanil dosage in the GE group were significantly lower than those in the GA and GN groups (P < 0.01). The VAS scores in the GE group were significantly better than those in GA and GN groups (P < 0.01). General anesthesia combined with epidural anesthesia attenuates the increase in inflammatory mediators. Its possible mechanisms include reducing perioperative stress response and reducing perioperative opioid use.

Posterior quadratus lumborum block versus posterior transversus abdominis plane block for unilateral inguinal hernia surgery.

Background: Ultrasound-guided truncal nerve blocks are increasingly used for postoperative pain relief after abdominal surgery. Aim: The aim of this prospective and randomized study was to compare posterior transversus abdominis plane block (pTAPB) with posterior quadratus lumborum block (pQLB) for postoperative analgesic efficacy in patients undergoing unilateral inguinal hernia surgery under general anesthesia (GA). Patients and Methods: A total of 90 adult patients were randomized into 3 groups: group pTAPB (n = 30), group pQLB (n = 30), and group Control (n = 30). The patients in groups pQLB and pTAPB received a unilateral block using 20 ml of 0.25% bupivacaine after the induction of GA. Intravenous (IV) tramadol patient control group analgesia (PCA) and paracetamol were used in the postoperative period as a part of the multimodal analgesic regimen in both groups. Postoperative pain was assessed using a visual analog scale (VAS) during postoperative 24 h. Dexketoprofene was used as a rescue analgesic when VAS is >3. The primary outcome measure was mean pain scores. Secondary outcome measures were consumption of rescue analgesics and the amount of tramadol delivered by PCA. P <0.05 was considered statistically significant. Results: Mean VAS scores were significantly lower in the group pQLB than group pTAPB and group Control at all-time points (pQLB < pTAPB < Control; P < 0.001). Rescue analgesic was not required in group QLB. Rescue analgesic consumption, the number of bolus demand on PCA, and total PCA dose were highest in group Control and lowest in the pQLB group (Control > pTAPB > pQLB; P < 0.001). Conclusion: It is concluded that both pQLB and pTAPB provided effective pain relief after unilateral inguinal hernia surgery. pQLB was superior to pTAPB due to lower pain scores and analgesic consumption.

Erector Spinae Plane Block versus Transversus Abdominis Plane Block for Postoperative Analgesia in Abdominal Surgery: A Systematic Review and Meta-Analysis.

BACKGROUND: Regional anesthesia technique has been reported to exert excellent analgesic efficacy for various surgeries. Erector spinae plane block (ESPB) and transversus abdominis plane (TAP) block are good ways to relieve postoperative pain after abdominal surgery. However, the analgesic efficacy between them remains controversial. This meta-analysis evaluated the analgesic effect between these two blocks in abdominal surgery with statistical and clinical interpretation. METHODS: PubMed, Web of Science, the Cochrane Library, ClinicalTrials.gov register, and Embase databases were systematically searched by two independent investigators from the inception to December 2021. RESULTS: 10 randomized controlled trials (RCTs) comprising 570 patients were included in the final meta-analysis. Meta-analysis revealed that ESPB decreased the opioid consumption and improved the pain scores during the first 24 postoperative hours compared with TAP groups statistically, while the magnitude of this difference did not reach the clinically significant threshold (10 mg of intravenous morphine consumption and 1.3 cm on the VAS scale). In addition, ESPB prolonged blockade duration and decreased the occurrence of postoperative nausea and vomiting (PONV). However, it did not improve the patients' satisfaction. CONCLUSIONS: Although ESPB does not provide better clinical analgesia than the TAP block, it could be a comparable nerve block technique for abdominal wall analgesia.

The Role of Maximal Locoregional Block in Autologous Breast Reconstruction.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) has become the standard of care in microsurgical breast reconstruction. The current literature provides overwhelming evidence of the benefit of ERAS pathways in improving quality of recovery, decreasing length of hospital stay, and minimizing the amount of postoperative narcotic use in these patients. However, there are limited data on the role of using maximal locoregional anesthetic blocks targeting both the abdomen and chest as an integral part of an ERAS protocol in abdominally based autologous breast reconstruction. The aim of this study is to compare the outcomes of implementing a comprehensive ERAS protocol with and without maximal locoregional nerve blocks to determine any added benefit of these blocks to the standard ERAS pathway. METHODS: Forty consecutive patients who underwent abdominally based autologous breast reconstruction in the period between July 2017 and February 2020 were included in this retrospective institutional review board-approved study. The goal was to compare patients who received combined abdominal and thoracic wall locoregional blocks as part of their ERAS pathway (study group) with those who had only transversus abdominis plane blocks. The primary end points were total hospital length of stay, overall opioids consumption, and overall postoperative complications. RESULTS: The use of supplemental thoracic wall block resulted in a shorter hospital length of stay in the study group of 3.2 days compared with 4.2 days for the control group (P < 0.01). Postoperative total morphine equivalent consumption was lower at 38 mg in the study group compared with 51 mg in the control group (P < 0.01). Complications occurred in 6 cases (15%) in the control group versus one minor complication in the thoracic block group. There was no difference between the 2 groups in demographics, comorbidities, and type of reconstruction. CONCLUSION: The maximal locoregional nerve block including a complete chest wall block confers added benefits to the standard ERAS protocol in microvascular breast reconstruction.

Ultrasound-guided rectus sheath block injections in miniature swine cadavers: technique description and distribution of two injectate volumes.

OBJECTIVE: To describe a technique for ultrasound-guided rectus sheath block in pigs and the distribution of two injectate volumes. STUDY DESIGN: Experimental study. ANIMALS: A group of 11 Hanford miniature pig cadavers. METHODS: The lateral border of each rectus abdominis muscle in 10 freshly euthanized pigs was visualized with a 6-15 MHz linear ultrasound probe. A spinal needle was inserted 1 cm cranial to the umbilicus, in-plane and medial to the probe, and advanced dorsal to lateral until the tip was ventral to the internal rectus sheath. Pigs were injected bilaterally with high volume (treatment HV; 0.8 mL kg-1) or low volume (treatment LV; 0.5 mL kg-1) of 1:1 solution of 1% methylene blue and 0.5% bupivacaine (1 mg kg-1) diluted with 0.9% saline. Nerve staining ≥ 1 cm circumferentially was determined by dissection 15 minutes postinjection. The Clopper-Pearson method was used to calculate 95% confidence intervals (CIs) for proportions of stained nerves. In another pig, a 1:1 solution of 1% methylene blue and 74% ioversol contrast was injected, and computed tomography performed at 15 minute intervals after injection. RESULTS: Nerve staining for thoracic (T) spinal nerves T9, T10, T11, T12, T13 and T14 occurred 20%, 60%, 90% 100%, 100% and 50%, and 0%, 20%, 90%, 100%, 100% and 50% of the time in treatments HV and LV, respectively. More nerves were stained in treatment HV in 4/10 animals (40%, 95% CI: 12%-74%) than in treatment LV (0%, 95% CI: 0%-31%). The greatest spread of injectate occurred within the first 15 minutes after injection. CONCLUSIONS AND CLINICAL RELEVANCE: Staining of T11-T14 nerves was the same in both treatments but the higher volume stained more T9-T10 nerves. Based on dye distribution, a rectus sheath block may only provide ventral abdominal analgesia cranial to the umbilicus in pigs.

Perioperative Multimodal Anesthetic Care Incorporating Transversus Abdominis Plane Block Is Associated With Reduced Narcotic Use in Laparoscopic Sleeve Gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric surgery performed in North America. As our knowledge of the importance in limiting narcotic use in postoperative patients increases, we sought to evaluate the effect of transversus abdominis plane (TAP) blocks on inpatient narcotic use in patients undergoing LSG. METHODS: A retrospective review of LSG performed at a single institution by 3 bariatric surgeons was performed. All cases over a 15-month period were included, and anesthesia records were reviewed to stratify patients that received a TAP block and those that did not. Demographic, as well as surgical, outcomes were collected for all patients. Narcotic utilization, as reported in morphine equivalents (ME), was evaluated between the 2 groups. RESULTS: 384 LSG patients were identified, of which 37 (9.6%) received a TAP block. There was no statistically significant difference in postoperative morbidity, length of stay, or readmission between groups. Median narcotic utilization in hospital days 1 and 2 in patients with TAP blocks was 49 ME (Interquartile Range (IQR) 14.5-84.5) to 82.5 ME (IQR 57.4-106) in the no-TAP group (P < .001). After controlling for multiple demographic- and patient-related cofactors, multiple linear regression analysis demonstrated TAP block patients utilized 22.48 ME less than the no-TAP group (P < .001) in the first 2 days of their hospitalization. DISCUSSION: Patients that received a TAP block as a part of their perioperative anesthetic care utilized less in-hospital narcotics than those patients that did not receive a TAP block. TAP blocks should be considered as part of a multimodal pain control strategy for patients undergoing LSG.

Transversus abdominis plane block provides effective and safe anesthesia in the cesarean section for an amyotrophic lateral sclerosis parturient: A case report.

RATIONALE: Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease with the fatal course of muscle weakness. The published experience of anesthesia management in the cesarean section with ALS parturient is scant. PATIENT CONCERNS: A 34-year-old woman was admitted to our center complaining of obvious dysphagia together with atrophy and weakness of quadriceps at 24 weeks of her pregnancy. Cesarean was planned at 36 weeks' gestation due to the rapid deterioration of the mother. DIAGNOSES: The results of neurological examination, electromyography and spinal magnetic resonance imaging suggested ALS according to the EI Escorial World Federation of Neurology criteria. INTERVENTIONS: Ultrasound-guided transversus abdominis plane block with 0.6 minimum alveolar concentration sevoflurane was used in this ALS parturient during her cesarean section procedure. OUTCOMES: This anesthesia strategy successfully met the demands of the surgery, helped avoid prolonged ventilation and prevent maternal respiratory complications. LESSONS: Transversus abdominis plane block with subanesthetic concentrations of sevoflurane can provide effective and safe anesthesia in the cesarean section for a patient with ALS.

Defining Enhanced Recovery Pathway with or without Liposomal Bupivacaine in DIEP Flap Breast Reconstruction.

BACKGROUND: Enhanced recovery after surgery (ERAS) includes multiple interventions that have yielded positive outcomes in a number of surgical fields. The authors evaluated whether an ERAS protocol and the subsequent addition of liposomal bupivacaine affect patient outcomes specifically in deep inferior epigastric perforator (DIEP) flap breast reconstruction. METHODS: All patients treated with DIEP flaps from January of 2016 to December of 2019 were reviewed retrospectively. The ERAS protocol was implemented midway through 2017; halfway through 2018, intraoperative transversus abdominis plane blocks with liposomal bupivacaine were added to the protocol. Such interventions allowed for comparison of three patient groups: before ERAS, during ERAS, and after ERAS plus liposomal bupivacaine. Primary outcomes observed were postoperative opioid consumption and length of stay. The p values were obtained using the Wilcoxon test for pairwise comparisons. RESULTS: After adjusting for ERAS group compliance, 216 patients were analyzed. The pre-ERAS group was composed of 67 patients, the ERAS group was composed of 69 patients, and the ERAS plus liposomal bupivacaine group was composed of 80 patients. Postoperative opioid consumption was reduced when comparing the pre-ERAS and ERAS groups (from 275.7 oral morphine equivalents to 146.7 oral morphine equivalents; p < 0.0001), and also reduced with the addition of liposomal bupivacaine (115.3 oral morphine equivalents; p = 0.016). Furthermore, hospital length of stay was decreased from 3.6 days in the pre-ERAS group to 3.2 days (p = 0.0029) in the ERAS group, and to 2.6 days (p < 0.0001) in the ERAS group plus liposomal bupivacaine groups. CONCLUSIONS: Enhanced recovery after surgery protocols decrease postoperative opioid consumption and hospital length of stay in DIEP flap breast reconstruction. The addition of liposomal bupivacaine further strengthens the impact of the protocol. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

A Prospective Randomized Trial of Surgeon-Administered Intraoperative Transversus Abdominis Plane Block With Bupivacaine Against Liposomal Bupivacaine: The TINGLE Trial.

BACKGROUND: Transversus abdominis plane blocks are increasingly used to achieve opioid-sparing analgesia after colorectal surgery. Traditionally, bupivacaine was the long-acting analgesic of choice, but the addition of dexamethasone and/or epinephrine to bupivacaine may extend block duration. Liposomal bupivacaine has also been suggested to achieve an extended analgesia duration of 72 hours but is significantly more expensive. OBJECTIVE: The purpose of this study was to compare pain control between laparoscopic transversus abdominis plane blocks using liposomal bupivacaine versus bupivacaine with epinephrine and dexamethasone. DESIGN: This was a parallel-group, single-institution, randomized clinical trial. SETTINGS: The study was conducted at a single tertiary medical center. PATIENTS: Consecutive patients between October 2018 to October 2019, ages 18 to 90 years, undergoing minimally invasive colorectal surgery with multimodal analgesia were included. INTERVENTIONS: Patients were randomly assigned 1:1 to receive a laparoscopic transversus abdominis plane block with liposomal bupivacaine or bupivacaine with epinephrine and dexamethasone. MAIN OUTCOME MEASURES: The primary outcome was total oral morphine equivalents administered in the first 48 hours postoperatively. Secondary outcomes included pain scores, time to ambulation and solid diet, hospital length of stay, and complications. RESULTS: A total of 102 patients (50 men) with a median age of 42 years (interquartile range, 29-60 y) consented and were randomly assigned. The primary end point, total oral morphine equivalents administered in the first 48 hours, was not significantly different between the liposomal bupivacaine group (median = 69 mg) and the bupivacaine with epinephrine and dexamethasone group (median = 47 mg; difference in medians = 22 mg, (95% CI, -17 to 49 mg); p = 0.60). There were no significant differences in pain scores, time to ambulation, time to diet tolerance, time to bowel movement, length of stay, overall complications, or readmission rate between groups. There were no treatment-related adverse outcomes. LIMITATIONS: This study was not placebo controlled or blinded. CONCLUSIONS: This first randomized trial comparing laparoscopic transversus abdominis plane block with liposomal bupivacaine or bupivacaine with epinephrine and dexamethasone showed that a liposomal bupivacaine block does not provide superior or extended analgesia in the era of standardized multimodal analgesia protocols.See Video Abstract at http://links.lww.com/DCR/B533. ESTUDIO PROSPECTIVO Y RANDOMIZADO DE BLOQUEO DEL PLANO MUSCULAR TRANSVERSO DEL ABDOMEN REALIZADO POR EL CIRUJANO CON BUPIVACANA VERSUS BUPIVACANA LIPOSOMAL ESTUDIO TINGLE: ANTECEDENTES:El bloqueo anestésico del plano muscular transverso del abdomen se utiliza cada vez más para lograr una analgesia con menos consumo de opioides después de cirugía colorrectal. Tradicionalmente, la Bupivacaína era el analgésico de acción prolongada de elección, pero al agregarse Dexametasona y/o Adrenalina a la Bupivacaína se puede prolongar la duración del bloqueo. También se ha propuesto que la Bupivacaína liposomal logra una duración prolongada de la analgesia de 72 horas, pero es significativamente más cara.OBJETIVO:Comparar el control del dolor entre bloqueo laparoscópico del plano de los transversos del abdomen usando Bupivacaína liposomal versus Bupivacaína con Adrenalina y Dexametasona.DISEÑO:Estudio clínico prospectivo y randomizado de una sola institución en grupos paralelos.AJUSTE:Centro médico terciario único.PACIENTES:Todos aquellos pacientes entre 18 y 90 años sometidos a cirugía colorrectal mínimamente invasiva con analgesia multimodal, entre octubre de 2018 a octubre de 2019 incluidos de manera consecutiva.INTERVENCIONES:Los pacientes fueron seleccionados aleatoriamente 1:1 para recibir un bloqueo laparoscópico del plano de los transversos del abdomen con Bupivacaína liposomal o Bupivacaína con Adrenalina y Dexametasona.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue el total de equivalentes de morfina oral administradas en las primeras 48 horas después de la operación. Los resultados secundarios incluyeron puntuaciones de dolor, inicio de dieta sólida, tiempo de inicio a la deambulación, la estadía hospitalaria y las complicaciones.RESULTADOS:Un total de 102 pacientes (50 hombres) con una mediana de edad de 42 años (IQR 29-60) fueron incluidos aleatoriamente. El criterio de valoración principal, equivalentes de morfina oral total administrada en las primeras 48 horas, no fue significativamente diferente entre el grupo de Bupivacaína liposomal (mediana = 69 mg) y el grupo de Bupivacaína con Adrenalina y Dexametasona (mediana = 47 mg; diferencia en medianas = 22 mg, IC del 95% [-17] - 49 mg, p = 0,60). No hubo diferencias significativas en las puntuaciones de dolor, tiempo de inicio a la deambulación, el tiempo de tolerancia a la dieta sólida, el tiempo hasta el primer evacuado intestinal, la duración de la estadía hospitalaria, las complicaciones generales o la tasa de readmisión entre los grupos. No hubo resultados adversos relacionados con el tratamiento.LIMITACIONES:Este estudio no fue controlado con placebo ni de manera cegada.CONCLUSIONES:Este primer estudio prospectivo y randomizado que comparó el bloqueo del plano de los músculos transversos del abdomen por vía laparoscópica, utilizando Bupivacaína liposomal o Bupivacaína con Adrenalina y Dexametasona, demostró que el bloqueo de Bupivacaína liposomal no proporciona ni mejor analgesia ni un efecto mas prolongado.Consulte Video Resumen en http://links.lww.com/DCR/B533.