Effect of Subcostal Anterior Quadratus Lumborum Block vs. Oblique Subcostal Transversus Abdominis Plane Block after Laparoscopic Radical Gastrectomy

Abstract

Objective

To evaluate the analgesic effect of ultrasound-guided subcostal anterior quadratus lumborum block (QLB) for laparoscopic radical gastrectomy surgery.

Methods

Patients (aged 20–65 years, ASA I — II, and weighing 40–75 kg) scheduled for elective laparoscopic radical gastrectomy were enrolled in the current study. Sixty patients were randomly assigned to two groups by computer-generated randomization codes: an ultrasound-guided oblique subcostal transversus abdominis plane block (TAPB) group (group T, n=30) or an ultrasound-guided subcostal anterior QLB group (group Q, n=30). In both groups, bilateral ultrasound-guided oblique subcostal TAPB and subcostal anterior QLB were performed before general anesthesia with 0.25% ropivacaine 0.5 mL/kg. For postoperative management, all patients received patient-controlled intravenous analgesia (PCIA) with nalbuphine and sufentanil after surgery, maintaining visual analogue scale (VAS) scores ≤4 within 48 h. The intraoperative consumption of remifentanil, the requirement for sufentanil as a rescue analgesic, and the VAS scores at rest and coughing were recorded at 1, 6, 12, 24 and 48 h after surgery. The recovery (extubation time after surgery, first ambulation time, first flatus time and length of postoperative hospital stay) and the adverse events (nausea and vomiting, skin pruritus, respiratory depression and nerve-block related complications) were observed and recorded. The primary outcome was the perioperative consumption of opioids.

Results

Compared with group T, the intraoperative consumption of remifentanil, requirement for sufentanil and the frequency of PCIA were reduced in group Q. Meanwhile, VAS scores at all points of observation were significantly lower in group Q than in group T. Patients in group Q were also associated with shorter time to first out-of-bed activity and flatus, and shorter length of postoperative hospital stay than group T (P<0.05). There were no skin pruritus, respiratory depression or nerve-block related complications in both groups.

Conclusion

Compared with ultrasound-guided oblique subcostal TAPB, ultrasound-guided subcostal anterior QLB provided greater opioid-sparing effect, lower visual analogue scores, and shorter postoperative hospital stay for laparoscopic radical gastrectomy.

Keywords

ultrasound-guided / transversus abdominis plane block / quadratus lumborum block / laparoscopic radical gastrectomy

References

[1] ZhengHL, LuJ, ZhengCH, et al.. Short- and long-term outcomes in malnourished patients after laparoscopic or open radical gastrectomy. World J Surg, 2018, 42(1): 195-203

[2] ChoiJB, ShimYH, LeeYW, et al.. Incidence and risk factors of postoperative nausea and vomiting in patients with fentanyl-based intravenous patient-controlled analgesia and single antiemetic prophylaxis. Yonsei Med J, 2014, 55(5): 1430-1435

[3] OderdaG. Challenges in the management of acute postsurgical pain. Pharmacotherapy, 2012, 32: 6S-11S 9 Suppl

[4] MaN, DuncanJK, ScarfeAJ, et al.. Clinical safety and effectiveness of transversus abdominis plane (TAP) block in post-operative analgesia: A systematic review and meta-analysis. J Anesth, 2017, 31(3): 432-452

[5] SrinivasNR. Reduced ketobemidone usage in quadratus lumborum block patients after cesarean delivery: Clinical pharmacology views. Anesth Analg, 2018, 127(1): 311

[6] MurouchiT, IwasakiS, YamakageM. Quadratus lumborum block: analgesic effects and chronological ropivacaine concentrations after laparoscopic surgery. Reg Anesth Pain Med, 2016, 41(2): 146-150

[7] JohnstonDF, SondekoppamRV. Continuous quadratus lumborum block analgesia for total hip arthroplasty revision. J Clin Anesth, 2016, 35: 235-237

[8] ElsharkawyH, El-BoghdadlyK, KolliS, et al.. Injectate spread following anterior sub-costal and posterior approaches to the quadratus lumborum block: A comparative cadaveric study. Eur J Anaesthesiol, 2017, 34(9): 587-595

[9] KadamVR. Ultrasound-guided quadratus lumborum block as a postoperative analgesic technique for laparotomy. J Anaesthesiol Clin Pharmacol, 2013, 29(4): 550-552

[10] HebbardP. Subcostal transversus abdominis plane block under ultrasound guidance. Anesth Analg, 2008, 106(2): 674-675

[11] ElsharkawyH. Quadratus lumborum block with paramedian sagittal oblique (subcostal) approach. Anaesthesia, 2016, 71(2): 241-242

[12] NutallGA, BrostBC, ConnisRT, et al.. Practice guidelines for perioperative blood transfusion and adjuvant therapies: An updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies. Anesthesiology, 2006, 105(1): 198-208

[13] PageAJ, EjazA, SpolveratoG, et al.. Enhanced recovery after surgery protocols for open hepatectomy—physiology, immunomodulation, and implementation. J Gastrointest Surg, 2015, 19(2): 387-399

[14] ThornbladeLW, SeoYD, KwanT, et al.. Enhanced recovery via peripheral nerve block for open hepatectomy. J Gastrointest Surg, 2018, 22(6): 981-988

[15] ChakrabortyA, KhemkaR, DattaT. Ultrasound-guided truncal blocks: A new frontier in regional anaesthesia. Indian J Anaesth, 2016, 60(10): 703-711

[16] CarlineL, McLeodGA, LambC. A cadaver study comparing spread of dye and nerve involvement after three different quadratus lumborum blocks. Br J Anaesth, 2016, 117(3): 387-394

[17] DamM, MorigglB, HansenCK, et al.. The pathway of injectate spread with the transmuscular quadratus lumborum block: A cadaver study. Anesth Analg, 2017, 125(1): 303-312

[18] ElsharkawyH, AhujaS, DeGrandeS, et al.. Subcostal approach to anterior quadratus lumborum block for pain control following open urological procedures. J Anesth, 2019, 33(1): 148-154

[19] AkermanM, PejcicN, VelickovicI. A review of the quadratus lumborum block and ERAS. Front Med (Lausanne), 2018, 5: 44

[20] WangY, WangX, ZhangK. Effects of transversus abdominis plane block versus quadratus lumborum block on postoperative analgesia: A meta-analysis of randomized controlled trials. BMC Anesth, 2020, 20(1): 103

[21] El BoghdadlyK, DesaiN, HalpernS, et al.. Quadratus lumborum block vs. transversus abdominis plane block for caesarean delivery: A systematic review and network meta-analysis. Anaesthesia, 2020, 76(3): 393-403

[22] ElsharkawyH, El-BoghdadlyK, BarringtonM. Quadratus lumborum block: Anatomical concepts, mechanisms, and techniques. Anesthesiology, 2019, 130(2): 322-335

[23] GriffithsJD, BarronFA, GrantS, et al.. Plasma ropivacaine concentrations after ultrasound-guided transversus abdominis plane block. Br J Anaesth, 2010, 105(6): 853-856

[24] GriffithsJD, LeNV, GrantS, et al.. Symptomatic local anaesthetic toxicity and plasma ropivacaine concentrations after transversus abdominis plane block for caesarean section. Br J Anaesth, 2013, 110(6): 996-1000

[25] YoshidaK, TanakaS, WatanabeK, et al.. The effectiveness of the intramuscular quadratus lumborum block in postoperative analgesia after cesarean section with vertical incision: A randomized, double-blinded placebo-controlled study. J Anesth, 2020, 34(6): 849-856