Association of the addition of a transversus abdominis plane block to an enhanced recovery program with opioid consumption, postoperative antiemetic use, and discharge time in patients undergoing laparoscopic bariatric surgery: a retrospective study

Abstract

BackgroundIncreasing numbers of laparoscopic bariatric surgeries are being performed and enhanced recovery from anesthesia and surgery (ERAS) protocols have been implemented to optimize care for these patients. We evaluated the effects of an anesthesiologist placed preoperative transversus abdominis plane block (TAP) as part of a bariatric surgery ERAS protocol. We hypothesized that an anesthesiologist placed preoperative TAP added to an ERAS protocol following laparoscopic bariatric surgery would reduce total opioid consumption.MethodsA retrospective cohort of consecutive patients between January 1, 2017 and December 31, 2018 at a single large tertiary care center studied. TAP blocks were added to the ERAS protocol beginning in the second quarter of 2017. The primary outcome was total opioid analgesia use in mg oral morphine equivalents. Secondary outcomes were antiemetics administered and length of hospitalization. Data were analyzed using a generalized linear mixed model adjusted for sociodemographic, surgical, and preoperative risk factors that have been associated with opioid and antiemetic use and length of hospitalization.ResultsFive hundred and nine cases were analyzed; TAP blocks were performed in 94/144 (65%) laparoscopic Roux-en-Y gastric bypass (LRYGB) and in 172/365 (47%) laparoscopic sleeve gastrectomy (LSG) patients. Mean (95% CI) adjusted total opioid administered was lower by 11% (1% to 19%, p=0.02), antiemetic drug administration was lower by 15% (-2% to 25%, p=0.06) and discharge time lower by 39% (26% to 48%, p<0.01) following LRYGB in the TAP group. Mean (95% CI) adjusted total opioid administered was lower by 9% (2% to 16%, p<0.01), antiemetic drug administration was lower by 11% (3% to 18%, p<0.01) and discharge time lower by 11% (2% to 18%, p=0.02) following LSG in the TAP group.ConclusionsTAP blocks added to a laparoscopic bariatric surgery ERAS protocol were associated with decreased total opioid use, number of antiemetic treatments, and length of stay; however, these changes were not likely clinically important. Our findings do not support widespread clinical benefit of TAP use in ERAS protocols for laparoscopic bariatric surgery.

A little better is still better: using marginal gains to enhance ‘enhanced recovery’ after surgery

“…In Regional Anesthesia and Pain Medicine , McCarthy and colleagues share the results of their retrospective cohort study evaluating the effects of implementing additional transversus abdominis plane (TAP) blocks to a robust enhanced recovery protocol on opioid consumption and other perioperative outcomes for minimally-invasive bariatric surgery patients 1. The adjusted outcomes show average decreases associated with TAP blocks in total opioid consumption of 11% for Roux-en-Y patients and 9% for sleeve gastrectomy patients 1. In addition, TAP block patients in both groups report decreased antiemetic medication administration, fewer patient requests for additional opioids, and shorter hospital length of stay 1.…”

“…The adjusted outcomes show average decreases associated with TAP blocks in total opioid consumption of 11% for Roux-en-Y patients and 9% for sleeve gastrectomy patients 1. In addition, TAP block patients in both groups report decreased antiemetic medication administration, fewer patient requests for additional opioids, and shorter hospital length of stay 1. Yet, the authors present these findings collectively as a negative study because these differences fall short of the ‘clinically significant reduction’ threshold of 25% set in the methods.…”

“…Context is key for interpreting any study. Rush University implemented their multidisciplinary enhanced recovery protocol in early 2016, including elements covering multimodal analgesia, prevention of thromboembolic complications, patient education, nutrition, infection prevention, management of lines and tubes, and antiemetic prophylaxis throughout the perioperative period, and reported adherence to the protocol is 91% on average 1. This itself is noteworthy as rates of adherence to enhanced recovery protocols are commonly lower,4 in part due to unnecessary complexity and lack of evidence to support certain elements 5.…”

“…This itself is noteworthy as rates of adherence to enhanced recovery protocols are commonly lower,4 in part due to unnecessary complexity and lack of evidence to support certain elements 5. The multimodal analgesic regimen included in the Rush enhanced recovery protocol for all minimally-invasive bariatric surgery patients incorporates most of the major categories of non-opioid analgesia available: acetaminophen, N-methyl-D-aspartate antagonists, steroids, local anesthetic infiltration, and opioids 1. It is important to note that all patients in this study had laparoscopic surgery and were included in this enhanced recovery protocol which includes infiltration of port sites at the end of surgery with 30 mL of 0.5% ropivacaine, three systemic non-opioid analgesics, and opioids postoperatively on a scheduled and as-needed basis; the only change in the protocol was the addition of bilateral TAP blocks (figure 1).…”

“…It is important to note that all patients in this study had laparoscopic surgery and were included in this enhanced recovery protocol which includes infiltration of port sites at the end of surgery with 30 mL of 0.5% ropivacaine, three systemic non-opioid analgesics, and opioids postoperatively on a scheduled and as-needed basis; the only change in the protocol was the addition of bilateral TAP blocks (figure 1). 1 Given this context, a 25% expected reduction in opioid dosage with the addition of TAP blocks to an already robust multimodal analgesic regimen for minimally-invasive surgery that includes local anesthetic infiltration seems optimistic best and unrealistic at worst. In our opinion, the 9% to 11% improvement in opioid reduction reported in the study is frankly remarkable.…”