Purely ropivacaine-based TEA vs single TAP block in pain management after elective laparoscopic colon surgery within an upgraded institutional ERAS program

Abstract

Background The aim of this study was to compare thoracic epidural analgesia (TEA) with transversus abdominis plane (TAP) block in post-operative pain management after laparoscopic colon surgery. Methods One hundred thirty-six patients undergoing laparoscopic colon resection randomly received either TEA or TAP with ropivacaine only. The primary endpoint was opioid requirement up to 48 h postoperatively. Intensity of pain, time to onset of bowel function, time to mobilization, postoperative complications, length of hospital stay, and patients’ satisfaction with pain management were also assessed. Results We observed a significant decrease in opioid consumption on the day of surgery with TEA compared with TAP block (30 mg vs 14 mg, p < 0.001). On the first two postoperative days (POD), the balance shifted to opioid consumption being smaller in the TAP group: on POD 1 (15.2 mg vs 10.6 mg; p = 0.086) and on POD 2 (9.2 mg vs 4.6 mg; p = 0.021). There were no differences in postoperative nausea/vomiting or time to first postoperative bowel movement between the groups. No direct blockade-related complications were observed and the length of stay was similar between TEA and TAP groups. Conclusion TEA is more efficient for acute postoperative pain than TAP block on day of surgery, but not on the first two PODs. No differences in pain management-related complications were detected.

PROcedure-SPECific postoperative pain management guideline for laparoscopic colorectal surgery

“…Han et al demonstrated that TAP blocks did not show additional analgesic effects when superimposed on intrathecal morphine 75 . When compared with thoracic epidural analgesia, one study showed less early morphine consumption in the epidural than in the TAP group, 58 whereas no difference was detected in two other studies 59,60 . Hamada et al 76 showed that the addition of dextran to levobupivacaine could prolong analgesic effects of TAP blocks in a setting without adequate baseline analgesia.…”

“…Some studies had more than two relevant study arms. These were separately listed for each relevant comparison, making the sum of studies in the following listing higher than the number of studies included: seven studies investigating adjuvant systemic analgesics, 39–45 three studies investigating varying degrees of neuromuscular blockade, 46–48 seven studies investigating intravenous lidocaine, 43,49–54 six studies investigating epidural analgesia, 55–60 four studies investigating spinal opioids, 55,61–63 twenty-eight studies investigating truncal nerve blocks, 53,58–60,64–87 seven studies investigating wound infiltration, 54,57,72–74,88,89 four studies investigating intraperitoneal local anaesthetics (IPLA) 90–93 and seventeen studies investigating surgical techniques 94–110 . Supplemental Table 1, http://links.lww.com/EJA/A901 lists the summary of key results from studies evaluating systemic analgesics, systemic analgesic adjuncts, regional analgesia and surgical procedures used to support the recommended interventions in patients after laparoscopic colectomy.…”

“…The authors reported no significant difference in pain scores and mean analgesic requirement; however, adequate baseline analgesia was not used in the study. Bumblyte et al , comparing thoracic epidural analgesia with transversus abdominis plane (TAP) blocks in patients receiving adequate baseline analgesia, found an early opioid-sparing but no analgesic effect (maximal pain score) for epidural analgesia 58 . No analgesic benefit was found when comparing TEA with TAP blocks with adequate baseline analgesia, 59 or without 60 …”

“…Some studies had more than two relevant study arms. These were separately listed for each relevant comparison, making the sum of studies in the following listing higher than the number of studies included: seven studies investigating adjuvant systemic analgesics, [39][40][41][42][43][44][45] three studies investigating varying degrees of neuromuscular blockade, [46][47][48] seven studies investigating intravenous lidocaine, 43,[49][50][51][52][53][54] six studies investigating epidural analgesia, [55][56][57][58][59][60] four studies investigating spinal opioids, 55,[61][62][63] twenty-eight studies investigating truncal nerve blocks, 53,[58][59][60] seven studies investigating wound infiltration, 54,57,[72][73][74]88,89 four studies investigating intraperitoneal local anaesthetics (IPLA) [90][91][92][93] and seventeen studies investigating surgical techniques. [94][95]…”

“…Bumblyte et al, comparing thoracic epidural analgesia with transversus abdominis plane (TAP) blocks in patients receiving adequate baseline analgesia, found an early opioidsparing but no analgesic effect (maximal pain score) for epidural analgesia. 58 No analgesic benefit was found when comparing TEA with TAP blocks with adequate baseline analgesia, 59 or without. 60 Considering the invasive nature of epidural analgesia, the doubtful analgesic efficacy in laparoscopic colorectal surgery, combined with a potential for serious complications, and the availability of alternative analgesic methods that are less invasive, epidural analgesia is not recommended.…”