Analgesic efficacy of erector spinae plane block versus transversus abdominis plane block in laparotomies for cancer surgeries: A randomized blinded control study

Ahmed Hussein Bakeer; Waleed Hamimy; Ahmed Zaghloul; Ahmed Shaban; Mohammed Magdy; Mahmoud Badry Ahmed

doi:10.4103/bjoa.bjoa_229_22

ORIGINAL ARTICLE

Year : 2023 | Volume : 7 | Issue : 1 | Page : 19-23

Analgesic efficacy of erector spinae plane block versus transversus abdominis plane block in laparotomies for cancer surgeries: A randomized blinded control study

Ahmed Hussein Bakeer¹, Waleed Hamimy², Ahmed Zaghloul², Ahmed Shaban¹, Mohammed Magdy¹, Mahmoud Badry Ahmed²
¹ Department of Anesthesia, Surgical Intensive Care Unit and Pain Management, National Cancer Institute, Cairo University, Cairo, Egypt
² Department of Anesthesia, Surgical Intensive Care Unit and Pain Management, Faculty of Medicine Kasr Alainy, Cairo University, Cairo, Egypt

Date of Submission	22-Sep-2022
Date of Decision	19-Dec-2022
Date of Acceptance	29-Dec-2022
Date of Web Publication	6-Mar-2023

Correspondence Address:
Mohammed Magdy
Surgical Intensive Care, and Pain Management, National cancer institute, Cairo University, El Kasr El Aini st/Fom Elkhakig Square, Cairo 11796
Egypt

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/bjoa.bjoa_229_22

Abstract

Background: Pain has a wide spectrum of effects on the body and inadequate management of postoperative pain outcomes in multiple physiological and psychological consequences; and increases morbidity. The use of opioid-based analgesia in high doses can have multiple adverse effects including respiratory depression, nausea, and vomiting. Objectives: Our aim was to evaluate the efficacy of analgesic and safety of both techniques (transversus abdominis plane block [TAPB] and erector spinae plane block [ESPB]) in cases having lower abdominal surgery through laparotomy. Materials and Methods: This randomized trial was performed on 62 cases who underwent laparotomy for lower abdominal surgery under general anesthesia were recruited. Subjects were equally distributed into either TAPB or ESPB. The primary outcome was total morphine intake postoperatively for 24 h. Other variables were intraoperative fentanyl consumption, delay to first morphine demand, and intraoperative morphine consumption, the number of patients who needed rescue analgesia by morphine, perioperative heart rate and mean blood pressure, numerical rating score (NRS), postoperative nausea and vomiting, and block-related complications. Results: ESPB patients consumed less total postoperative morphine than the TAPB group (5.35 ± 2.65 vs. 8.52 ± 3.35 mg; P < 0.001). Patients who received ESPB showed less postoperative pain scores and, thus, needed rescue medication after a longer period than the TAPB group (12.50 ± 7.31 h vs. 7.72 ± 5.69 h; P = 0.008). In addition, ESPB patients needed less intraoperative fentanyl doses than TAPB (138.71 ± 35.85 vs. 203.23 ± 34.00 mcg; P < 0.001). ESPB group demonstrated statistically significant lower scores of NRS at rest and at movement. Conclusions: Ultrasound (US)-guided ESPB provides more safe and effective analgesia in lower abdominal surgeries compared with US-guided TAPB.

Keywords: Hysterectomy, low anterior resection, lower abdominal surgery, postoperative analgesia, radical cystectomy, regional anesthesia

How to cite this article:
Bakeer AH, Hamimy W, Zaghloul A, Shaban A, Magdy M, Ahmed MB. Analgesic efficacy of erector spinae plane block versus transversus abdominis plane block in laparotomies for cancer surgeries: A randomized blinded control study. Bali J Anaesthesiol 2023;7:19-23

How to cite this URL:
Bakeer AH, Hamimy W, Zaghloul A, Shaban A, Magdy M, Ahmed MB. Analgesic efficacy of erector spinae plane block versus transversus abdominis plane block in laparotomies for cancer surgeries: A randomized blinded control study. Bali J Anaesthesiol [serial online] 2023 [cited 2023 Mar 27];7:19-23. Available from: https://www.bjoaonline.com/text.asp?2023/7/1/19/371176

Introduction

Pain induces a biochemically and physiologically complicated stress response that impairs respiratory, immune, and metabolic systems. The present ideal for postoperative pain management is opioids. However, consumption of high doses results in many adverse effects of variable severity including dizziness, nausea, vomiting, constipation, respiratory depression, hypoventilation, and apnea.^[1] Without compromising proper and effective analgesia, alternatives to opioids are, therefore, advised, particularly among patients with cancer, who are more prone to addiction and tolerance.

The transversus abdominis plane block (TAPB) is a method of local anesthetic utilized for various surgeries, including, but not limited to, laparotomies. As with other nerve blocks, the method depends on ultrasound (US)-guided needle manipulation, Targeting the plane formed by the internal oblique muscles and transversus abdominis.^{[2],[3],[4],[5],[6]}

In 2016, Forero et al.^[7] introduced the erector spinae plane block (ESPB) for the treatment of persistent neuropathic pain after a malunited rib fracture and postthoracotomy neuropathy, the patient had severe discomfort.^[7],[8],[9] ESPB has been demonstrated to be a good analgesic alternative for a variety of surgical procedures, for example, lumbar spine surgery, laparoscopic cholecystectomy, thoracotomy procedures, and ventral hernia repair surgery. Moreover, ESPB has been demonstrated to be a reliable anesthetic alternative, either as a standalone technique or in combination with other regional techniques, as an alternative to general anesthesia for mastectomy in high-risk individuals.

Although ESPB can provide a block comparable to that of the paravertebral block, it is thought to be technological simplicity, given that the needle is oriented away from the pleura, thus reducing the possibility of the block-related complications, for example, pneumothorax.^[10] In addition, it is likely to be safe in patients with suboptimal coagulation status compared with the epidural or paravertebral block.^{[11],[12],[13]} This study aims to assess the analgesic efficacy and safety profile of ESPB block and TAPB in cancer patients undergoing abdominal laparotomies.

Materials and Methods

This randomized trial was performed in the National Cancer Institute of Cairo University and registered in Clinical Trial Registration (NCT04555993 on September 21, 2020). Before enrolling any patient in the trial, signed informed permission was sought from each individual.

Inclusion criteria included 18–65 years old patients with American Society of Anaesthesiologists Physical Status II and III scheduled for the cancer-related lower abdominal procedure with a body mass index of 20–35 kg/m². Patient with known psychological disorder, chronic pain, known sensitivity to any of the study drugs, significant liver, or renal insufficiency, severe respiratory, or cardiac disorder were excluded from the study. Contraindications to regional anesthetic, such as peripheral neuropathies, local sepsis, and coagulopathy, were omitted from this research.

A previous study^[14] found that the mean morphine consumption within 24 h postoperatively was 5.65 ± 1.55 mg in the TAPB group. Assuming a difference in morphine consumption of 1.13 (20% difference in morphine consumption), a minimum of 62 patients was needed to achieve a study power of 80% and the type-1 error of 0.05. The 72 subjects were equally and randomly assigned to either TAPB or ESPB group utilizing computer-created random numbers and concealed closed envelope containing details of drug preparation and the assigned block.

Patients were assessed the day before surgery by reviewing their medical status and laboratory investigations. On the day of the surgery in holding area, a cannula of 20-G was inserted, and routine monitors were applied (5-lead electrocardiogram, PO₂, and noninvasive blood pressure). Baseline mean blood pressure (MAP) and heart rate (HR) were documented as the average of three consecutive readings with 2-min interval, and premedication with 0.02 mg/kg midazolam was administered intravenously 5-min before block performance. All blocks were under complete aseptic condition using Sonosite EDGE (Fujifilm Sonosite, Inc., Bothell, WA) with a high-frequency linear transducer 6–13 MHz.

Postoperative acetaminophen of 1 g and ketorolac of 30 mg were given to all patients every 6 h. The numerical rating score (NRS) was measured immediately after surgery, then 30 min, 1, 2, 4, 6, 12, and 24 h later. If NRS was more than 3, 2-mg morphine by intravenous patient-controlled analgesia (PCA) was administered. The primary outcome was total morphine intake postoperatively for 24 h. Other variables were intraoperative fentanyl consumption, delay to first morphine demand, and intraoperative morphine consumption, the number of patients who needed rescue analgesia by morphine, perioperative HR and MAP, NRS, postoperative nausea and vomiting, and block-related complications such as local anesthetic toxicity, pneumothorax, and lower limb affliction.

Statistical Package for the Social Sciences (IBM Corp. Released in 2019. IBM SPSS Statistics for Windows, version 26.0. IBM Corp., Armonk, NY) version 26 was utilized to manage and analyze data. The Shapiro–Wilk test was utilized to examine the normality of continuous data. Continuous data were summarized using the mean standard deviation or medians (quartiles) and evaluated using the relevant unpaired t test or Mann–Whitney test. Categorical data were presented as numbers and percentages and evaluated with Chi-square or Fisher’s exact tests, as applicable. A P-value of less than 0.05 was deemed statistically significant.

Results

Seventy-two cases were evaluated for eligibility, four cases were omitted because they did not match the inclusion criteria. Sixty-eight cases were randomized to receive either TAPB (n = 34) or ESPB (n = 34). Three cases in each group were then excluded due to incomplete data collection. Sixty-two patients were available for final assessment [Figure 1]. Patients’ demographic information were comparable across the two groups [Table 1].

Figure 1: Consort flow of the study

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Table 1: Demographic data of the study’s subjects

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Patients in the ESPB group had lower morphine consumed within the first 24 h, longer time for the first rescue morphine requirement, and lower intraoperative fentanyl consumption than patients in the TAPB group [Table 2]. Furthermore, moderate nausea and vomiting were significantly lower in the ESPB group than TAPB group (P = 0.037). At 8 h postoperatively, lower NRS was reported in the ESPB group at rest and during movement, otherwise, the NRS was generally comparable between both groups at rest and during movement [Table 3].

Table 2: Intraoperative and postoperative data between TAPB and ESPB groups

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Table 3: Numerical rating score

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Discussion

Effective postoperative analgesia improving patients’ outcomes allowing earlier ambulation, reduced hospital staying period, minimizing hospitalization charges, and augmentation of patient satisfaction. Consequently, measuring pain alleviation is becoming an increasingly essential postoperative quality indicator.

Postoperative analgesia’s primary objective is to alleviate or avoid pain and discomfort with minimal adverse effects. Postoperative pain is usually managed by opioids but usually combined with side effects such as prolonged sedation, respiratory depression, nausea, vomiting, and ileus, and recently multiple studies suggested a link between opioids and cancer recurrence.^[15] To reduce these complications, multiple regional techniques including thoracic epidural analgesia, thoracic paravertebral block, TABP, and Quadrates Lumborum block have been used for the management of pain after laparotomy incision. According to our knowledge, there is no randomized clinical trials comparing ESPB with TAPB in lower abdominal cancer surgeries.

In this study, we reported that patients in the ESPB group required less intra- and postoperative opioids and had less severe nausea than the patients in the TAPB group. Furthermore, the duration of analgesia was longer in the ESPB group than in the TAPB group. This was anticipated, as the injected local anesthetics in ESPB act on the dorsal of the thoracic spinal nerves, so inhibiting sympathetic fibers and resulting in good treatment of somatic and visceral pain.

In accordance with our results, Altiparmak et al.^[16] conducted a randomized trail on 72 patients comparing ESPB at the level of T7 and subcostal TAPB in laparoscopic cholecystectomy using 20 mL of 0.375% bupivacaine for both blocks. They found less postoperative tramadol consumption of 139.1 ± 21.9 mg in the erector spinae plane (ESP) group compared with 199.4 ± 27.7 mg in the TAPB group (P < 0.001), which is equivalent to 13.9 ± 2.19 mg and 19.94 ± 2.77 mg of morphine, respectively.

Moreover, they reposted that the ESP group had significantly lower NRS scores by 1 point, so it was statistically significant but not clinically significant. However, they found no differences in rescue analgesic consumptions, Contrary to our results, the difference in the first rescue analgesia (hours) in the TAPB group was 7.72 ± 5.69 h compared with 12.50 ± 7.31 h in the ESPB group (P = 0.008). The following differences can be explained by having a different type of surgery and different postoperative analgesia in their study.^[16]

Hamed et al.^[17] compared ESPB with the control group in 60 patients undergoing abdominal complete hysterectomy through Pfannenstiel incision throughout general anesthesia. They found that patients who received ESPB showed less postoperative fentanyl consumption through PCA compared with (485 ± 20.39 vs. 445 ± 67.49 mcg; P = 0.003). The control group had considerably higher visual analogue score pain scores, the main differences compared with our study were that the ESPB was performed at a lower level T9, and a different type of surgery was chosen.

Kumar et al.^[14] compared TABP versus Quadratus Lumborum Block for analgesia postoperatively following lower abdominal surgery. Seventy adult patients were allocated into two equal groups. A total of 20 mL of 0.25% ropivacaine on each side was used in both blocks. Postoperative morphine consumption was 5.65 ± 1.55 mg in the TAPB group compared with (8.52 ± 3.35 mg) in our study. The time of initial analgesic rescue was 243.00 ± 97.36 min in the TAPB group. The difference in postoperative morphine consumption could be related to different local anesthetics or may be due to different types of operations.

Both regional techniques are simple and safe to perform because of the recognizable ultrasonographic markers and an injection endpoint, In addition, these blocks have a low risk of serious consequences because they are injected into tissue planes that are separated from major blood arteries and nerves.^[18]

Unfortunately, our study lacked a control group that utilized systemic analgesia or one of the gold-standard regional methods in abdominal surgery (i.e., thoracic epidural analgesia). Moreover, the exact level of sensory loss and onset of sensory block were not measured, because our main goal was measurement of postoperative analgesic effect, and patients were sedated, which may interfere with adequate response. In addition, long-term effect (effect on chronic pain) was not considered because a 3–6 month follow-up is required, which will exceed our time schedule and will require more resources.

Conclusion

US-guided ESPB provides more safe and effective analgesia in laparotomies for lower abdominal surgery compared with US-guided TAPB. Furthermore, it also helps in consuming less intraoperative fentanyl, less postoperative morphine, and lower numeric pain scale scores.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Randerath WJ, George S Opioid-induced sleep apnea: Is it a real problem? J Clin Sleep Med 2012;8:577-8.
2.	Tsai HC, Yoshida T, Chuang TY, Yang SF, Chang CC, Yao HY, et al. Transversus abdominis plane block: An updated review of anatomy and techniques. Biomed Res Int 2017;2017:18284363-12.
3.	Finnerty O, Carney J, McDonnell JG Trunk blocks for abdominal surgery. Anaesthesia 2010;65:76-83.
4.	Hebbard P Subcostal transversus abdominis plane block under ultrasound guidance. Anesth Analg 2008;106:674-5.
5.	Yarwood J, Berrill A Nerve blocks of the anterior abdominal wall. Continuing Education in Anaesthesia Critical Care & Pain 2010;10:182-6.
6.	Abrahams MS, Horn JL, Noles LM, Aziz MF Evidence-based medicine: Ultrasound guidance for truncal blocks. Reg Anesth Pain Med 2010;35:S36-42.
7.	Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ The erector spinae plane block: A novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med 2016;41:621-7.
8.	El-Boghdadly K, Pawa A The erector spinae plane block: Plane and simple. Anaesthesia 2017;72:434-8.
9.	Fusco P, S DIC, Scimia P, Luciani A, Petrucci E, Marinangeli F Could the new ultrasound-guided erector spinae plane block be a valid alternative to paravertebral block in chronic chest pain syndromes? Minerva Anestesiol 2017;83:1112-3.
10.	Tulgar S, Balaban O Local anaesthetic injection point of erector spinae plane block. Indian J Anaesth 2018;62:403-4.
11.	Kietaibl S, Ferrandis R, Godier A, Llau J, Lobo C, Macfarlane AJ, et al. Regional anaesthesia in patients on antithrombotic drugs: Joint ESAIC/ESRA guidelines. Eur J Anaesthesiol 2022; 39:100-32.
12.	Schwartzmann A, Peng P, Maciel MA, Forero M Mechanism of the erector spinae plane block: Insights from a magnetic resonance imaging study. Can J Anaesth 2018;65:1165-6.
13.	Restrepo-Garces CE, Chin KJ, Suarez P, Diaz A Bilateral continuous erector spinae plane block contributes to effective postoperative analgesia after major open abdominal surgery: A case report. A A Case Rep 2017;9:319-21.
14.	Kumar GD, Gnanasekar N, Kurhekar P, Prasad TK A comparative study of transversus abdominis plane block versus quadratus lumborum block for postoperative analgesia following lower abdominal surgeries: A prospective double-blinded study. Anesth Essays Res 2018;12:919-23.
15.	Nguyen J, Luk K, Vang D, Soto W, Vincent L, Robiner S, et al. Morphine stimulates cancer progression and mast cell activation and impairs survival in transgenic mice with breast cancer. Br J Anaesth 2014;113 Suppl 1:ii44-i13.
16.	Altıparmak B, Korkmaz Toker M, Uysal AI, Kuşçu Y, Gümüş Demirbilek S Ultrasound-guided erector spinae plane block versus oblique subcostal transversus abdominis plane block for postoperative analgesia of adult patients undergoing laparoscopic cholecystectomy: Randomized, controlled trial. J Clin Anesth 2019;57:31-6.
17.	Hamed MA, Goda AS, Basiony MM, Fargaly OS, Abdelhady MA Erector spinae plane block for postoperative analgesia in patients undergoing total abdominal hysterectomy: A randomized controlled study original study. J Pain Res 2019;12:1393-8.
18.	Hamilton DL, Manickam B Erector spinae plane block for pain relief in rib fractures. Br J Anaesth 2017;118:474-5.