Laparoscopic-guided transversus abdominis plane block with liposomal bupivacaine.

Abstract

We read with great interest the recent article by Wong et al. [ [1] Wong K.A. Cabrera A.G. Argiroff A.L. et al. Transversus abdominis plane block with liposomal bupivacaine and its effect on opiate use after weight loss surgery: a randomized controlled trial. Surg Obes Relat Dis. 2020; 16: 886-893 Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar ] titled, “Transversus abdominis plane (TAP) block with liposomal bupivacaine and its effect on opiate use after weight loss surgery: a randomized controlled trial.” This long-awaited, well-designed study compared laparoscopic-guided TAP block (L-TAP) with liposomal bupivacaine, L-TAP with regular bupivacaine, and no block in patients undergoing laparoscopic bariatric surgery. In line with a recent randomized trial, no difference was found between liposomal and regular bupivacaine in terms of postoperative pain scores and opioid consumption [ [2] Ma P. Lloyd A. McGrath M. et al. Efficacy of liposomal bupivacaine versus bupivacaine in port site injections on postoperative pain within enhanced recovery after bariatric surgery program: a randomized clinical trial. Surg Obes Relat Dis. 2019; 15: 1554-1562 Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar ]. Strikingly, however, the results showed no difference in outcomes between L-TAP with regular bupivacaine and no block. In a recent meta-analysis culling data of 10 randomized trials, we demonstrated that TAP block using short-acting anesthetic agents significantly improves early and late postoperative pain, and opioid consumption in patients undergoing laparoscopic bariatric surgery; most trials however employed ultrasound-guided TAP block [ [3] Hamid HKS, Ahmed AY, Saber AA, et al. Transversus abdominis plane block using a short-acting local anesthetic reduces pain and opioid consumption after laparoscopic bariatric surgery: a meta-analysis. Surg Obes Relat Dis. Epub 2020 Apr 4. Google Scholar ]. We performed a post hoc sensitivity analysis including only studies comparing regular bupivacaine with no block (n = 7). TAP block was significantly associated with lower early and late postoperative pain scores, reduced 24- and 48-hour opioid consumption, and a shorter time to ambulation (Table 1). Considering that L-TAP is equivalent to ultrasound-guided TAP block [ [4] Hamid HKS, Emile SH, Saber AA, et al. Laparoscopic-guided transversus abdominis plane block for postoperative pain management in minimally invasive surgery: a systematic review and meta-analysis. J Am Coll Surg. Epub 2020 Jun 2. Google Scholar ], it is expected that L-TAP with regular bupivacaine would improve postoperative pain control and reduce opioid consumption after laparoscopic bariatric surgery. Similarly, the study by Wong et al. [ [1] Wong K.A. Cabrera A.G. Argiroff A.L. et al. Transversus abdominis plane block with liposomal bupivacaine and its effect on opiate use after weight loss surgery: a randomized controlled trial. Surg Obes Relat Dis. 2020; 16: 886-893 Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar ] showed no benefit for liposomal bupivacaine over no block regarding pain control and opioid consumption. This goes against several lines of evidence supporting the benefit of TAP block with liposomal bupivacaine in laparoscopic bariatric and nonbariatric surgery [ [5] Bhakta A. Glotzer O. Ata A. et al. Analgesic efficacy of laparoscopic-guided transverse abdominis plane block using liposomal bupivacaine in bariatric surgery. Am J Surg. 2018; 215: 643-646 Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar ]. Table 1Outcomes of TAP block with regular bupivacaine in laparoscopic bariatric surgery Outcome SMD or OR (95%CI) P value Pain at rest at 24 hr −.79 (−1.21, −.37) <.001 Pain on movement at 24 hr −1.01 (−2.04, .02) .06 Pain at rest at 0–3 hr −1.93 (−2.85, −1.01) <.001 Pain on movement at 0–3 hr −2.05 (−3.31, −.78) .002 24-hr opioid consumption −2.86 (−4.19, −1.53) <.001 48-hr opioid consumption −26.39 (−30.24, −22.53) <.001 Time to ambulation −1.29 (−2.10, −.48) .002 SMD = standardized mean difference; OR = odd ratio; CI = confidence interval. Open table in a new tab SMD = standardized mean difference; OR = odd ratio; CI = confidence interval.