Erector Spinae Plane Block Enhances Multimodal Analgesia for Laparoscopic Cholecystectomy

This article refers to:

Comparison of Ultrasound-Guided Erector Spinae Plane Block and Subcostal Transversus Abdominis Plane Block for Postoperative Analgesia after Laparoscopic Cholecystectomy: A Randomized, Controlled Trial

In a recently published randomized controlled trial, the authors compared the effectiveness of an erector spinae plane (ESP) block versus a subcostal transversus abdominis plane (STAP) block for postoperative pain management in adult patients undergoing laparoscopic cholecystectomy [1]. This study was well-designed and replicable in clinical practice, and provides a systematic comparison of two truncal blocks which are commonly used in multimodal analgesia for laparoscopic cholecystectomy. The results showed a more favorable analgesic effect with the ESP block compared to the STAP block. However, we questioned the fundamental analgesic regimen for enhanced recovery after laparoscopic cholecystectomy.

Laparoscopic cholecystectomy has become the gold standard for the treatment of gallbladder disease, with the advantages being minimal invasiveness, less postoperative pain, and faster recovery. The enhanced recovery after surgery (ERAS) protocols for laparoscopic gastrointestinal surgery have shown beneficial outcomes, not only in terms of reducing opioid consumption, but also in reducing the number of adverse events and achieving a shorter hospital stay [2,3]. To our best knowledge, there are no reports of ERAS guidelines for minor abdominal procedures, such as laparoscopic cholecystectomy. We were thus interested to see how the authors used multimodal analgesia, which is one of the core elements of ERAS protocols, in their comparative study of EPS and STAP blocks [1]. The authors report using a routine multimodal analgesia regimen including a preoperative ESP or STAP block, intraoperative paracetamol and tenoxicam, postoperative intravenous paracetamol, and patient-controlled fentanyl analgesia. Our major concern with this study is that we found it partially against ERAS guidelines to use patient-controlled fentanyl analgesia and meperidine as a rescue in laparoscopic surgery. The purpose of multimodal analgesia is to reduce opioid consumption and associated adverse events for enhanced recovery after abdominal surgery [4].

Acute pain after laparoscopic cholecystectomy may arise from somatic (abdominal wall and/or peritoneum), visceral (gallbladder), and referred (shoulder) impulses [5]. A more central approach (i.e., ESP block) might provide better pain relief than a peripheral approach (i.e., transversus abdominis plane block). A STAP block prevents somatic pain of the anterior abdomen via a neurovascular plane from T6 to T10. This blocks both somatic and visceral pain via the ventral, dorsal, and communicating rami of the spinal nerves. Two randomized controlled trials have now shown that ESP is superior to TAP when added to intravenous patient-controlled analgesia (PCA) for pain management after laparoscopic cholecystectomy [1,6]. In another randomized controlled trial, a bilateral ESP block was as effective as a bilateral STAP block in combination with patient-controlled morphine analgesia [7]. Both blocks were better than the port-site local infiltration in the analgesic and recovery profiles.

In an evidence-based pain control protocol for laparoscopic cholecystectomy, multimodal analgesia with restrictive opioid use is highly recommended [8]. This updated pain management review suggested that both surgical techniques (i.e., pneumoperitoneum) and analgesic medication (i.e., paracetamol, non-steroidal anti-inflammatory drugs) were important components of routine analgesia. The STAP block was considered to be an adjuvant when routine analgesia was inadequate. An increasing number of studies support the ESP block being implemented in multimodal analgesia from chest and abdominal to lumbar spine surgery [9]. With more evidence, the ESP block has the potential to be incorporated into the ERAS guidelines.

This study is significant as a model for multimodal analgesia in patients undergoing laparoscopic surgery. The evidence showed that multimodal analgesia was associated with better pain management, lower opioid doses, fewer adverse events, and reduced chronic postoperative pain. We believe that nerve blocks, as a part of the analgesia regimen, have the potential to be implemented in more ERAS protocols for various types of surgery.

Acknowledgments

We appreciate the great help from Taylor & Francis Editing Services.

Disclosure statement

The authors report no financial interests nor conflicts of interest.

Funding

Kaohsiung Municipal Siaogang Hospital, Grant/Award Number: H-109-001.