Korean J Pain.  2022 Jul;35(3):303-310. 10.3344/kjp.2022.35.3.303.

Ultrasound-guided erector spinae plane block for pain management after gastrectomy: a randomized, single-blinded, controlled trial

• Jeong H
• Choi JW
• Sim WS
• Kim DK
• Bang YJ
• Park S
• Yeo H
• Kim H

• KMID: 2530985
• DOI: http://doi.org/10.3344/kjp.2022.35.3.303

Abstract

Background
Open gastrectomy causes severe postoperative pain. Therefore, we investigated the opioid-sparing effect of the ultrasound-guided bilateral erector spinae plane block (ESPB) after open gastrectomy.
Methods
Adult patients undergoing open gastrectomy were randomly assigned to either the ESPB group (ESPB + fentanyl based intravenous patient-controlled analgesia [IV-PCA]) or a control group (fentanyl based IV-PCA only). The primary outcome was total fentanyl equivalent consumption during the first 24 hour postoperatively. Secondary outcomes were pain intensities using a numeric rating scale at the postanesthesia care unit (PACU) and at 3, 6, 12, and 24 hour postoperatively, and the amount of fentanyl equivalent consumption during the PACU stay and at 3, 6, and 12 hour postoperatively, and the time to the first request for rescue analgesia.
Results
Fifty-eight patients were included in the analysis. There was no significant difference in total fentanyl equivalent consumption during the first 24 hour postoperatively between the two groups (P = 0.471). Pain intensities were not significantly different between the groups except during the PACU stay and 3 hour postoperatively (P < 0.001, for both). Time to the first rescue analgesia in the ward was longer in the ESPB group than the control group (P = 0.045).
Conclusions
Ultrasound-guided ESPB did not decrease total fentanyl equivalent consumption during the first 24 hour after open gastrectomy. It only reduced postoperative pain intensity until 3 hour postoperatively compared with the control group. Ultrasound-guided single-shot ESPB cannot provide an efficient opioid-sparing effect after open gastrectomy.

Keyword

Analgesia; Patient-Controlled; Analgesics; Opioid; Fentanyl; Gastrectomy; Nerve Block; Nociceptive Pain; Pain Management; Pain; Postoperative; Ultrasonography; Interventional

Figure

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  Fig. 1 CONSORT (Consolidated Standards of Reporting Trials) flow diagram of the study. ESPB: erector spinae plane block.

Reference

1. Venerito M, Link A, Rokkas T, Malfertheiner P. 2019; Review: gastric cancer-Clinical aspects. Helicobacter. 24 Suppl 1:e12643. DOI: 10.1111/hel.12643. PMID: 31486238.

2. Tegels JJ, De Maat MF, Hulsewé KW, Hoofwijk AG, Stoot JH. 2014; Improving the outcomes in gastric cancer surgery. World J Gastroenterol. 20:13692–704. DOI: 10.3748/wjg.v20.i38.13692. PMID: 25320507. PMCID: PMC4194553.

3. Park YK, Yoon HM, Kim YW, Park JY, Ryu KW, Lee YJ, et al. 2018; Laparoscopy-assisted versus open D2 distal gastrectomy for advanced gastric cancer: results from a randomized phase II multicenter clinical trial (COACT 1001). Ann Surg. 267:638–45. DOI: 10.1097/SLA.0000000000002168. PMID: 28187041.

4. van Boekel RLM, Warlé MC, Nielen RGC, Vissers KCP, van der Sande R, Bronkhorst EM, et al. 2019; Relationship between postoperative pain and overall 30-day complications in a broad surgical population: an observational study. Ann Surg. 269:856–65. DOI: 10.1097/SLA.0000000000002583. PMID: 29135493.

5. Royse CF, Chung F, Newman S, Stygall J, Wilkinson DJ. 2013; Predictors of patient satisfaction with anaesthesia and surgery care: a cohort study using the Postoperative Quality of Recovery Scale. Eur J Anaesthesiol. 30:106–10. DOI: 10.1097/EJA.0b013e328357e584. PMID: 22907610.

6. Wick EC, Grant MC, Wu CL. 2017; Postoperative multimodal analgesia pain management with nonopioid analgesics and techniques: a review. JAMA Surg. 152:691–7. DOI: 10.1001/jamasurg.2017.0898. PMID: 28564673.

7. Guay J, Nishimori M, Kopp S. 2016; Epidural local anaesthetics versus opioid-based analgesic regimens for postoperative gastrointestinal paralysis, vomiting and pain after abdominal surgery. Cochrane Database Syst Rev. 7:CD001893. DOI: 10.1002/14651858.CD001893.pub2. PMID: 27419911. PMCID: PMC6457860.

8. Manion SC, Brennan TJ. 2011; Thoracic epidural analgesia and acute pain management. Anesthesiology. 115:181–8. DOI: 10.1097/ALN.0b013e318220847c. PMID: 21606825.

9. Wildsmith JA. 2012; Continuous thoracic epidural block for surgery: gold standard or debased currency? Br J Anaesth. 109:9–12. DOI: 10.1093/bja/aes177. PMID: 22696554.

10. Tilleul P, Aissou M, Bocquet F, Thiriat N, le Grelle O, Burke MJ, et al. 2012; Cost-effectiveness analysis comparing epidural, patient-controlled intravenous morphine, and continuous wound infiltration for postoperative pain management after open abdominal surgery. Br J Anaesth. 108:998–1005. DOI: 10.1093/bja/aes091. PMID: 22466819.

11. Rawal N. 2012; Epidural technique for postoperative pain: gold standard no more? Reg Anesth Pain Med. 37:310–7. DOI: 10.1097/AAP.0b013e31825735c6. PMID: 22531384.

12. Machi A, Joshi GP. 2019; Interfascial plane blocks. Best Pract Res Clin Anaesthesiol. 33:303–15. DOI: 10.1016/j.bpa.2019.08.001. PMID: 31785716.

13. Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. 2016; The erector spinae plane block: a novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med. 41:621–7. DOI: 10.1097/AAP.0000000000000451. PMID: 27501016.

14. Tulgar S, Kapakli MS, Senturk O, Selvi O, Serifsoy TE, Ozer Z. 2018; Evaluation of ultrasound-guided erector spinae plane block for postoperative analgesia in laparoscopic cholecystectomy: a prospective, randomized, controlled clinical trial. J Clin Anesth. 49:101–6. DOI: 10.1016/j.jclinane.2018.06.019. PMID: 29913392.

15. Canıtez A, Kozanhan B, Aksoy N, Yildiz M, Tutar MS. 2021; Effect of erector spinae plane block on the postoperative quality of recovery after laparoscopic cholecystectomy: a prospective double-blind study. Br J Anaesth. 127:629–35. DOI: 10.1016/j.bja.2021.06.030. PMID: 34340839.

16. Abu Elyazed MM, Mostafa SF, Abdelghany MS, Eid GM. 2019; Ultrasound-guided erector spinae plane block in patients undergoing open epigastric hernia repair: a prospective randomized controlled study. Anesth Analg. 129:235–40. DOI: 10.1213/ANE.0000000000004071. PMID: 30801359.

17. Freise H, Van Aken HK. 2011; Risks and benefits of thoracic epidural anaesthesia. Br J Anaesth. 107:859–68. DOI: 10.1093/bja/aer339. PMID: 22058144.

18. Onishi E, Toda N, Kameyama Y, Yamauchi M. 2019; Comparison of clinical efficacy and anatomical investigation between retrolaminar block and erector spinae plane block. Biomed Res Int. 2019:2578396. DOI: 10.1155/2019/2578396. PMID: 31032339. PMCID: PMC6458933.

19. Schulz KF, Altman DG, Moher D. 2010; CONSORT 2010 Statement: updated guidelines for reporting parallel group randomised trials. Trials. 11:32. DOI: 10.1186/1745-6215-11-32. PMID: 20334632. PMCID: PMC2857832.

20. Kang R, Chin KJ, Gwak MS, Kim GS, Choi SJ, Kim JM, et al. 2019; Bilateral single-injection erector spinae plane block versus intrathecal morphine for postoperative analgesia in living donor laparoscopic hepatectomy: a randomized non-inferiority trial. Reg Anesth Pain Med. 44:1059–65. DOI: 10.1136/rapm-2019-100902. PMID: 31649028.

21. Patanwala AE, Duby J, Waters D, Erstad BL. 2007; Opioid conversions in acute care. Ann Pharmacother. 41:255–66. Erratum in: Ann Pharmacother 2007; 41: 531. DOI: 10.1345/aph.1H421. PMID: 17299011.

22. Walls RM, Hockberger RS, Gausche-Hill M, Bakes K, Baren JM, Erickson TB, et al. 2018. Rosen's emergency medicine: concepts and clinical practice. 9th ed. Elsevier;Philadelphia: p. 42. https://www.worldcat.org/title/rosens-emergency-medicine-concepts-and-clinical-practice/oclc/1050016573?referer=br&ht=edition. DOI: 10.1345/aph.1h421a.

23. Wu Y, Liu F, Tang H, Wang Q, Chen L, Wu H, et al. 2013; The analgesic efficacy of subcostal transversus abdominis plane block compared with thoracic epidural analgesia and intravenous opioid analgesia after radical gastrectomy. Anesth Analg. 117:507–13. DOI: 10.1213/ANE.0b013e318297fcee. PMID: 23744953.

24. Abdelhamid BM, Khaled D, Mansour MA, Hassan MM. 2020; Comparison between the ultrasound-guided erector spinae block and the subcostal approach to the transversus abdominis plane block in obese patients undergoing sleeve gastrectomy: a randomized controlled trial. Minerva Anestesiol. 86:816–26. DOI: 10.23736/S0375-9393.20.14064-1. PMID: 32449336.

25. Mostafa SF, Abdelghany MS, Abu Elyazed MM. 2021; Ultrasound-guided erector spinae plane block in patients undergoing laparoscopic bariatric surgery: a prospective randomized controlled trial. Pain Pract. 21:445–53. DOI: 10.1111/papr.12975. PMID: 33295128.

26. Kim MG, Kim BS, Kim TH, Kim KC, Yook JH, Kim BS. 2011; The effects of laparoscopic assisted total gastrectomy on surgical outcomes in the treatment of gastric cancer. J Korean Surg Soc. 80:245–50. DOI: 10.4174/jkss.2011.80.4.245. PMID: 22066043. PMCID: PMC3204674.

27. Hong B, Bang S, Chung W, Yoo S, Chung J, Kim S. 2019; Multimodal analgesia with multiple intermittent doses of erector spinae plane block through a catheter after total mastectomy: a retrospective observational study. Korean J Pain. 32:206–14. DOI: 10.3344/kjp.2019.32.3.206. PMID: 31257829. PMCID: PMC6615445.

28. Adhikary SD, Bernard S, Lopez H, Chin KJ. 2018; Erector spinae plane block versus retrolaminar block: a magnetic resonance imaging and anatomical study. Reg Anesth Pain Med. 43:756–62. DOI: 10.1097/AAP.0000000000000798. PMID: 29794943.

29. Aponte A, Sala-Blanch X, Prats-Galino A, Masdeu J, Moreno LA, Sermeus LA. 2019; Anatomical evaluation of the extent of spread in the erector spinae plane block: a cadaveric study. Can J Anaesth. 66:886–93. DOI: 10.1007/s12630-019-01399-4. PMID: 31119551.

30. Ivanusic J, Konishi Y, Barrington MJ. 2018; A cadaveric study investigating the mechanism of action of erector spinae blockade. Reg Anesth Pain Med. 43:567–71. DOI: 10.1097/AAP.0000000000000789. PMID: 29746445.

31. Dautzenberg KHW, Zegers MJ, Bleeker CP, Tan ECTH, Vissers KCP, van Geffen GJ, et al. 2019; Unpredictable injectate spread of the erector spinae plane block in human cadavers. Anesth Analg. 129:e163–6. DOI: 10.1213/ANE.0000000000004187. PMID: 31107261.

32. Krishna SN, Chauhan S, Bhoi D, Kaushal B, Hasija S, Sangdup T, et al. 2019; Bilateral erector spinae plane block for acute post-surgical pain in adult cardiac surgical patients: a randomized controlled trial. J Cardiothorac Vasc Anesth. 33:368–75. Erratum in: J Cardiothorac Vasc Anesth 2022; 36: 627. DOI: 10.1053/j.jvca.2018.05.050. PMID: 30055991.

33. Dost B, Kaya C, Ozdemir E, Ustun YB, Koksal E, Bilgin S, et al. 2021; Ultrasound-guided erector spinae plane block for postoperative analgesia in patients undergoing open radical prostatectomy: a randomized, placebo-controlled trial. J Clin Anesth. 72:110277. DOI: 10.1016/j.jclinane.2021.110277. PMID: 33838536.

34. Nagaraja PS, Ragavendran S, Singh NG, Asai O, Bhavya G, Manjunath N, et al. 2018; Comparison of continuous thoracic epidural analgesia with bilateral erector spinae plane block for perioperative pain management in cardiac surgery. Ann Card Anaesth. 21:323–7. DOI: 10.4103/aca.ACA_16_18. PMID: 30052229. PMCID: PMC6078032.

35. Bagaphou CT, Santonastaso DP, Rispoli M, Piraccini E, Fusco P, Gori F. 2020; Bilateral continuous erector spinae plane block: an alternative to epidural catheter for major open abdominal surgery. Minerva Anestesiol. 86:993–4. DOI: 10.23736/S0375-9393.20.14557-7. PMID: 32490608.

36. Zullino V, Bonvicini D, Alfonsi L, Ferrarese B, Rinta-Nikkola M, Gambardella M. 2020; Bilateral continuous erector spinae plane block in open abdominal aortic aneurysm repair. J Cardiothorac Vasc Anesth. 34:1588–90. DOI: 10.1053/j.jvca.2020.01.053. PMID: 32127265.

37. Leyva FM, Mendiola WE, Bonilla AJ, Cubillos J, Moreno DA, Chin KJ. 2018; Continuous erector spinae plane (ESP) block for postoperative analgesia after minimally invasive mitral valve surgery. J Cardiothorac Vasc Anesth. 32:2271–4. DOI: 10.1053/j.jvca.2017.12.020. PMID: 29336964.

38. Tulgar S, Selvi O, Senturk O, Serifsoy TE, Thomas DT. 2019; Ultrasound-guided erector spinae plane block: indications, complications, and effects on acute and chronic pain based on a single-center experience. Cureus. 11:e3815. DOI: 10.7759/cureus.3815. PMID: 30868029. PMCID: PMC6402723.