Transversus Abdominis Plane Block versus Quadratus Lumborum Block for Postoperative Pain in Abdominal Surgery: A Systematic Review and Meta-analysis
AbstractBackground: Regional anaesthesia for the prevention and minimization of postoperative pain aims to decrease postoperative pain, opioid consumption and patient controlled analgesia (PCA) requirements. Quadratus Lumborum (QL) blockade and Transversus Abdominis Plane (TAP) blockade are two options for regional anaesthesia following abdominal surgery. The aim of this systematic review was to compare the efficacy of QL versus TAP blockade for management of postoperative pain in abdominal surgery.Methods: A systematic review of 5 databases (Pubmed, Web of Science, SCOPUS, Medline and CINAHL) was performed. Studies comparing QL block to TAP block for postoperative pain management in abdominal surgery were included. The primary outcome was pain postoperatively. Secondary outcomes included time to rescue analgesia, adverse effects and morphine consumption.Results: Four studies with a total of 188 patients were included in the final review. A significant reduction in postoperative pain was identified with QL blockade by -0.42 (95%CI= -0.67 to -0.17; I2= 94%; p=0.001). Two high quality studies showed a significant reduction in 24-hour morphine consumption when utilising QL blocks (13.63 mg; 95%CI= 1.48 to 25.78 mg; I2= 98%; p=0.03). However, this review identified no significant difference in time to breakthrough analgesia of 459.69 minutes with QL block (95%CI= -85.33 to 1004.71; I2= 100%; p=0.10). The incidence of adverse effects was similar between the two blocks.Conclusion: QL blockade leads to a significant reduction in 24-hour morphine consumption and postoperative pain scores, with no increase in adverse event rates. Therefore, QL blockade is likely a preferable regional analgesic technique to TAP blockade, but further large randomised controlled trials are required to confirm these findings.
Macrae WA. Chronic post-surgical pain: 10 years on. Br J Anaesth. 2008; 101(1):77-86.
Elizaga AM, Smith DG, Sharar SR, Edwards WT, Hansen ST Jr. Continuous regional analgesia by intraneural block: Effect on postoperative opioid requirements and phantom limb pain following amputation. J Rehabil Res Dev. 1994; 31(3):179-87.
Johns N, O'Neill S, Ventham NT, Barron F, Brady RR, Daniel T. Clinical effectiveness of transversus abdominis plane (TAP) block in abdominal surgery: a systematic review and meta-analysis. Colorectal Dis. 2012; 14(10):e635-42.
Andreae MH, Andreae DA. Regional anaesthesia to prevent chronic pain after surgery: a Cochrane systematic review and meta-analysis. Br J Anaesth. 2013; 111(5):711–20.
McDonnell JG, O’Donnell BD, Farrell T, Gough N, Tuite D, Power C, et al. Transversus abdominis plane block: a cadaveric and radiological evaluation. Reg Anesth Pain Med. 2007; 32(5):399-404.
Rafi AN. Abdominal field block: a new approach via the lumbar triangle. Anesthesia. 2001; 56(10): 1024–6.
Jakobsson J, Wickerts L, Forsberg S, Ledin G. Transversus abdominal plane (TAP) block for postoperative pain management: a review. F1000Res. 2015; 4.
Blanco R. Tap block under ultrasound guidance: the description of a “no pops” technique: 271. Reg Anesth Pain Med. 2017; 32(5):130.
Akerman M, Pejcic N, Velickovic I. A Review of the Quadratus Lumborum Block and ERAS. Front Med (Lausanne). 2018; 5: 44.
Kadam VR. Ultrasound-guided quadratus lumborum block as a postoperative analgesic technique for laparotomy. J Anaesthesiol Clin Pharmacol. 2013; 29(4): 550-2.
Ueshima H, Otake H, Lin JA. Ultrasound-Guided Quadratus Lumborum Block: An Updated Review of Anatomy and Techniques. BioMed Research International. 2017; 2017.
Howick J, Chalmers I, Glasziou P, Greenhalgh T, Heneghan C, Liberati A, Moschetti I, Phillips B, Thornton H. The 2011 Oxford CEBM Levels of Evidence (Introductory Document). Oxford Centre for Evidence-Based Medicine. 2011; http://www.cebm.net/index.aspx?o=5653. Accessed 09/05/2015.
Julian PT and Douglas G Altman. Chapter 8: Assessing risk of bias in included Studies. Cochrane Database. 2008; http://hiv.cochrane.org/sites/hiv.cochrane.org/files/uploads/Ch08_Bias.pdf. Accessed 09/05/2015.
Higgins JP, Altman DG, Gotzsche PC, Juni P, Moher D, Oxman AD, et al. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ. 2011; 343:d5928.
Blanco R, Ansari T, Riad W, Shetty N. Quadratus Lumborum Block Versus Transversus Abdominis Plane Block for Postoperative Pain After Cesarean Delivery: A Randomized Controlled Trial. Reg Anesth Pain Med. 2016; 41(6):757-62.
Murouchi T, Iwasaki S, Yamakage M. Quadratus Lumborum Block: Analgesic Effects and Chronological Ropivacaine Concentrations After Laparoscopic Surgery. Reg Anesth Pain Med. 2016; 41(2):146-50.
Shafeek AM, Gomaa GA. AbdElmalek FA. A Comparative Study between Ultrasound Guided Quadratus Lumborum Block versus Ultrasound Guided Transversus Abdominis Plane Block in Laporoscopic Bariatric Surgery. The Egyptian Journal of Hospital Medicine. 2018; 70(12):2090-199.
Öksüz G, Bilal B, Gürkan Y, Urfalioğlu A, Arslan M, Gişi G, et al. Quadratus Lumborum Block Versus Transversus Abdominis Plane Block in Children Undergoing Low Abdominal Surgery: A Randomized Controlled Trial. Reg Anesth Pain Med. 2017; 42(5):674-679.
White LD, Hodge A, Vlok R, Hurtado G, Eastern K, Melhuish TM. Efficacy and adverse effects of buprenorphine in acute pain management: systematic review and meta-analysis of randomised controlled trials. Br J Anaesth. 2018; 120(4):668-78.
Vlok R, An GH, Binks M, Melhuish T, White L, et al. Sublingual buprenorphine versus intravenous or intramuscular morphine in acute pain: A systematic review and meta-analysis of randomized control trials. Am J Emerg Med. 2018; pii: S0735-6757(18)30433-9.
White L, Vlok R, Melhuish T. Case 37-2017: A Man with Unintentional Opioid Overdose. N Engl J Med. 2018. 378 (9), 872-873.