TAP blocks vs wound infiltration in laparoscopic colectomies Results of a Randomised Controlled Clinical Trial

Transcription

1 TAP blocks vs wound infiltration in laparoscopic colectomies Results of a Randomised Controlled Clinical Trial Kim Gorissen Frederic Ris Martijn Gosselink Ian Lindsey Dept of Colorectal Surgery Dept of Anaesthetics Dept of Statistics Anwar Rashid James Shorthouse Nick Crabtree Adrian Smith OXFORD UNIVERSITY HOSPITALS

2 Rationale Adequate pain relief is essential in ERAS Surgical trauma Recovery Surgical outcomes Multimodal analgesic regiments golden standard

3 However.. Epidural Opioids NSAIDS Reduced mobility Technical failure rates Local complications Evidence? Reduced splanchnic blood flow PONV, prolonged ileus Sedation, urinary retention, respiratory depression Interference ERAS Increased leakage rates

4 TAP block Substantial proportion pain is caused by surgical trauma skin & parietal peritoneum Local field block Peripheral nerve block

5 Innervation anterior abdominal wall Th 6- L1 Iliohypogastric Ilioinguinal

6 Transverse Abdominal Plane block Th 6- L1 Iliohypogastric Ilioinguinal TAP block

7 Evidence TAP blocks TAP reduces 24h morphine consumption a Possible faster recovery However Mainly gynaecologic surgery Very limited observational data (open) colorectal 1 RCT in laparoscopic colectomy, TAP vs control b NO comparison of TAP vs simple wound infiltration a Charlton S et al, Cochrane database 2010 b Walter CJ. Surg. Endos 2013

8 Methods Single centre, randomised, double blinded trial TAP vs WOUND INFILTRATION Inclusion Right hemicolectomy or High anterior resection ASA 1-3 Elective surgery Exclusion Previous colorectal resections, chronic abdominal pain Opioid tolerance, allergy or intolerance BMI > 35 or weight <50kg

9 Methods 1:1 randomisation Sample size calculation assuming 40% reduction in morphine Power 80 Significance 5% 36 Each arm

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13 Results Randomised N=72 Allocated to TAP-block N=36 Allocated to Local Anaesthetic N=35 TAP block employed N=36 Wound infiltration employed N=35 Operative procedure employed N=32 Operative procedure employed N=32 Complete ward follow-up N=28 Complete ward follow-up N=28 Analysed N=28 Analysed N=28

14 Results Randomised N=72 Allocated to TAP-block N=36 Allocated to Local Anaesthetic N=35 TAP block employed N=36 Wound infiltration employed N=35 Operative procedure employed N=32 Operative procedure employed N=32 Complete ward follow-up N=28 Complete ward follow-up N=28 Analysed N=28 Analysed N=28

15 Results: Patients characteristics TAP-block (N = 28) Local Anaesthetic (N = 28) P- value Mean age - yr (CI) 67.6 ( ) 68.0 ( ) P=0.885 Mean BMI (CI) 26.9 ( ) 28.9 ( ) P=0.104 Gender Male Female ASA classification I II III Diagnosis of cancer 16 (57) 12 (43) 8 (29) 18 (64) 2 (7) 15 (54) 13 (46) 4 (14) 23 (82) 2 (1) P=0.788 P= (75) 25 (89) P=0.216 Previous Surgery 8 (29) 6 (22) P=0.239

16 Results: Patients characteristics TAP-block (N = 28) Local Anaesthetic (N = 28) P- value Mean age - yr (CI) 67.6 ( ) 68.0 ( ) P=0.885 Mean BMI (CI) 26.9 ( ) 28.9 ( ) P=0.104 Gender Male Female ASA classification I II III Diagnosis of cancer 16 (57) 12 (43) 8 (29) 18 (64) 2 (7) NS 15 (54) 13 (46) 4 (14) 23 (82) 2 (1) P=0.788 P= (75) 25 (89) P=0.216 Previous Surgery 8 (29) 6 (22) P=0.239

17 Results: Procedural variants TAP-block (N = 28) Local Anaesthetic (N = 28) P- value Surgical procedure Lap Right hemi Lap High anterior 9 (32) 19 (68) 5 (18) 23 (82) P=0.116 Wound length median cm (IQR) 6 (5-7) 5(4-6) P=0.188 Duration operative procedure median minutes (IQR) Postoperative complications 200 ( ) 205 ( ) P= (11) 5 (18) P=0.226

18 Results: Procedural variants TAP-block (N = 28) Local Anaesthetic (N = 28) P- value Surgical procedure Lap Right hemi Lap High anterior 9 (32) 19 (68) NS 5 (18) 23 (82) P=0.116 Wound length median cm (IQR) 6 (5-7) 5(4-6) P=0.188 Duration operative procedure median minutes (IQR) Postoperative complications 200 ( ) 205 ( ) P= (11) 5 (18) P=0.226

19 Results: Cumulative Morphine TAP block LA 24h 48h

20 Pain at rest h 12h 24h 48h TAP WOUND INFILTRATION TAP-block Local Anaesthetic P value n Median (IQR) n Median (IQR) Mann-Whitney test 24 h 25 2 (1-3) 25 2 (1-5) h 21 1 ( ) 23 2 (0-3) 0.820

21 Pain at movement h 12h 24h 48h TAP TAP-block WOUND INFILTRATION Local Anaesthetic n Median (IQR) n Median (IQR) Mann-Whitney test 24h 22 5 (2-7) 24 4 ( 2-7) h 21 2 (1.5 5) 22 2 (1-5) 0.941

22 Days TAP-block Local Anaesthetic Nausea 24h 21 0 (0 0.5) 23 0 (0 0) Nausea 48h 15 0 (0-0) 18 0 (0-0.25) Mobilisation 26 1 (0.5 2) 28 1 (0.5 2) Discharge (3 9) (3 8) 0.910

23 Conclusion TAP may seem like great idea BUT wound infiltration = EQUALLY EFFECTIVE (AND) Easy Quick Reliable

24 Conclusion TAP may seem like great idea BUT has NO benefit

25 Questions