From the Journals

TAPs top epidurals in ventral hernia repair



Patients use fewer opioids and have shorter hospital stays when they had transversus abdominis plane (TAP) blocks instead of epidurals for pain control after ventral hernia repair, according to a review of 246 cases at the Greenville Health System, in South Carolina.

“Regional anesthesia using TAP block[s] provides an effective alternative to epidural analgesia or opioid use alone for perioperative pain control ... In light of these findings, use of TAP block should be strongly considered as an adjunct to abdominal surgery,” wrote investigators led by general surgeon Jeremy Warren, MD, of the University of South Carolina School of Medicine, Greenville, in the Journal of the American College of Surgeons.

Prompted by favorable reports in the literature, the team switched from epidural analgesia to TAP blocks in early 2017. To see how it’s worked out, they reviewed all patients who had ventral hernia repairs at the Greenville Health System from Feb. 2015 to March 2018. They were all mesh cases, without parastomal hernias or enterostomy reversal.

Seventy-four patients had TAP blocks, which were placed in the OR after anesthesia induction and consisted of 200 mg ropivacaine, 100 mcg epinephrine, and 100 mcg clonidine in 60 ml saline, with 30 ml injected on each side under ultrasound guidance.

Their outcomes were compared with 172 patients who received epidurals, which were placed preoperatively and consisted of 0.125% bupivacaine initiated shortly before patients came out of anesthesia, at a rate of 8-12 ml/hr.

Hospital lengths of stay were significantly shorter in the TAP group, a median of 2.4 versus 4.5 days (P less than .001), and TAP patients received fewer opioids, a mean of 40 versus 54.1 morphine milligram equivalents (MME) on postop day 1, and 36.1 versus 52.5 MME on postop day 2 (P = .018).

There were no differences in the rates of surgical site infections or other wound complications. The mean duration of epidural infusion was 49.5 hours.

The shorter length of stay with TAP block was probably related to side effects of epidurals, which can include leg paresthesias, hypotension, and urinary retention, all of which get in the way of early ambulation. “Additionally, the decision of when to discontinue epidural analgesia in our series was left to the judgment of the pain management and surgical team based on reporting of patient pain, rather than duration determined by a protocol,” which may have also played a role, the study team said.

Overall, the results mirror outcomes from previous TAP block studies, but there were caveats. Epidural patients had wider hernias (median 10.8 cm versus 8.8 cm); required more myofascial releases; and had longer operative times, “indicating a higher degree of complexity that may influence the need for longer hospitalization and greater opioid use,” the investigators said.

Also, a greater number of TAP block patients received non-opioid pain killers, including ketorolac and acetaminophen.

The study was conducted within the health system’s enhanced recovery after surgery protocol, which includes a preoperative cocktail of pregabalin 75 mg, celecoxib 400 mg, and acetaminophen 1,000 mg, given within 1-2 hours of surgery. Post-operative management includes intravenous ketamine infusions at sub-anesthetic doses, NSAIDs, and acetaminophen, among other measures. The approach has pretty much eliminated patient-controlled analgesia.

There were slightly more men than women in the review. Study participants, on average, were in their late 50s. There were no significant differences in comorbidities.

No funding was reported, and the investigators didn’t have any relevant disclosures.

SOURCE: Warren JA et al., J Am Coll Surg. 2019 Jan 7. pii: S1072-7515(19)30014-6. doi: 10.1016/j.jamcollsurg.2018.12.017

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