Erector Spinae Plane Block in Laparoscopic Cholecystectomy, Is There a Difference? A Randomized Controlled Trial

Abstract

Background: The ultrasound (US)-guided erector spinae plane (ESP) block and oblique subcostal transversus abdominis plane (OSTAP) block are used to decrease postoperative pain and subsequently opioids consumption.

Aim: The aim was to test the hypothesis that US-guided ESP blocks can produce more reduction in opioid usage during the first 24 h after laparoscopic cholecystectomy when compared to OSTAP block.

Settings and design: Seventy adult patients (20-60 years old) who were planned to undergo elective laparoscopic cholecystectomy were allocated in three groups in randomized controlled trial.

Materials and methods: The three groups received either port site infiltration, US-guided bilateral ESP block (ESP group), or OSTAP (OSTAP group) with bupivacaine hydrochloride 0.25%.

Statistical analysis: Postoperative 24 h Morphine consumption, visual analogue scale (VAS), the intraoperative fentanyl (μg) and equivalent morphine dose in the recovery unit were recorded and analyzed using one-way analysis of variance.

Results: The mean 24-h morphine consumption was statistically significant between groups (P < 0.001), but it was insignificant between ESP and OSTAP (P = 0.173). Median (range) and interquartile range of intraoperatively consumed fentanyl showed significance between the three groups (P < 0.001). There was insignificance between ESP block Group II and OSTAP block Group III (P = 0.95) by post hoc analysis. The mean values of VAS at both rest and movement of the control group were significantly higher than the ESP block group at 6 and 12 h postoperative.

Conclusion: Bilateral US-guided ESP block was found to be as effective as bilateral US OSTAP block. There was more decrease in intraoperative rescue fentanyl, PACU morphine analgesia, 24-h morphine, and pain assessment score in both groups than the control port-site infiltration group.Clinical trial registration number: NCT03398564.

Keywords: Analgesia; erector spinae plane block; morphine consumption; oblique subcostal transversus abdominis plane.

Figure 1

Flow chart showing inclusion and exclusion criteria, enrollment, allocation and outcomes

Figure 2

Technique of erector spinae plane block and oblique subcostal transversus abdominis plane block. (a) Longitudinal parasagittal placement of ultrasound probe. (b) Ultrasound anatomy and needle placement craniocaudally till it gently hit the transverse process with deposition of local anesthetic. Right location of needle tip is confirmed by fluid spread (local anesthetic) under erector spinae muscle, separating it from the transverse process. Note: Rhomboid major is absent at this level. (c) Oblique subcostal transversus abdominis plane block, local anesthetic spread between transversus abdominis muscle and beneath the rectus abdominis

Figure 3

Twenty-four hour morphine consumption is shown on the left-hand axis. The upper and lower limits of the box show the limits of the interquartile range between 25^th and 75^th percentiles (8–12 mg for control group, 5–7.5 mg for erector spinae plane block group, and 6–9 mg for oblique subcostal transversus abdominis plane block group), and the dark middle horizontal line represents the median value (approximately 10, 6, and 8 mg, respectively). The whiskers, extend to the extreme values of the sample

Figure 4

VAS at rest (a) and VAS at movement (b) change over time. ESP = Erector spinae plane, VAS = Visual analog scale. *P<0.05 when comparing ESP block group and OSTAP groups with control group at rest. †P<0.05 when comparing ESP block group and OSTAP groups with control group at movement